A loop-assisted inversion technique for easy removal of a gastric stromal tumor in the fundus

A 54-year-old woman presented with a stromal tumor (approximately 2 × 1 cm) in the gastric fundus ([Fig. 1] and [Fig. 2 a]). After it had been marked and submucosal injection performed under endoscopic guidance, an electrosurgical knife was used to make a circular incision ([Video 1]). This was challenging because of the difficult approach and the high risk of perforation, with an IT knife being used to make the incision ([Fig. 2 b]). A clip-anchored loop was fixed 1 cm from the incised wound ([Fig. 2 c]). A snare was then used to trap the incised mucosa and lift it, with the loop ring being slowly tightened ([Fig. 2 d]). After the snare was released, inversion of the tumor was observed ([Fig. 2 e] and [Fig. 3]). Next, an electrosurgical knife was used to cut and expose the tumor margins, and a snare was then used to trap the tumor base and perform electrosurgical excision ([Fig. 2 f]). After the excision, the clean inverted wound was sutured using clips ([Fig. 2 g]). Finally, the loop was released. The resected specimen was an intact tumor measuring approximately 2 × 1 cm ([Fig. 4]). At follow-up 1 month later, a flat wound with a residual loop was observed ([Fig. 5]).

Fig. 1 Computed tomography image showing a stromal tumor (about 2 × 1 cm) at the gastric fundus.

Fig. 2 Schematic showing the stages involved in the procedure: a a tumor is present in the gastric fundus; b circumferential incision is performed after sufficient submucosal injection; c a loop is placed encircling the tumor and anchored by clips fixed 1 cm away from the incision; d a snare is used to entrap the incised mucosa and pull it towards the cardia, with the loop slowly tightened as the snare is pulled; e a protrusion that includes the tumor and normal tissue is seen after tightening of the loop and release of the snare; f an electrosurgical knife is used to cut and expose the tumor margins, then a snare placed around the margins of the tumor is used to trap and completely resect it by thermal snare cutting; g the internal wound surface is sutured, forming the double suture in combination with the loop ligation.

Video 1 The loop-assisted inversion technique is performed to easily remove a gastric fundal tumor.

Fig. 3 Endoscopic image showing the inverted tumor.

Fig. 4 Photograph of the resected intact tumor.

Fig. 5 Endoscopic appearance at follow-up showing a flat wound closed by clips with the residual loop still in place after 1 month.

Endoscopic full-thickness resection (EFTR) is regularly used to treat gastric stromal tumors, is considered safe, and has a clinical outcome equivalent to surgery [1]. Gastric fundal tumors are associated with a high risk of perforation [2]. If perforation occurs, infection, intraperitoneal implantation metastasis, and postoperative bleeding of the serosal surface are potential concerns [3]. Several methods have been recommended for the management of unavoidable perforations [4]. We used a clip to fix the loop around the tumor and a snare to invert it. Double-suture techniques involving loops and clips are safe, easy, and quick.

Endoscopy_UCTN_Code_TTT_1AO_2AG

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Liu S, Zhou X, Yao YX. et al. Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients’ tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection. Surg Endosc 2020; 34: 4053-4064
• 2 Li L, Wang F, Wang B. et al. Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria. Exp Ther Med 2013; 6: 391-395
• 3 Chen Q, Yu M, Lei Y. et al. Efficacy and safety of endoscopic submucosal dissection for large gastric stromal tumors. Clin Res Hepatol Gastroenterol 2020; 44: 90-100
• 4 Lee JH, Kedia P, Stavropoulos SN. et al. AGA clinical practice update on endoscopic management of perforation in gastrointestinal tract: expert review. Clin Res Hepatol Gastroenterol 2021; 19: 2252-2261

Publication History

Article published online:
17 July 2023