Post written by Shashideep Singhal, MD, from the Division of Gastroenterology, Hepatology & Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, USA.

An 81-year-old man was complaining of GERD. An EGD showed an incidental gastric body nodule. An EUS revealed a 1.5-cm by 1.4-cm submucosal tumor extending into the muscularis propria. Cytology from FNA showed spindle cells, suggestive of a GIST.  Using an IT nano knife, we made a 360-degree circumferential incision extending into the submucosa. Hemostasis was achieved by using coagulation forceps for small vessels, and hemostatic clip for larger vessels. The incision was then extended deeper into the muscularis layers along the line of the initial incision. With the IT nano knife, we completed the 300-degree full thickness incision. We intentionally avoided the last 60 degrees of the serosal layer to prevent migration of the resected specimen into the peritoneum. A 4-cm full-thickness defect was seen visualizing the mesenteric fat endoscopically. The remaining pedicle was resected using a hot snare and retrieved using a roth net. The defect was closed with interrupted sutures using an overstitch device. A helix device was used to facilitate suturing.

Pathology confirmed full-thickness resection. CT abdomen with enteric contrast confirmed adequate closure of the resection site. Patient was discharged after a 23-hour observation. A 2 month follow-up, endoscopy showed hyperplastic tissue at the suture site without any residual nodule.

Incidental submucosal tumors can be found in about 1 in 300 upper endoscopies. Currently, EUS can aid in establishing diagnosis of highly malignant features of a nodule, but it cannot provide appropriate malignant potential due to an absence of histological mitotic count. FNA is useful for making a definitive diagnosis, but many times it can be inconclusive, which submits the patient to continued endoscopic surveillance. Endoscopic full-thickness resection provides definitive diagnosis with malignant risk stratification eliminating the need for continued endoscopic surveillance.

This technique of endoscopic full-thickness resection (EFTR) using an overstitch device for closure is minimally invasive, technically feasible, safe, and provides definitive diagnosis with malignant risk stratification. Appropriate accessories for endoscopic hemostasis should be available during resection. Special caution should be taken to prevent migration of resected specimen into peritoneum. Closure of defect should be confirmed with imaging using enteric contrast.

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