Post written by Fatih Aslan, MD, from Gastroenterology and Advanced Endoscopy, Koc University Hospital, Istanbul, Turkey.

In this video case, we present a step-by-step demonstration of endoscopic full-thickness resection (EFTR) for a GI stromal tumor located on the greater curvature of the distal body.

The tumor, originating from the muscularis propria and measuring 20 mm, was completely and curatively resected using a multitechnique strategy that combines snare-clip traction, handmade balloon-valve air management, and endoscopic suturing with barbed sutures (V-Loc 180, 3-0, CV-20, Medtronic Ltd, Dublin, Ireland) via a needle holder (Sutuart, FG 260U, Olympus, Tokyo, Japan). Each phase of the procedure was carefully optimized to ensure orientation, minimize adverse events, and enable secure closure—even in the presence of full-thickness defects and intra-abdominal air leakage.

Why this case matters

Although it offers curative potential for subepithelial lesions, EFTR is inherently challenging because of risks of air leakage, orientation loss, and closure difficulty. These issues can compromise procedural safety and prolong duration. In this case, we tackled each of these challenges through 3 main innovations:

• Traction-assisted resection: A snare passed externally and fixed to the lesion via a hemostatic clip (SureClip; Micro-Tech, Nanjing, China) enabled dynamic and directional traction. This significantly improved visualization, orientation, and efficiency during muscular dissection.
• Balloon-assisted air control: Air leakage through the full-thickness defect is a common but under-addressed adverse event in EFTR. Our handmade balloon catheter—constructed using a spray catheter (Olympus) and a surgical glove—was inserted intraperitoneally to tamponade the defect. This controlled leakage, maintained gastric distension, and optimized the endoscopic field throughout closure.
• Secure closure with barbed sutures: Using a double-channel endoscope (Olympus GIF-2TH180), we applied barbed sutures (commonly used in surgical practice) in a running manner, first to the muscularis and then the mucosa. This ensured tension-free closure with high security and minimized the need for additional clips or devices.

Lessons for endoscopists

This case offers several take-home messages for advanced endoscopists:

• Effective traction reduces procedural complexity. Whether with endoscopic submucosal dissection or EFTR, achieving consistent and adjustable traction can convert a complex dissection into a more controlled, linear process.
• Intra-abdominal air control matters. Unchecked CO₂ leakage can disorient the endoscopist and impact the patient’s physiology. Simple, cost-effective tools such as a handmade balloon catheter can provide major clinical benefits.
• Endoscopic suturing is evolving. The integration of barbed sutures and laparoscopic closure logic into endoscopic practice bridges the gap between endoscopy and surgery, enabling safer closure after full-thickness interventions.

EFTR is still considered a technically demanding procedure, but innovations in traction, air management, and closure are gradually expanding its feasibility and safety profile. The technique shown in this case not only mimics principles from laparoscopic surgery but also adapts them to the endoscopic realm in a minimally invasive and resource-conscious way.

We believe this multitechnique strategy has the potential to become part of the standard EFTR toolbox—especially in centers that prioritize innovation and precision. As the boundaries of therapeutic endoscopy continue to evolve, cases such as this demonstrate how creative procedural integration can lead to meaningful clinical advancement.

The endoscopic appearance of a subepithelial lesion.

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