Gastric subcentimeter subepithelial tumor: successful resection with an over-the-scope padlock clip

A 60-year-old woman was referred for endoscopic resection of two 5-mm gastric subepithelial lesions ([Fig. 1]) incidentally found during a screening endoscopy. Abdominal computed tomography (CT) revealed no lesions. The lesions were hypoechoic and originated from the muscle layer on endoscopic ultrasonography and were undetected on the endoscopy performed 5 years before. Follow-up was advised owing to the small lesions, but the patient requested an endoscopic resection to further clarify the nature of the tumor.

Fig. 1 Endoscopic view of the gastric subepithelial lesions. Left: middle body posterior wall. Right: gastric cardia.

Endoscopy was performed after coagulation marking on the lesion ([Fig. 1], right). Two padlock clips (Steris, Mentor, Ohio, USA) were placed after suction of the targeted lesions ([Fig. 2], left). The lesion with the overlying mucosa was removed using single-step hot snare resection ([Fig. 2], right; [Video 1]). Both tumors were completely resected ([Fig. 3]). Abdominal radiography revealed no perforation ([Fig. 4]). The patient received a restricted diet and was discharged the next day. Pathological examination revealed that the lesion from the gastric cardia was a gastrointestinal stromal tumor [CD 117 (+), Dog1 (+), CD 34 (+), desmin (−), and S-100(−)] and the other one from the body was a leiomyoma [CD 117 (−), Dog1 (−), CD 34 (−), desmin (+), and S-100 (−)].

Fig. 2 Endoscopic view of the resection process. Left: ligation of the lesion with a padlock clip. Right: endoscopic view after resection of the tumor.

Video 1 Successful resection of gastric subcentimeter subepithelial tumor with an over-the-scope padlock clip.

Fig. 3 Endoscopic view of the resected specimen. Left: body. Right: gastric cardia.

Fig. 4 Abdominal X-ray after placement of two padlock clips.

A subepithelial lesion of the stomach is a common incidental finding during endoscopy especially for lesions < 2 cm in size [1] [2]. Surveillance endoscopy is recommended owing to the low risk of disease progression, but patient compliance is poor [3]. Leiomyoma and gastrointestinal stromal tumor (GIST) are the two leading causes of subepithelial lesions arising from the muscle layer. While leiomyomas are almost benign, larger GISTs have a malignant potential. Endoscopic or radiological differentiation of the two conditions is difficult as demonstrated in this case. Several endoscopic resection techniques were proposed for such lesions but are technically demanding [1], with a high perforation risk. This case demonstrates the usefulness of over-the-scope clips [4] as an easy treatment method for small subepithelial lesions.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Aslanian HR, Sethi A. ASGE Technology Committee. et al. ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection. VideoGIE 2019; 4: 343-350
• 2 Faulx AL, Kothari S. Standards of Practice Committee. et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117-1132
• 3 Kushnir VM, Keswani RN, Hollander TG. et al. Compliance with surveillance recommendations for foregut subepithelial tumors is poor: results of a prospective multicenter study. Gastrointest Endosc 2015; 81: 1378-1384
• 4 Suthar D, Kramer EH, Khara HS. Successful endoscopic removal of toothpick perforating gastric antrum with over-the-scope padlock clip closure. Cureus 2020; 12: e11263

Publication History

Article published online:
08 June 2021