An 82-year-old woman with multiple comorbidities underwent upper endoscopy, which
showed a 25 mm subepithelial lesion in the gastric fundus. Gastric biopsies of the
antrum and body were unremarkable.
Upper endoscopic ultrasound showed a nonbleeding, hypoechoic, submucosal mass, measuring
24 mm × 17 mm in diameter, arising from layer 3 and extending to the muscularis propria
(layer 4). Fine-needle core biopsy was performed with a 22 gauge needle. Pathology
revealed epitheloid stromal cells consistent with gastrointestinal stromal tumor (GIST).
The patient was referred for endoscopic submucosal dissection of the GIST ([Video 1]). A multipurpose knife (Erbe Elektromedizin GmbH, Tübingen, Germany) was used to
mark the borders of the lesion, with a 1 – 2 mm margin of normal mucosa, using soft
coagulation setting. The lesion was lifted with a solution consisting of 0.9 % normal
saline, methylene blue, and hextan. After adequate expansion of the submucosal space,
the mucosa was incised with the multipurpose knife. Using repeated submucosal injections
followed by short bursts of needle-knife dissection, the submucosal space beneath
the lesion was carefully dissected until the proximal edge of the GIST was seen ([Fig. 1]). Further dissection was carried out to better expose the GIST along the semi-circumferential
borders until the lesion was well exposed on its proximal side. An insulated-tip knife
(IT2; Olympus, Tokyo, Japan) was then used to dissect underneath the lesion until
it was completely freed from the muscularis propria on the distal side, and the lesion
was released in a flap-like fashion. The lesion was removed en bloc with no defect
seen in the resection bed of the muscularis propria. The resection bed was closed
with an endoscopic suturing device (Overstitch; Apollo Endosurgery Inc., Austin, Texas,
USA) using three sutures.
Video 1 Step-by-step full-thickness resection of a gastrointestinal stromal tumor, followed
by suturing.
Fig. 1 Endoscopic exposure of a gastrointestinal stromal tumor during endoscopic dissection.
Final pathology demonstrated a 2.4 cm × 2.4 cm × 1.7 cm low grade GIST with negative
margins. At 6 month follow-up, the patient had no symptoms, and repeat upper endoscopy
did not show any residual lesion.
Gastric GISTs account for about 55 % of all GISTs and can become symptomatic due to
bleeding or pain [1]. The National Institutes of Health classifies the malignant potential of GIST based
on size and mitotic index, with a tumor size > 2 cm considered a higher risk feature
[2]. Endoscopic submucosal dissection and endoscopic full-thickness resection techniques
have been successfully described, mostly in the Eastern literature, with high success
rates and low rates of complications for en bloc curative resection without the need
for traditional surgery [3]
[4]
[5]. However, the closure technique used in most of these cases involved hemostatic
clips or over-the-scope clips. We describe successful endoscopic full-thickness resection
of a medium-sized gastric GIST using hemi-circumferential opening followed by endoscopic
suturing of the large resection defect.
Endoscopy_UCTN_Code_TTT_1AO_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
