Endoscopic intraperitoneal subserosal dissection for extraluminal gastric submucosal tumors: feasibility is not adoption

10.1055/a-2573-9069

Ma et al. report a prospective single-center series of endoscopic intraperitoneal subserosal dissection (EISD) for predominantly extraluminal gastric submucosal tumors, noting en bloc resection, brief hospital stay, and no recurrence at 32.1 months [1]. These findings confirm feasibility in carefully selected patients but not practice-level safety.

First, design and population restrict inference. The study is single arm (n = 10 patients), excludes prior abdominal surgery, limits size to ≤5 cm, and requires >75% extraluminal growth; most lesions arise in the gastric body/greater curvature with very low/low National Institutes of Health risk. Such selection inflates apparent generalizability and partly explains the absence of recurrence [1].

Second, oncologic adequacy is incompletely documented. R0 margin status is not reported, and a consensus framework for tumor “rupture” is not applied. One case required intragastric piecemeal retrieval after mucosal closure; this scenario should be adjudicated under standardized rupture criteria because rupture carries prognostic and adjuvant therapy implications [2].

Third, EISD is an exposed transmural approach. The report does not describe leak testing, contamination control steps (e.g. irrigation, retrieval bag policy), or gas physiology data; adverse events rely on narrow thresholds (e.g. hemoglobin drop >2 g/dL). For a technique that transiently communicates lumen and peritoneum, closure verification and broader adverse event grading are essential [3].

Finally, retrieval – not dissection – defines the practical ceiling. The authors infer an effective transverse diameter around 3–3.5 cm, yet retrieval metrics (time, overtube/bag use, dilation strategy, mucosal shear) are not reported systematically, limiting indication setting [1].

An expertise-based multicenter comparison against nonexposure laparoscopic and endoscopic cooperative surgery and endoscopic full-thickness resection/submucosal tunnel endoscopic resection is warranted. A composite primary end point should include R0, capsule integrity, no rupture, and no major 30-day adverse events, with predefined retrieval metrics, costs, and 3-year recurrence-free survival. Only with standardized oncologic and exposure controls can the role of EISD be defined [3] [4].

Publication History

Article published online:
20 March 2026

• References

• 1 Ma LY, Guo KY, Liu XY. et al. Efficacy and safety of endoscopic intraperitoneal subserosal dissection for gastric submucosal tumors with extraluminal growth pattern. Endoscopy 2025; 57: 1261-1267
• 2 Nishida T, Hølmebakk T, Raut CP. et al. Defining tumor rupture in gastrointestinal stromal tumor. Ann Surg Oncol 2019; 26: 1669-1675
• 3 ASGE Technology Committee. Guideline for endoscopic full‑thickness resection and submucosal tunnel endoscopic resection. VideoGIE 2019; 4: 343-350
• 4 Onimaru M, Inoue H, Ikeda H. et al. Combination of laparoscopic and endoscopic approaches with non-exposure techniques (NEWS/CLEAN-NET) in gastric tumors. Ann Transl Med 2019; 7: 582