The EndoResect study: endoscopic full-thickness resection of gastric subepithelial tumors

We read with great interest the article by Schlag et al. [1], who evaluated the feasibility of endoscopic resection of small gastric subepithelial tumors using a grasp-and-snare technique followed by over-the-scope clip (OTSC) closure of the gastric wall. Their finding that endoscopic snare resection enables safe treatment of small subepithelial tumors (diameter ≤ 3 cm) and that the OTSC system may be potentially useful as a new closure method of smaller leaks in the clinical settings is promising.

However, several aspects of this study need to be discussed. First, smaller subepithelial tumors are not easily found in endoscopic operations; we often remove mucosal and submucosal tissues to expose the tumors by endoscopic submucosal dissection. Secondly, the tissue anchor has difficulty in grasping the muscularis and can easily damage the tumor, resulting in the inability to ensure the integrity of the tumor. Moreover, in the study, the gastric lumen is completely opened to the peritoneal cavity. The potential risk of contamination to the peritoneal cavity and peritoneal infection cannot be ignored in this technique. Therefore there remains a need to improve endoscopic full-thickness resection (EFTR) devices or to develop new approaches, such as a combination of laparoscopic and endoscopic methods, in order to avoid exposure and contamination. von Renteln et al. have introduced a novel EFTR device and method for resection of gastric submucosal tumors that avoids spillage of the gastric contents and potential intraperitoneal infection [2].

Finally, the main limitation of the OTSC technique is its inability to treat a leak larger than 2.5 cm [3]. In conclusion, technical modifications and improvements have to be implemented before the goal of EFTR for large gastric submucosal tumors will be reached.

• References

• 1 Schlag C, Wilhelm D, Delius SV et al. EndoResect study: endoscopic full-thickness resection of gastric subepithelial tumors. Endoscopy 2013; 45: 4-11
• 2 von Renteln D, Kratt T, El-Masry M. Endoscopic full-thickness resection of submucosal gastric tumors. Dig Dis Sci 2012; 57: 1298-1303
• 3 Manta R, Manno M, Bertani H et al. Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: case series from a tertiary referral center. Endoscopy 2011; 43: 545-548