Endoscopic subserosal dissection of a giant gastric gastrointestinal stromal tumor with risk factors

Gastric gastrointestinal stromal tumors (GISTs) are mesenchymal tumors with variable malignancy potential. Standard management typically involves surgical resection, and owing to the low likelihood of regional lymph node metastasis, there is no need to perform dissection of clinically negative lymph nodes ¹ . Advancements in endoscopic techniques and devices for closure of gastric perforation have enabled endoscopic resection to become a viable treatment option for gastric GISTs ² , offering benefits such as faster recovery, shorter hospital stays, and reduced costs compared with laparoscopic resection ³ . Furthermore, endoscopic resection offers other advantages over surgical resection, including preservation of gastric functionality and reduced postoperative pain ⁴ .

An 87-year-old patient was referred to our unit with a predominantly intraluminal gastric GIST that had grown from 19 mm to more than 30 mm over 2 years ( Fig. 1 ), and which displayed necrotic foci on endoscopic ultrasound. The case was reviewed by a multidisciplinary committee, which decided to proceed with endoscopic resection, including intragastric fragmentation if necessary.

Fig. 1.

Intraluminal gastric gastrointestinal stromal tumor of almost 5 cm.

Endoscopic dissection of the GIST was conducted using a Splash M Knife (Pentax Medical, Tokyo, Japan) ( Video 1 ). Owing to the involvement of the muscularis propria ( Fig. 2 a ), a subserosal dissection was also performed ( Fig. 2 b ). Subsequent endoscopic suturing was completed using an Overstitch device (Apollo Endosurgery, Austin, Texas, USA) to close the full-thickness defect ( Fig. 2 c ). Given the resected specimen’s substantial size (5 cm), fragmentation of the sample was necessary to facilitate oral extraction and was carried out after the closure of the full-thickness defect ( Fig. 3 ).

Fig. 2.

Endoscopy images. a Gastric gastrointestinal stromal tumor arising from the muscularis propria layer of the stomach wall. b Subserosal dissection preserving the serosal layer. c Preserved serosal layer.

Fig. 3.

Fragments of the endoscopically resected gastric gastrointestinal stromal tumor.

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Endoscopic submucosal and subserosal dissection of a giant gastric gastrointestinal stromal tumor with risk factors.

Video 1

The pathology report characterized the GIST as low risk, with fewer than 5 mitoses per 50 high-power fields and no necrotic foci. Follow-up gastroscopy and computed tomography scans at 12–18 months were normal.

In conclusion, endoscopic treatment of gastric GISTs larger than 3 cm is a viable alternative to surgery in selected cases. Fragmentation of the sample may be necessary for complete resection and extraction of larger lesions. Further studies are needed to establish standardized guidelines for the endoscopic management of large gastric GISTs.

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