Johns Hopkins Medical Institutes Baltimore, MD, United States
Linda Y. Zhang, MBBS, Mouen A. Khashab, MD Johns Hopkins Medical Institutes, Baltimore, MD
Introduction: Gastrointestinal stromal tumors (GISTs) >2cm are considered for resection. GISTs with significant muscularis propria (MP) involvement require endoscopic full thickness resection (EFTR), surgery or a combined laparoscopic/endoscopic approach. We present a GIST treated by EFTR and through the scope suture (TTSS) defect closure.
Case Description/Methods: A 49-year-old male was referred for a 2cm gastric fundus subepithelial lesion. At EUS, a well-defined hypoechoic lesion with a hyperechoic center was seen, arising from the MP. Fine needle aspiration confirmed a GIST and the patient elected for endoscopic resection.
A therapeutic gastroscope with a clear distal attachment was used for the procedure. The borders of the lesion were first marked with an ESD knife. Submucosal injection was performed using a hetastarch/methylene blue/dilute adrenaline mixture. A snare was then used to resect the overlying mucosa in order to expose the lesion and relevant mucosal planes. Submucosal dissection was performed circumferentially around the tumor until the muscle attachment was visualized. There was significant muscle attachment. Hence, en bloc tumor resection necessitated an intentional and controlled perforation. Once a narrow muscular attachment remained, the single channel gastroscope was exchanged to a double channel therapeutic gastroscope. Grasping forceps were used to pull the lesion entirely into the gastric cavity. A snare was opened around the lesion which was then resected at the base. Macroscopic appearance suggested en bloc removal and the tumor capsule appeared intact. Attention was then turned to defect closure. As the procedure had been almost entirely completed in the retroflexed position, decision was made to use the X-Tack TTSS system. Two systems were used with excellent defect closure. The patient was admitted overnight and discharged on day one with no periprocedural adverse events.
Discussion: EFTR can be safe and effective in expert hands for resection of GISTs with significant MP involvement. Removing the overlying mucosa exposes the tumor and improves visualization of the mucosal planes. This is of particular importance when resecting subepithelial lesions such as GISTs. When removing GISTs with significant MP involvement, a controlled perforation is required. Secure closure is key, with choice of device depending on the defect and endoscopist experience. In our case, use of TTSS allowed effective closure of the full-thickness defect despite a retroflexed position.
Disclosures: Linda Zhang indicated no relevant financial relationships. Mouen Khashab: Apollo Endosurgery – Consultant. Boston Scientific – Consultant. GI Supply – Consultant. Medtronic – Consultant. Olympus – Consultant.
Linda Y. Zhang, MBBS, Mouen A. Khashab, MD. P0679 - Endoscopic Full Thickness Resection with Through the Scope Suture Closure for Gastrointestinal Stromal Tumor, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.