Snare traction-assisted ultra-long tunnel endoscopic resection of a giant exophytic cardia subepithelial tumor with diaphragmatic adherence

The incidental finding on the contrast-enhanced computed tomography scan ( Fig. 1 a ) of a 31-year-old man was as follows: an irregular soft-tissue mass located between the gastric fundus-cardia and the hepatogastric space. Gastroscopy ( Fig. 1 b ) revealed a submucosal bulge on the posterior wall of the cardia. Endoscopic ultrasound ( Fig. 1 c ) demonstrated a hypoechoic lesion arising from the muscularis propria, with clear margins and abundant peripheral blood flow ( Video 1 ). A therapeutic gastroscope fitted with a transparent cap was used to create a submucosal tunnel in the esophageal wall 3 cm proximal to the lesion on the posterior cardia wall, exposing a milky white tumor ( Fig. 2 a ). Dissection with an ITknife2 revealed an exophytic, complex, multifocal mass extending into the peritoneal cavity; standard tunnel vision was limited. An endoscopically introduced snare was tightened around part of the tumor with hemostatic forceps, and continuous traction toward the esophageal lumen ( Fig. 2 b ) provided panoramic exposure of the peritumoral plane. Meticulous dissection freed the tumor from surrounding connective tissue and severed its continuity with the gastric muscularis propria, while simultaneous right upper-quadrant needle decompression prevented pneumoperitoneum. Adhesions to the diaphragm were carefully released under traction. The intact specimen (≈ 8 × 2 cm, irregular) was extracted through the tunnel orifice ( Fig. 2 c ). Postoperative wound hemostasias was achieved ( Fig. 2 d ), and the tunnel entry was closed with seven metal clips. Histopathology confirmed leiomyoma. Postoperative recovery was uneventful, with no hemorrhage or perforation.

Fig. 1.

a The contrast-enhanced computed tomography shows an irregular soft-tissue mass located between the gastric fundus-cardia and the hepatogastric space. b Gastroscopy shows a submucosal bulge on the posterior wall of the cardia. c Endoscopic ultrasound shows a hypoechoic lesion arising from the muscularis propria.

Fig. 2.

Endoscopic images. a A submucosal tumor with a milky white appearance. b Snare was tightened around part of the tumor. c The resected specimen, which was 8 × 2 cm in size. d Postoperative wound.

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Snare traction-assisted ultra-long tunnel endoscopy resection of a giant exophytic cardia subepithelial tumor with diaphragmatic adherence.

Video 1

Classic submucosal tunneling endoscopy resection (STER) is limited to intraluminal lesions ≤3.5 cm in transverse diameter; tumor irregularity, deep origin, or operative duration >60 min are independent risk factors for complications ^{1 2 3 4} . Exophytic lesions >4 cm or with complex morphology have previously required combined laparoscopic-endoscopic approaches ⁵ . In this case, snare traction assistance provided complete exposure, enabling precise hemostasias and en bloc resection, shortened operative time, and reduced complications, thus offering a purely endoscopic solution for complex exophytic cardia lesions and extending the indications for STER.

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