Enhanced resection of exophytic gastric gastrointestinal stromal tumor using traction-assisted subserosal dissection and endoscopic suturing

A 49-year-old man was incidentally found to have a gastric subepithelial lesion located at the lesser curvature of the upper body during routine endoscopic screening ( Fig. 1 ). Although the lesion appeared small on conventional endoscopy, endoscopic ultrasound (EUS) revealed an exophytic, hypoechoic mass with heterogeneous echotexture and internal hyperechoic foci, originating from the muscularis propria layer. During a 6-month surveillance period, the lesion increased from 1.2 to 1.5 cm. Contrast-enhanced harmonic EUS (CEH-EUS) with intravenous Sonazoid revealed early and heterogeneous enhancement ( Fig. 2 ). Due to high-risk EUS features and patient preference, endoscopic subserosal dissection (ESSD) was undertaken ( Video 1 ).

Fig. 1.

An endoscopically visualized small but exophytic tumor was identified at the lesser curvature of the upper gastric body.

Fig. 2.

EUS showed internal hyperechoic foci; CEH-EUS revealed early and heterogeneous enhancement. EUS, endoscopic ultrasound; CEH-EUS, Contrast-enhanced harmonic EUS.

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Traction-assisted endoscopic subserosal dissection and endoscopic suturing of an exophytic gastric GIST.

Video 1

The procedure was performed using a GIF-H290Z gastroscope (Olympus, Japan) with the EVIS X1 system (Olympus, Japan) and an electrosurgical knife (DualKnife J; Olympus, Japan). Following submucosal injection of a glycerol solution mixed with indigo carmine, a partial mucosal incision was made on the anal side using EndoCut I settings (effect 2, duration 3, interval 2; VIO300D, ERBE, Germany). To facilitate subserosal exposure, the clip-and-snare traction technique was employed, enabling effective visualization of exophytic tumor capsule for further dissection ( Fig. 3 ). ESSD was completed without perforation and the lesion was resected en bloc. Closure of the mucosal defect was achieved with an endoscopic suturing system (OverStitch NXT; Boston Scientific, USA; Fig. 4 ). The patient tolerated the procedure well and resumed oral intake on postoperative day 1 with discharged uneventfully.

Fig. 3.

Clip-and-snare traction exposing the dissection plane, facilitating en bloc resection.

Fig. 4.

Endoscopic closure of the mucosal defect using the OverStitch NXT suturing system.

This case demonstrates the feasibility of ESSD for exophytic gastric GISTs using traction and endoscopic suturing. The clip-and-snare technique provided excellent exposure of the subserosal plane and tumor capsule ¹ , while OverStitch NXT ensured secure full-thickness closure of the mucosal defect ² . CEH-EUS aided in the differential diagnosis and supported the decision for endoscopic resection ³ . With careful patient selection, ESSD may offer a minimally invasive, organ-preserving alternative to surgery for exophytic gastric GISTs ⁴ .

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