Endoscopic full-thickness resection using double endoscope–assisted snare traction for a large exophytic gastric subepithelial lesion

Video

Video 1

Endoscopic full-thickness resection using double endoscope–assisted snare traction facilitates precise resection of a large exophytic gastric subepithelial lesion.

Background

Endoscopic resection of gastric subepithelial lesions (SELs) arising from the muscularis propria has become increasingly performed for intraluminal types with the development of endoscopic techniques.¹ However, the endoscopic removal of exophytic-type SELs remains technically challenging.² Herein, we introduce a successful endoscopic full-thickness resection (EFTR) using a double endoscope–assisted snare traction technique that uses an adjustable snare through an additional endoscope to enable precise exploration of the outer edge of a large exophytic tumor.³ This approach allows us to maintain an intraluminal resection process, which reduces the risks of extraluminal bleeding and minimizes the area of muscular defect.

Case Presentation

A 66-year-old woman was referred to our hospital for a large gastric SEL. A CT scan revealed a 30-mm exophytic tumor on the greater curvature of the middle body (Fig. 1). EUS confirmed its muscularis propria origin. The therapeutic approach for EFTR was established through a comprehensive multidisciplinary discussion and incorporating shared decision making with the patient. Additionally, approval from the surgical team was obtained in anticipation of addressing any serious adverse events that might arise during the procedure.

Figure 1.

One 30-mm exophytic-type subepithelial lesion at greater curvature of gastric body.

Procedure

A broad-spectrum antibiotic with anaerobe coverage was administered prophylactically for exposed EFTR. The procedure began with the use of the HybridKnife (T type; Erbe GmbH, Tübingen, Germany) to create a circumferential mucosal incision, followed by submucosal dissection. After exposing the tumor from the oral side, we inserted a 25-mm snare (Snare Master SD-210U-25; Olympus, Tokyo, Japan) through a separate endoscope (GIF-Q260; Olympus) to provide efficient traction (Fig. 2; Video 1, available online at www.videogie.org). After the snare firmly encircled the tumor, we withdrew the traction endoscope gradually while advancing the snare, to keep it in place (Fig. 3A) until the tip of the traction scope was outside the patient’s mouth. Subsequently, we reinserted the original therapeutic endoscope (GIF-Q260J; Olympus) to proceed with the EFTR. Double endoscope–assisted snare traction allowed real-time adjustment for more precise exploration of the dissecting plane (Fig. 3B). We used the IT-nano knife (KD-612; Olympus) to further mobilize the tumor until its outer edge and peritoneal layer were reached. By adjusting the traction direction and applying controlled force, we were able to pull the tumor into the gastric lumen and keep the dissection process intraluminally, minimizing the risk of damaging the serosal vessels (Fig. 3C and D). In the later stages of the procedure, we used an 18-gauge catheter for decompression. This decompression was necessary because of the development of pneumoperitoneum, which resulted in increasing intra-abdominal pressure and a decrease in tidal volume.

Figure 2.

Schematic representation of double endoscope with snare traction method facilitating endoscopic full-thickness resection for exophytic gastric subepithelial lesion.

Figure 3.

Use of snare-assisted endoscopic full-thickness resection for a large exophytic subepithelial lesion. A and B, Snare traction enables precise exploration of the dissecting plane. C and D, By pushing the snare, the exophytic tumor could be pulled into the gastric lumen to keep the dissection process intraluminal without damaging the serosal vessels.

Following successful en bloc resection, we used the purse-string method with clips and endoloop for gastric wall defect closure (Fig. 4). The patient abstained from oral intake for 1 day, and an upper-GI series revealed no signs of contrast extravasation the next day (Fig. 5). The patient smoothly resumed a semiliquid diet and was discharged uneventfully on the fifth day postoperatively. Final histopathology confirmed a diagnosis of schwannoma with intact capsule (Fig. 6).

Figure 4.

Purse-string method with clips and endoloop for gastric wall defect closure.

Figure 5.

Post–endoscopic full-thickness resection upper-GI series revealed no contrast extravasation.

Figure 6.

Histopathology confirmed the diagnosis of schwannoma with intact capsule.

Conclusions

Our case illustrates that the double endoscope–assisted snare traction method offers a promising approach to broaden the application of EFTR for exophytic-type gastric SELs. This method provides a level of safety and efficiency in resection that is comparable to that of intraluminal SELs.

Disclosure

The authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Endoscopic full-thickness resection using double endoscope–assisted snare traction facilitates precise resection of a large exophytic gastric subepithelial lesion.