A 73-year-old man with a history of diabetes mellitus, hypertension, coronary artery
disease, and atrial fibrillation was found to have a 20-mm reddish elevated lesion
of the lower gastric body ([Fig. 1 a]). Endoscopic ultrasound revealed a submucosal tumor originating from the muscularis
propria. The patient preferred an endoscopic excision. An endoluminal resection was
performed using the endoscopic submucosal dissection (ESD) technique with carbon dioxide
insufflation. An indigo carmine-saline mixture was injected into the base of the lesion.
After creation of incision with the tip of a snare, the IT-knife2 (Olympus, Melville,
New York, United States) was then used to circumferentially cut the mucosa and submucosa
around the tumor. Careful dissection was performed, exposing the entire capsulized
round tumor, which was completely excavated from its base and enucleated ([Fig. 1 b]). The resection was deep exposing the muscle layer. Given the patient’s high risk
cardiovascular status and continued need for antiplatelet agents, the wound was closed
endoscopically using an over-the-scope clip (OTSC; 12/6 t, Ovesco, Tübingen, Germany).
Air was suctioned from the stomach to decrease the surface area of the wound. Then
the OTSC device was directed towards the wound and suction was applied to pull the
lateral mucosa edges into the cap. The clip was released and the wound closed successfully
([Fig. 1 c]). The patient was discharged home and did well. The resected specimen confirmed
enucleation of the gastric leiomyoma ([Fig. 1 d]).
Fig. 1 Endoscopic enucleation of a gastric submucosal tumor in a 73-year-old man with a
history of diabetes mellitus, hypertension, coronary artery disease, and atrial fibrillation.
a A 20-mm reddish elevated lesion of the lower gastric body. b Careful dissection was performed, exposing the entire capsulized round tumor, which
was completely excavated from its base and enucleated. c The over-the-scope clip was released and the wound closed successfully. d Resected specimen of gastric leiomyoma with hyperplastic epithelium on the surface.
While ESD and excavation techniques are potential therapeutic options for the removal
of a gastric submucosal tumor, they more frequently result in perforation than ESD
for early gastric cancer [1]
[2]. This case shows the utility of OTSC for full-wall closure during a one-step process,
thus minimizing the risk of delayed bleeding and perforation. Although endoclips can
be used, that is technically a more arduous and difficult procedure, usually necessitating
several clips. Although the OTSC device is more expensive than a single clip, the
use of more than three clips may exceed the price of an OTSC. In addition, the apposition
forces of OTSC are much stronger and thus may result in a more secure closure [3]
[4].
Endoscopy_UCTN_Code_TTT_1AO_2AG
