Resection of subepithelial lesions by a novel technique: “Band endoscopic full-thickness resection”

Endoscopic full-thickness resection (EFTR) using a full-thickness resection device is a Food and Drug Administration (FDA)-approved minimally invasive technique for resecting subepithelial tumors of the gastrointestinal (GI) tract [1] [2] [3] [4] [5]. Grasping and pulling the entire lesion into the cap is a technical challenge, as the mucosa tears off despite cautious traction. We describe a novel technique deploying a band and subsequently grasping and resecting the lesion en bloc. The “pseudo-polyp” reduces the tension on the mucosa as the subepithelial tumor anchored by the band is partially held onto by the grasper, minimizing the shearing forces between the mucosa and the underlying tumor.

A 50-year-old woman was referred for evaluation of a firm subepithelial lesion noted incidentally on the lateral wall of the second portion of duodenum. Endoscopic ultrasound-guided biopsy confirmed an 18-mm GI stromal tumor (GIST). The patient opted for endoscopic full-thickness resection over surveillance.

After prophylactic dilation of the upper esophageal sphincter and the pyloric channel to 20 mm, a gastroscope fitted with a transparent cap was advanced to the lesion. The margins were marked with argon plasma coagulation. An endoscopic mucosal resection device was used to deploy a band over the lesion. A double-channel therapeutic scope mounted with the full-thickness resection device (Ovesco Endoscopy AG, Tübingen, Germany) was used. With the band in place, it was relatively easy to grasp and pull the pseudo-polyp and the lesion entirely into the cap. This was followed by deployment of the integrated over-the-scope metal clip at the base of the lesion below the rubber band. The integrated snare was closed above the clip and the resection was performed using cutting current. The lesion was retrieved ([Fig. 1]). Repeat endoscopy showed the resection to be complete with an intact base with the clip in place ([Video 1]). Pathology confirmed the lesion to be a GIST with R0 resection.

Fig. 1 Duodenal lesion after banding and creation of a “pseudo-polyp” (left). Resected lesion showing intact bands (right).

Video 1 Resection of a subepithelial duodenal lesion using band-assisted endoscopic full-thickness resection using full-thickness resection device.

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• References

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