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Endoscopic management of gastric gastrointestinal stromal tumors (GISTs) is challenging because of possible unmanageable perforation. Submucosal tunneling endoscopic resection (STER) can maintain the mucosal flap to facilitate wound closure [1]. To maintain the serosa, endoscopic subserosa dissection can prevent air leakage [2]. Both require precise endoscopic dissection to preserve mucosa or serosa and are only feasible in favorable endoscopic anatomy. If the large perforation can be managed confidently, we can do whole-layer resection directly [3].
The 80-year-old patient had a growing gastric myogenic tumor in the greater curvature (GC) of the upper body ([Fig. 1]). The anatomy is challenging for endoscopic resection because of the approach angle. We decided to do wide-field endoscopic full-thickness resection (EFTR) followed by endoscopic suturing. First, we separated the tumor from the gastric wall by whole-layer dissection of the gastric wall around the tumor. Then the tumor was resected from the remaining attached gastric wall with snare resection ([Video 1]). Traction with a snare from the additional gastroscope was built to facilitate resection ([Fig. 2]). Air leakage was controlled by changing the patient’s position. All the blood clots and fluid in the peritoneum were removed to maintain peritoneal hygiene ([Fig. 3]). The wound was closed in a z-shaped suture for eight bites with Overstitch Sx (Apollo Endosurgery, Austin, Texas, USA) ([Video 1], [Fig. 4]). The final pathology was a complete resected GIST with muscle, serosa, and mucosa ([Fig. 5]). The post-procedure course was smooth with 5 days of antibiotics. Diet was resumed 2 days after the procedure.
Fig. 1 The location of the gastric gastrointestinal stromal tumor was difficult for endoscopic management.Video 1 Endoscopic suturing system can change endoscopic management of gastric gastrointestinal stromal tumors at greater curvature.
Fig. 2 The snare traction was built to assist our dissection. Fig. 3 The omental fat could be seen after the tumor was resected. Fig. 4 The perforation was fully closed with Overstitch. Fig. 5 The specimen resected contained tumor, mucosa, serosa (blue arrow), and muscle (green arrow).Instead of delicately maintaining the mucosal flap and separating the tumor and serosa in the gastric GC, whole-layer dissection is a less demanding technique and resects more tissue for a safe margin. The suturing system with reliable whole-layer wound closure can allow endoscopists to do wide-field EFTR in challenging anatomy.
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Publication HistoryArticle published online:
18 November 2022
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