Post written by Yuto Shimamura, MD, from Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.

Our video demonstrates a case of successful endoscopic resection of an exophytic subepithelial lesion in the stomach by applying a double scope traction technique.

The creation of a mucosal opening followed by dissection of the lesion was performed using a Triangle Tip J knife (KD-645L; Olympus Corp, Tokyo, Japan). After partial resection of the lesion, an assistant endoscopist carefully inserted a second gastroscope alongside the therapeutic scope with sufficient lubrication to avoid esophageal trauma.

A snare was then advanced through the second gastroscope to grasp the lesion. The assistant endoscopist carried out controlling ideal traction and maneuvering the second gastroscope, while the main endoscopist continued safe and effective dissection until full-thickness resection of the lesion was achieved.

In addition, we opted to close the defect using our novel endoscopic purse-string “Loop 9” technique. “Loop 9” is a premade loop with surgical sutures delivered through a channel and released at the defect site. After it has been anchored by 2 clips positioned on opposite sides of the defect edge, “Loop 9” is tightened by pulling the end of the suture intraluminally using biopsy forceps. Additional clips were placed to achieve complete closure.

Endoscopic resection of gastric subepithelial lesions is now technically feasible with advancements in endoscopic techniques, such as peroral endoscopic tumor resection, endoscopic subserosal dissection, and endoscopic full-thickness resection. However, endoscopic resection of exophytic lesions is challenging. Using our double scope traction technique, endoscopic resection of these lesions has become technically feasible.

The main advantages of using the double scope traction technique are (1) snare traction gives good grasp and traction in round tumors, especially in cases of extraluminal growth and (2) by the use of the second scope, the maneuvering and positioning of the snare can be facilitated in an optimal position under direct visualization. This technique may expand the endoscopic approach to these challenging lesions.

It is essential to apply the traction technique when performing full-thickness resection. This method can be used in resecting challenging lesions, even in exophytic subepithelial lesions endoscopically.

In addition, our closure technique (“Loop 9”) can be applied not only in closing the postresected site, but also in other situations when the closure of the defect is required.

The tumor was pulled into the gastric lumen and effective traction was controlled by the assistant operator.

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