Endoscopic full-thickness resection with omental patch closure for a gastric stromal tumor in the gastric cardia

Gastrointestinal stromal tumors (GISTs) of ≥ 2 cm should be resected because of their malignant potential [1]. Recently, endoscopic techniques for en bloc resection of GISTs have been described, including endoscopic submucosal dissection (ESD) and full-thickness resection (EFTR). Closure of the resection site, usually accomplished with clips or endoscopic suturing, is paramount to avoid peritonitis [2] [3]. Prior feasibility studies have shown that omental patch closure appears to be effective for closure of gastric perforations [4] [5]. Data on the use of this technique for the closure of defects after EFTR in the gastric cardia are not yet available.

We describe the case of an 82-year-old man with a gastric cardia mass found on a computed tomography (CT) scan of the abdomen ([Fig. 1]). Upper gastrointestinal endoscopy and endosonography showed a subepithelial mass arising from the muscularis propria ([Fig. 2]). Fine needle biopsy confirmed the diagnosis of a GIST.

Fig. 1 Coronal view of a computed tomography scan of the abdomen showing a mass in the gastric cardia.

Fig. 2 The mass in the gastric cardia is seen: a endoscopically; b on endosonographic view, with the mass shown to be originating from the muscular layer.

The mass was approached in retroflexed fashion for a standard ESD technique and it was evident that part of the mass was clearly originating from the muscularis propria. The mass was then dissected off the muscularis propria, leaving approximately a 12-mm defect in the muscularis propria and another smaller defect lateral to this. The defects could not be reliably closed with endoscopic suturing owing to their difficult location. A double-channel endoscope and forceps were used to pull omental fat through the larger muscular defect and this was patched to the gastric mucosa using multiple through-the-scope clips (Resolution; Boston Scientific, Marlborough, Massachusetts, USA) ([Fig. 3]; [Video 1]). The smaller muscular defect was closed using endoscopic suturing (Apollo Endosurgery, Austin, Texas, USA). Pathology showed a GIST with negative margins ([Fig. 4]). The patient had no adverse events and there has been no recurrence over a follow-up period of 14 months.

Fig. 3 Endoscopic view showing the defect being closed using an omental patch.

Video 1 Endoscopic full-thickness resection of a 3-cm stromal tumor in the gastric cardia, followed by a combination of endoscopic suturing and omental patch closure of the resulting defects.

Fig. 4 Histologic appearance showing an en bloc resection of the gastric cardia mass.

After en bloc EFTR of a gastric GIST in a difficult location, such as the gastric cardia, a combination of omental patch closure and endoscopic suturing is a feasible method for defect closure.

Endoscopy_UCTN_Code_CPL_1AH_2AZ

Competing interests

Mouen A. Khashab is a consultant and on the medical advisory board for Boston Scientific and Olympus America. Vivek Kumbhari is a consultant for ReShape Life Sciences, Apollo Endosurgery, Medtronic, and Boston Scientific, and receives consulting fees from Pentax Medical and C2 Therapeutics. Anthony N. Kalloo is a founding member and equity holder for Apollo Endosurgery. The other authors have nothing to declare. There is no funding support related to this submitted manuscript.

• References

• 1 Demetri GD, Benjamin RS, Blanker CD. et al. NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST) – update of the NCCN clinical practice guidelines. J Natl Compr Canc Netw 2007; 5 (Suppl. 02) S1-S29
• 2 Xu M, Cai Q. Editorial: endoscopic resection of the upper gastrointestinal subepithelial tumors: promising new endoscopic techniques – are they here to stay?. Am J Gastroenterol 2016; 111: 797-799
• 3 Abe S, Council L, Cui X. et al. Endoscopic resection and enucleation of gastric submucosal tumor facilitated by subsequent closure of incision using over-the-scope-clip. Endoscopy 2015; 47: E153-E154
• 4 Hashiba K, Carvalho AM, Diniz Jr G. et al. Experimental endoscopic repair of gastric perforations with an omental patch and clips. Gastrointest Endosc 2001; 54: 500-504
• 5 Abidi WM, Thompson CC. Endoscopic closure of an iatrogenic perforation with an omental patch. Gastrointest Endosc 2016; 83: 652