Gastric submucosal tumor with extraluminal growth: successful resection with transgastric natural orifice transluminal endoscopic surgery

A 56-year-old woman was admitted to our hospital for endoscopic resection of a 2.8-cm gastric fundus submucosal lesion ( Fig. 1 ) incidentally found during a screening endoscopy. An extraluminal component was seen on an abdominal enhanced computed tomography (CT) scan ( Fig. 1 ). The lesion was hypoechoic and originated from the muscle layer on endoscopic ultrasonography ( Fig. 2 ).

Fig. 1.

 Endoscopic view and computed tomography images of a gastric stromal tumor in the fundus of stomach.

Fig. 2.

 Endoscopic ultrasonography view images of a gastric stromal tumor in the fundus of stomach.

After multidisciplinary team discussion, we decided to remove the lesion using endoscopic resection ( Video 1 ). The procedure was performed with the patient under endotracheal intubation and general anesthesia in a left lateral decubitus position and with antibiotic prophylaxis.

Video 1  Gastric submucosal tumor with extraluminal growth: successful resection with transgastric natural orifice transluminal endoscopic surgery (NOTES).

Download video file ^{(62.4MB, mp4)}

An incision was made along the incisura lesion of the gastric fundus and the entire layer of the gastric wall was incised using a hook knife and IT knife ( Fig. 3 ). The endoscope was passed into the abdominal cavity, and the extraluminal growth of the tumor body from the gastric wall could be seen ( Fig. 4 ). The snare was applied directly to the tumor body to bring the lesion into the luminal side and to finish the resection ( Fig. 5 ). The wound was treated with hot coagulation forceps, and the incision in the gastric wall was then sutured with titanium endoclips.

Fig. 3.

 Endoscopic view of the resection process. a Incision of the gastric wall by hook knife. b Endoscopic view after incision of the entire layer of the gastric wall.

Fig. 4.

 Endoscopic view showing an abdominal cavity after full-thickness incision.

Fig. 5.

 Endoscopic view of the final cut and the successfully resected specimen.

Subsequently, the patient remained asymptomatic and was discharged after 3 days without complications. The final pathological examination revealed a 2.8-cm low-risk gastrointestinal stromal tumor [CD 34 (+), CD 117 (+), Dog-1 (+), SDHB (+), desmin (rare +), Ki-67 (< 5 % +), SOX10 (−), STST6 (−), Bcl-2 (+), and S-100(−)].

Endoscopic resection maneuvers for gastric submucosal tumors have advanced substantially in recent decades ^{1 2 3} . However, patients with a large (> 30 mm) submucosal tumor, an extraluminal component, and ulceration are recommended for laparoscopic resection (with/without endoscopic assistance) ⁴ . This case demonstrates the usefulness and feasibility of endoscopic resection as a treatment method for gastric submucosal tumors with extraluminal growth.

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