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

This video demonstrates en bloc endoscopic submucosal dissection (ESD) of a giant gastric polyp extending from the cardia to the antrum in a 36-year-old woman presenting with alarm symptoms including nausea, vomiting, weight loss, and iron deficiency anemia requiring monthly parenteral iron therapy.

Despite the patient undergoing prior endoscopies with biopsies reported as a hyperplastic polyp and indefinite for dysplasia, a definitive diagnosis could not be established, and her symptoms persisted. The procedure used a tunneling technique for safe and efficient dissection, followed by complete closure of the large mucosal defect with the OverStitch suturing system (Apollo Endosurgery, Austin, Tex, USA). After resection, the lesion was removed from the stomach and pinned on a styrofoam board, where its long axis measured 41 cm.

This case presents a minimally invasive, organ-preserving alternative to total gastrectomy for symptomatic giant gastric polyps. It illustrates that even extensive lesions can be safely removed en bloc with the tunneling technique while post-ESD suturing significantly reduces delayed adverse events. Moreover, suturing plays a crucial role in reducing the risk of stricture formation by limiting myofibroblast activation, which is particularly critical in large mucosal defects.

Importantly, ESD is not only therapeutic but also a diagnostic and staging method enabling accurate histological evaluation and preventing unnecessary organ loss—especially in a young patient with persistent alarm symptoms and inconclusive biopsy results despite endoscopic evaluations.

Endoscopists can learn the following from this case:

• Tunneling technique advantages:
  • Improves orientation during dissection.
• • Minimizes bleeding by enabling easier coagulation of vascular structures.
• • Provides better visualization and a clean submucosal working space.
  • Facilitates safe and efficient en bloc resection, even for large lesions.
• Resection strategy:
  • Selecting an appropriate en bloc resection strategy is crucial to ensure the procedure is performed safely, efficiently, and rapidly.
  • Gravity assistance can be used to optimize visualization and facilitate dissection.
• Endoscopic suturing:
  • Prevents adverse events such as delayed bleeding or perforation.
  • Promotes faster recovery after extensive mucosal resections.

This case shows that ESD should be considered not only for diagnostic but also therapeutic purposes, particularly in patients refusing surgery. Combining ESD with advanced closure techniques may expand therapeutic indications for endoscopic treatment of large benign and premalignant gastric lesions. In addition, endoscopic suturing can significantly enhance the endoscopist’s confidence during complex procedures, fostering the broader and more strategic adoption of minimally invasive techniques.

With the integration of endoscopic suturing into routine clinical practice, we believe that advanced endoscopic interventions will enter a new era—driving development of innovative techniques and opening new minimally invasive therapeutic opportunities for many complex GI diseases previously considered difficult or impossible to treat or those managed exclusively with surgery.

Macroscopic view of the excised specimen.

Read the full article online.

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