Endoscopic hand suturing with clips for a large defect after endoscopic full-thickness resection of gastric gastrointestinal stromal tumor

Few studies have focused on endoscopic full-thickness resection (EFTR) for gastric gastrointestinal stromal tumors (g-GISTs) ≥35 mm [1], which could be attributed to the difficulty of endoscopic resection and closure of the defect, although multiple closure techniques have been developed for post-EFTR defects [2] [3] [4]. Recently, endoscopic hand-suturing (EHS) has been proved safe and effective for gastrointestinal superficial defects [5], and can be expected to be similarly efficacious for closing large defects after EFTR. Here, we describe a successful case of full-thickness closure using EHS with clips (EHS-Clips) for a large g-GIST defect.

A 72-year-old man who underwent gastroscopy was diagnosed with a submucosal tumor approximately 4.0 × 3.5 cm in size at the fundus ([Fig. 1]). Endoscopic ultrasonography and contrast-enhanced computerized tomography suggested a g-GIST ([Fig. 2]). After comprehensive multidisciplinary discussions and thorough communication with the patient, the lesion was removed en bloc through EFTR, leaving a large full-thickness defect ([Fig. 3]). The defect was completely sutured via EHS, and this was followed by the application of clips for additional mucosal closure, to enhance the reliability of closure and ensure patient safety ([Fig. 4], [Fig. 5], [Video 1]). The abdominal gas accumulation was released through abdominal puncture. The resection time and suture time were 33 minutes and 60 minutes respectively. On postoperative day 5, a follow-up endoscopy confirmed continued closure, allowing discharge of the patient. No adverse events occurred during or after the operation. Histologically, complete resection of a very low risk g-GIST had been obtained.

Fig. 1 Gastroscopy in a 72-year-old man showed a gastric submucosal tumor at the fundus, approximately 4.0 × 3.5 cm in size.

Fig. 2 Contrast-enhanced computerized tomography suggested a gastric gastrointestinal stromal tumor (g-GIST) (yellow arrow).

Fig. 3 Defect after endoscopic full-thickness resection (EFTR) of a g-GIST at the fundus. The yellow dash-dotted lines outline the defect; the white dotted lines indicate the diaphragm.

Fig. 4 The defect after closure by endoscopic hand-suturing (EHS). Dotted line and arrow, suture direction; arrow, resected tumor.

Fig. 5 Additional clips, applied for reliable closure and patient safety.

Complete closure of a large defect after endoscopic full-thickness resection (EFTR) of a gastric gastrointestinal stromal tumor (g-GIST), using endoscopic hand-suturing followed by clipping (EHS-Clips) for additional mucosal closure, to enhance reliability of closure and ensure patient safety.Video 1

To our knowledge, this EHS-Clips case is the first such report of complete closure of a large full-thickness defect. Notably, the suturing process should ensure the protection of adjacent organs and tissues from injury. Therefore, the EHS-Clips approach can be considered as an optional closure method for full-thickness defect after EFTR in selected patients. Further accumulation of clinical experience is needed.

Endoscopy_UCTN_Code_TTT_1AO_2AZ

• References

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