Our video demonstrates endoscopic en bloc complete resection of a 4 cm gastric GI stromal tumor (GIST) with a substrantial 2 cm extraluminal component extending into the peritoneal cavity. In this elderly patient with comorbidities and an enlarging GIST, we were able to offer endoscopic full thickness resection (EFTR), a natural orifice transluminal endoscopic surgery (NOTES) approach to achieve complete surgical resection of the tumor. This approach spared the patient the standard surgical resection and attendant increased physiologic stress, larger organ resection, longer recovery, pain, and increased risk of potential adverse events such as surgical wound infection.
Over the past decade, pioneering Asian centers have used endoscopic submucosal dissection (ESD), a technique originally developed for en bloc resection of mucosal neoplasms, to perform deeper dissection extending into the muscularis propria in order to “excavate” subepithelial neoplasms arising from the muscularis propria in an effort to remove them en bloc. This technique, however, may leave small tumor residua in the muscularis propria. To address this issue, over the past 3 years, 3 pioneering Chinese centers reported in small series a novel technique, EFTR, which removes the tumor along with the associated muscularis and serosa leaving a sizable iatrogenic perforation that is then closed endoscopically. This is a complex endoscopic surgical procedure that requires expert ESD skills. At our center we have performed endoscopic en-bloc excavation of over 100 muscle based subepithelial tumors, ESD of over over 100 mucosal neoplasms, and 150 peroral endoscopic myotomy (POEM) procedures over the past 5 years. This experience has allowed us to develop the skills necessary to proceed with EFTR of subepithelial tumors over the past 2 years.
In general, EFTR is applied to tumors, mainly gastric GISTs, that have no or very small extraluminal extension. We selected to present a video from our series of 30 EFTR cases of a particularly challenging case with a GIST that had a large extraluminal component. The video also includes an excellent demonstration of the technique of “omental patch” closure which is ideal for closure of large defects for which simple clip closure may be inadequate.
EFTR offers a less invasive approach to complete en-bloc resection of subepithelial tumors. It can also offer easier resection of tumors that may be very challenging for the laparoscopic surgeon such as those that are mainly intraluminal and/or in difficult locations such as the GE junction, pylorus or esophagus. EFTR is still in development, but with the advent of endoscopic suturing and other coming innovations, it has the potential to follow in the footsteps of POEM and, along with submucosal tunnel endoscopic resection (STER) a complementary technique for endoscopic full thickness resection, become the next Natural Orifice muscularis-centered enndoscopic surgical procedure to enjoy wide adoption.
This video of a challenging EFTR of an extraluminal GIST from our center, the first center to perform POEM and EFTR in the West, demonstrates that with adequate training and experience in ESD, the parent technique for such endoscopic surgical procedures, these procedures need not be restricted to Asian centers. The rapid growth in ESD training venues in the United States portends well for further growth in this new field of muscularis-centered natural orifice surgery.
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