Post written by Nao Takeuchi, MD, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.

Our video presents a case of two-stage endoscopic resection (TSER) for a large gastric tumor located at the fornix. The tumor, over 10 cm in size, had a villous structure, and a biopsy suggested pyloric gland adenoma.

Because of the tumor’s size, malignancy was highly suspected. As the large head portion of the tumor obscured the lesion’s base margin, we opted for TSER to safely remove the tumor in 2 stages while ensuring precise pathological evaluation.

First, we performed piecemeal polypectomy to reduce the tumor’s volume. Two weeks later, after the basal margin became visible, we performed en bloc resection of the base using endoscopic submucosal dissection (ESD).

Both procedures were completed without adverse events, and the final pathological diagnosis revealed R0 resection of an 82 x 35-mm intramucosal adenocarcinoma, surrounded by a 112 x 76-mm gastric adenoma. This successful TSER procedure demonstrates the use of this technique for treating large gastric tumors.

We felt it was important to share this case because TSER is a novel and effective strategy for managing large protruding gastric tumors that are difficult to resect en bloc through conventional ESD. Endoscopists can learn that TSER may offer an additional option for managing challenging gastric lesions, particularly those too large for conventional ESD.

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