Endoscopic submucosal dissection (ESD) with traction of gastric submucosal tumor associated with Transparietal endoscopic excavation and endoscopic closure : A pilot serie

Aims ESGE guidelines concerning gastric subepithelial tumor (SEL) originating for propria muscularis layer offer endoscopic resection for exophytic gastric lesions less than 35 mm after discussion in a multidisciplinary staff. GIST tumor are found frequently in the stomach and are often developed in the submucosa but originated from the muscular propria. The endoscopic treatment of GIST tumor need a Complete endoscopic resection and no effraction of tumor capsule. Three techniques are actually recommended by ESGE : STER (Submucosal Tunneling Endoscopic Resection, l'EFTR (Endoscopic Full Thickness Resection – OVESCO) and the technique of submucosal endoscopic excavation [1] [2].

Methods 5 female patients aged from 23 to 71 years with a gastric SEL<35 mm were included in this study after endoscopic ultrasound (EUS) and upper endoscopic evaluation for a GIST (2 low grade GIST according to histology and 3 SEL with negative histologic biopsy but originating from the 4th EUS layer compatible with a GIST or a leiomyoma). All the patients were treated by transparietal endoscopic excavation with a single channel gastroscope (2,8 or 3,8 mm operating channel) under general anesthesia, CO2, prophylactic IV PPI and antibiotics administration. Endoscopic procedure was separated in different steps : 1-Peripheral marking around the lesion with a 10 mm margin with a knife; 2- Injection of Fructose/glycerol or plasmion; 3-Circomferential incision and trimming with a 1,5 mm ESD knife (Flushknife ou Dualknife); 4-Double clips rubber traction fixed to the gastric wall opposite to the lesion; 5-Dissection of the lesion, preserving the tumor capsule until identification of muscular insertion of the SEL; 6-Section of the muscular propria of the gastric wall and full Thickness resection of gastric wall with a traction type knife (IT knife nano, Hook Knife, TT knife) to avoid injuring extra gastric anatomical structure; 7-Closure of the defect either by a technic with TTS clips and endoloop or OTS-clip; 8-Extraction of the tumor by used a basket snare. An oral opacified CT was performed 2 days after the procedure. In the absence of leakage, a normal regimen was reintroduced

Results 5 endoscopic procedures were done with a 100% technical success. A significant clinical pneumoperitoneum was seen in 4 to 5 patients and was exsufflated during the procedure. Median size of the SEL was 20 mm (16-35 mm). Median size of muscular insertion of the SEL was 12 mm (10 – 25 mm). No leakage was noticed on the oral opacified CT at day 2 with a median hospital stay of 3 days (3-6). Histologically, a GIST was identified in 4 patients (Low risk according to Miettinen classification in 3 cases and intermediate risk in one), the other SEL was a leiomyoma. RO resection rate was 100%

Conclusions Combination of endoscopic excavation – EFTR – muscular defect endoscopic closure is feasible and safe for endoscopic resection of gastric SEL<35 mm originating from the 4th layers in EUS (proper gastric muscle) and should be discussed in patients when laparoscopic approach is difficult (cardiac area, posterior gastric wall, surgery declined….).

Publication History

Article published online:
27 March 2025

• References

• 1 Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54 (6): 591-622
• 2 Marin FS. et al Closure of gastrointestinal perforations using an endoloop system and a single-channel endoscope: description of a simple, reproducible, and standardized method. Sure Endosc 2024; 38 (3): 1600-1607