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DOI: 10.1055/a-2719-8232
Staged endoscopic submucosal dissection for a giant gastric fundus lesion: a strategy for the incompletable
Autoren
Gefördert durch: Capitalʼs Funds for Health Improvement and Research 2022-2-40710
Gefördert durch: National High Level Hospital Clinical Research Funding (Interdepartmental Research Project of Peking University First Hospital) 2024IR01
A 73-year-old female presented with anemia and underwent gastroscopy at a local hospital, which identified a large villous lesion in the gastric fundus measuring approximately 7 cm × 6 cm ([Fig. 1]). The lesion was attached to the gastric fundus and cardia via a pedicle-like structure. Biopsy confirmed high-grade intraepithelial neoplasia (HGIN). Given multiple comorbidities, the patient was considered high-risk for surgery, and ESD was elected ([Video 1]).
Due to the considerable size of the lesion, visual exposure of the submucosal layer was inadequate. Traction assistance was provided sequentially using a clip-with-rubber-band system and a snare. Numerous large vessels within the lesion were identified and managed with clips and hemostatic forceps coagulation ([Fig. 2]). The initial ESD session lasted 7.5 hours. Although most of the lesion was resected, the remaining portion – which still contained multiple large vessels – was endoscopically inaccessible despite repeated attempts. The procedure was therefore discontinued.
Postoperatively, the patient received proton pump inhibitor therapy, prophylactic antibiotics, and nutritional support. Repeat gastroscopy 1 week later revealed extensive necrosis ([Fig. 3]). The necrotic tissue was retrieved with a snare. The residual lesion had become clearly demarcated and readily accessible, enabling completion of resection via endoscopic piecemeal mucosal resection (EPMR) ([Fig. 4]).
The patient recovered uneventfully and was discharged. Final pathology reported a pyloric gland adenoma with low-grade and focal HGIN. A 3-month follow-up endoscopy showed complete healing without residual or recurrence ([Fig. 5]).
Staged ESD has previously been described by Japanese researchers for the management of circumferential Barrettʼs carcinoma [1]. To our knowledge, this is the first reported application of this strategy for a giant gastric lesion. We demonstrated a novel, safe endoscopic option for complex gastric lesions, expanding treatment possibilities for high-risk patients and highlighting techniques for managing challenging lesions.
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Publikationsverlauf
Artikel online veröffentlicht:
14. November 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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Reference
- 1 Tanaka I, Hirasawa D, Saito H. et al. Stepwise endoscopic submucosal dissection for circumferential Barrett's esophageal dysplasia and carcinoma: a case series. Endosc Int Open 2022; 10: E215-E221