Subepithelial lesions (SELs) in the gastrointestinal (GI) tract are common and often
necessitate removal, particularly when >20 mm [1]
[2]. The choice of endoscopic resection depends on various factors, including lesion
characteristics, location, and evidence of deeper tissue involvement [2]
[3]. Challenges in achieving full-thickness resection have driven the development of
innovative over-the-scope devices [4]. However, these devices are typically restricted to lesions <30 mm, and their size
and rigidity often hinder passage beyond the pharynx. We present here a novel technique
for accomplishing full-thickness resection of SELs, known as endoscopic sutured purse-string
resection (ESPR). ESPR employs the Overstitch device (Apollo Endosurgery, Austin,
Texas, USA), a well-established tool for placing full-thickness endoscopic sutures.
It involves creating a purse-string configuration around the lesion ([Fig. 1]) before resection, enabling the safe and complete removal of even larger lesions.
Fig. 1 Schematic showing lesion marking and suture placement for endoscopic sutured purse-string
resection. a Lesion (L) of diameter (d), which allows placement of mucosal diathermy marks (m)
and purse-string sutures (ps). b Lesion after tightening of the purse string, with corresponding sites of mucosal
marks and suture sites. Snare resection is conducted at or underneath the diathermy
marks. SM, submucosal layer; MP, muscularis propria.
Patient selection followed European Society of Gastrointestinal Endoscopy guidelines,
with a preference for lesions located on the greater curve of the stomach, primarily
due to the easier access provided by the Overstitch device. Lesions underwent thorough
characterization using endoscopic direct visualization, endoscopic ultrasound, and
cross-sectional imaging (computed tomography), following a standardized protocol.
ESPR is conducted as follows ([Video 1]): marking the boundaries of the lesion, applying an endoscopic purse string, tenting
the lesion with forceps, and creating a pseudopolyp by tightening the purse string.
Resection was carried out using a large snare, and the site underwent meticulous inspection
for completeness before being oversewn with a Z-shaped suture ([Fig. 2]). In the two cases where this technique was employed, no perioperative complications
were encountered. Patients were discharged on the same day, and histological examination
confirmed complete resection, including the muscularis propria and serosa layers,
along with omental fat in one case.
Fig. 2 Image showing the two lesions (a and b) resected using the endoscopic sutured purse-string resection technique. a1 30-mm gastric antral subepithelial lesion. b1 15-mm greater curvature lesion. a2, b2 Resected site showing complete resection. a3, b3 Closure of the resected site with Z-shaped suture (4-suture point).
Endoscopic sutured purse-string resection for the removal of subepithelial lesions
in the gastrointestinal tractVideo 1
This technique presents a safe and viable solution for resecting gastric SELs, effectively
addressing the limitations of existing techniques. Its potential applicability extends
beyond the stomach, offering a promising avenue for further exploration and adoption
in the field of GI endoscopy.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB
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