Optimal Endoscopic Resection Technique for Selected Gastric GISTs. The Endoscopic Suturing System Combined with ESD—a New Alternative?

Abstract

Background and Study Aim: In terms of therapeutic management, gastrointestinal stromal tumors (GISTs) seem to be the most difficult group of subepithelial gastrointestinal lesions (SELs). Despite various treatment option, choice of optimal management remains a dilemma in daily practice. Our aim was to evaluate a new hybrid resection technique of gastric GISTs type III as a modality of endoscopic full-thickness resection. Methods: Three males and one female (mean age of 68) were qualified for the procedure. Endoscopic full-thickness resections consisted of the endoscopic resection combined with suturing by Apollo OverStitch System. The main inclusion criterium was a complete diagnosis of GISTs (computed tomography (CT), endoscopic ultrasound (EUS), fine-needle biopsy (FNB)) with the evaluation of the tumor features, especially, the location in the gastric wall. All of the tumors were type III with a diameter between 20–40 mm. The lesions were located in the corpus (1), antrum (1) and between gastric body and fundus (2). All procedures were performed in 2019. Results: The technical and therapeutic success rate was 100% and the mean resection time 107.5 min. Neither intra- nor postprocedural complications were observed. In all four cases, R0 resection was achieved. Histopathologic assessment confirmed GIST with <5mitose/50HPF in all of the tumors, with very low risk. Conclusion: Based on our outcomes, endoscopic resection combined with the sewing by Apollo OverStitch of gastric GISTs type III, with the diameter between 20–40 mm, seems to be an effective therapeutic option with a good safety profile, however further studies with a larger treatment group are needed.

On the Track of New Endoscopic Alternatives for the Treatment of Selected Gastric GISTs—A Pilot Study

“…ESD is a resection method for early tumorous lesions limited to the superficial layers of the intestinal lining. Previously, we reported [ 11 ] that a precise pre-procedural evaluation of a tumour/MP connection using EUS was crucial for achieving complete resection. ESD enables an R0 resection of large sub-mucosal tumours, provided that they have a relatively narrow connection with the MP, such as type I tumours.…”

“…ESD enables an R0 resection of large sub-mucosal tumours, provided that they have a relatively narrow connection with the MP, such as type I tumours. In the case of lesions with a broader connection with the MP (type II and III), it is difficult to achieve a safe R0 resection [ 11 ]. A similar correlation was observed by An et al [ 12 ].…”

“…Type II and III GISTs have more profound intramuscular growth and wider connection with the MP, increasing the risk of incomplete resection and perforation during endoscopic resection ( Figure 1 ) [ 7 , 10 ]. Deep resection during ESD, which is necessary to provide adequate excision, is associated with a perforation rate of up to 12% [ 11 , 12 , 13 , 14 ]. Thus, tumours infiltrating the deeper layers of the stomach wall may limit the clinical usefulness of some techniques [ 15 ].…”

Endoscopic Operating Platforms and Advancements

“…17 Recently, the Overstitch system has also shown benefit in endoscopic resection of type III gastrointestinal stromal tumors, treatment of gastroesophageal reflux disease, and further facilitation of ESD procedures. [18][19][20] A newer version of the system-the OverStitch Sx-launched in late 2018 is compatible with single-channel endoscopes, eliminating a key limitation of the original system (►Fig. 3).…”

Application of a traction metal clip with a fishhook-like device in wound sutures after endoscopic resection

“… 1 With the development of endoscopic technology, endoscopic submucosal dissection (ESD) cannot only completely remove the mucosal lesions but also completely remove a portion of the submucosal tumors, achieving results equivalent to surgery, with minimal trauma, fast recovery, and low costs. 2 , 3 Effective suturing of a wound after endoscopic resection can reduce the risks of postoperative wound bleeding and perforation, promote wound healing, reduce inflammation, and prevent abdominal infection. 4 , 5 The effect of endoscopic wound suturing is an important factor that affects the ability to remove large and full-thickness lesions during ESD.…”