Reply to Liu et al.

10.1055/a-2773-2452

We appreciate the insightful comments by Liu et al. on our study [1]. As noted, conventional resection is optimal for most intraluminal gastric submucosal tumors. We confirm that our inclusion criteria did not specify National Institutes of Health risk classification or tumor location, and our study focused solely on extraluminal lesions, where endoscopic intraperitoneal subserosal dissection (EISD) offers distinct benefits.

En bloc dissection along the tumor capsule under direct visualization preserved capsule integrity. Piecemeal retrieval was performed in one case after mucosal closure; in our experience and reports, this does not increase peritoneal seeding, recurrence, or metastasis risk, though further prospective studies with long-term follow-up are needed to confirm safety [2].

EISD, a novel natural orifice transluminal endoscopic surgery technique combining submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR), adopts controlled carbon dioxide pneumoperitoneum with percutaneous decompression to maintain safe intra-abdominal pressure [3]. In our study, on closure of the mucosal defect, successful sealing was verified by the restoration of normal gastric distension and the absence of gas escaping through the decompression needle. Adverse events were defined according to American Society for Gastrointestinal Endoscopy criteria [4]. The short hospital stay in our cohort also confirmed the absence of clinically significant adverse events. With an increasing number of cases, we may monitor a broader spectrum of adverse events in future studies.

Tumor extraction was completed rapidly and uneventfully via the oral route in most cases, without dilation or mucosal injury. Several studies have identified that tumors with a maximal diameter of 3.5–4.0 cm can be retrieved safely via the natural orifice, which constitutes the primary rationale for defining the current indications for EISD [5]. We agree that multicenter comparative study is warranted to evaluate the efficacy of EISD against non-exposure laparoscopic and endoscopic cooperative surgery and EFTR/STER.

In conclusion, we sincerely thank Liu et al. for their constructive comments. These insights will help us further optimize the EISD technique and promote its rational clinical application.

Publication History

Article published online:
20 March 2026

• References

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