Post written by Chukwunonso Benedict Ezeani, MD, from Baton Rouge General Medical Center, Baton Rouge, Louisiana, USA.

This is a case of a patient with compensated alcohol-related cirrhosis (MELD-Na 7 points, Child Turcotte Pugh class A) who underwent an upper EGD for variceal screening. She was incidentally found to have a 1-cm well-circumscribed upper esophageal submucosal lesion. EUS noted a mass measuring 1 x 1 cm that was oval with hypoechoic and homogenous echotexture and well-demarcated borders arising from the muscularis propria layer. Pathology from biopsies was consistent with a GI stromal tumor (GIST).

Our video demonstrates stepwise submucosal tunneling endoscopic resection (STER) starting with tunnel creation and stepwise resection leading to en bloc resection with an intact capsule and closure with hemoclips (Resolution 360 ULTRA clip; Boston Scientific, Natick, Mass, USA).

Our case highlights the use of STER in the management of esophageal GISTs with excellent clinical outcomes:

• STER can achieve acceptable complete en bloc resection of GISTs with low risk of perforation. We observed good wound healing, no GI tract leakage, reduced hospital stays, and more precise hemostasis.
• Because GISTs are more fragile than other submucosal tumors, resection with an intact capsule is essential, and appropriate patient selection is important.

Peroral endoscopic tunnel resection and STER are safe and effective if en bloc resection with an intact capsule is achieved. However, because GISTs are more fragile than other submucosal tumors, and resection with an intact capsule is technically more challenging, additional surgery and monitoring should be considered if piecemeal excision occurs, or pathology reveals a GIST with high-risk features.

STER is a treatment option for minimally invasive resection of submucosal tumors including GISTs. It is important to aim for full-thickness resection with an intact capsule. Pathology confirmation of clear margins also is crucial.

Further prospective studies are needed to establish the role of STER with larger submucosal tumors.

Luminal view of smooth-surfaced oval mass seen on submucosal dissection.

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