A 65-year-old woman received a diagnosis of a gastric subepithelial tumor on the lesser curvature of the lower body (Fig. 1A). EUS (UM-2R, 12 MHz; Olympus, Tokyo, Japan) showed a hypoechoic lesion growing exophytically into the perigastric area (Fig. 1B). We attempted endoscopic resection because of the high operative risks of a cerebral infarction and fibrillation.
Figure 1.
A, Gastric subepithelial tumor protruding partially into the stomach lumen on the lesser curvature side of the gastric lower body. B, EUS showing a homogeneous hypoechoic lesion with an exophytic growth pattern located in the fourth layer of the stomach. C, Dissected subserosal surface adjacent to the tumor. D, Gross appearance of the removed tumor surrounded by a whitish capsule. E, The defective area sutured with 8 long clips. F, Typical spindle cells with eosinophilic fibrillary cytoplasm (H&E, orig. mag. ×100). G, Diffuse and strong cytoplasmic immunoreactivity of KIT and CD34 (KIT and CD34 immunostain, orig. mag. ×100). H, Healed lesion without recurrence on follow-up endoscopy at 24 months. I, Schematic illustration of endoscopic subserosal dissection.
After we injected a mixed solution of indigo carmine and epinephrine by using an endoscope (GIF-Q260, Olympus) with the patient under conscious sedation, we precut the mucosa with a needle knife (KD-1L-1, Olympus), dissected the submucosa and muscularis propria by endoscopic muscularis dissection (EMD), and dissected the subserosal space around the tumor with a hook (KD-620LR, Olympus) and IT II knives (KD-611L, Olympus). Full excision of the tumor was completed (Figs. 1C, D, and I) (ICC 200, endocut 60W, forced coagulation 80W), and it was sutured with clips (HX-610-090L, Olympus) after making holes on both sides of the defect (Fig. 1E). No adverse events occurred (Video 1, available online at www.VideoGIE.org). Histologic examination showed the tumor to be a GI stromal tumor (GIST) of low malignant potential (Figs. 1F and G). There was no tumor recurrence in 24 months (Fig. 1H).
Several modalities for subepithelial tumor resection include EMD, submucosal tunneling endoscopic resection (STER), and endoscopic full-thickness resection (EFTR). STER decreases the risk of perforation because of the mucosal flap, but it has the disadvantages of limited size (<5 cm) of the tumor and the existence of the tabooed area as the lesser curvature and fundus as the preferred procedure on a direct view. EFTR has the risks of pneumoperitoneum and the shedding of tumor cells. Our technique is a modified new method beyond EMD through the working space of the subserosa, especially for tumors on the lesser curvature and in the middle part of the gastric wall with an exophytic growth pattern. The key to this procedure is the successful closure of a relatively large wall defect compared with STER. Further study of these suture techniques is required.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Footnotes
Written transcript of the video audio is available online at www.VideoGIE.org.
Supplementary data
We injected a mixed solution of indigo carmine and epinephrine using an endoscope. We precut the mucosa with a needle-knife and dissected the submucosa and muscularis propria by the endoscopic muscularis dissection technique, and the subserosal space around the tumor with a hook and IT II knives step by step. We sutured with endoclips after making holes on both sides of the defect.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
We injected a mixed solution of indigo carmine and epinephrine using an endoscope. We precut the mucosa with a needle-knife and dissected the submucosa and muscularis propria by the endoscopic muscularis dissection technique, and the subserosal space around the tumor with a hook and IT II knives step by step. We sutured with endoclips after making holes on both sides of the defect.