Post written by Yasi Xiao, MD, and Dennis Yang, MD, from the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.

We present a video of a 61-year-old woman with a symptomatic large subepithelial lesion (SEL) in the gastric fundus. This SEL was biopsied on EUS and found to be a leiomyoma.

After multidisciplinary discussion with thoracic surgery, the decision was made to proceed with endoscopic resection. In this video, we demonstrate a new technique of submucosal tunneling endoscopic resection (STER) in which 2 mucosal incisions, proximal and distal to the SEL, are created to facilitate both dissection and extraction. The resected specimen, measuring 60 x 30 mm, was successfully removed en bloc.

STER can be challenging in the fundus. In this case, after initial conventional STER technique, we created a second mucosal incision immediately distal to the lesion. Through this mucosal incision, we were able to complete the dissection in retroflexion in the fundus. The mucosal incision in the fundus also facilitated direct extraction of the large leiomyoma.

Importantly, conservation of a mucosal flap with mucosal incisions, as opposed to a full-thickness resection approach, permitted easy closure in an otherwise difficult position.

In complicated cases of large SELs in the fundus, creating a second mucosal incision distally on the gastric side can facilitate completion of dissection, extraction, and closure during the STER process. This is a viable alternative to an exposed endoscopic full-thickness resection.

A, Transverse mucosal incision in the esophagus proximal to the subepithelial lesion (SEL) for establishing a submucosal tunnel. B, A mucosal incision is made immediately distal to the SEL to allow access in the retroflexed position. C, Dissection in retrograde fashion through the second mucosal incision facilitated scope stabilization and completion of the resection. D, Mucosal incisions were adequately closed with through-the-scope clips. E, Final resected specimen, measuring 60 × 30 mm.

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