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Submucosal tunneling and en bloc endoscopic resection facilitates laparoscopic transgastric removal of a large GI stromal tumor at the esophagogastric junction
Endoscopic resection of gastrointestinal stromal tumor (GIST) of the esophagogastric
junction (EGJ) can be performed by submucosal tunneling and endoscopic resection (STER).
However, the maximal reported lesion size is 3.3 cm. En bloc resection is mandatory
because of the malignant potential of a GIST. Laparoscopic wedge resection (LWR) at
the EGJ is technically challenging, with a risk of lumenal narrowing leading to dysphagia
and injury of the lower esophageal sphincter. STER of large EGJ lesions can release
the tumor from the EGJ and facilitate easy access for transgastric LWR while avoiding
the risks of LWR techniques. A 74-year-old man with iron deficiency had a 6.6-cm GIST
at the EGJ extending into the lesser curve. Using a triangle-tip knife to create a
mucosal incision 5-cm proximal to the EGJ and submucosal tunnel to the GIST, we performed
STER (Fig. 1 and Video 1, available online at www.giejournal.org). The submucosal fibers and underlying muscle fibers were dissected away, leaving
the tumor capsule intact. A gastrostomy was formed on the anterior gastric wall laparoscopically.
The GIST was freed from the EGJ, and surgical staples were easily placed at an appropriate
angle to prevent narrowing of the EGJ. The GIST was removed through the gastrostomy.
Combining STER with LWR offers a minimally invasive, safe, and effective solution.
Figure 1Endoscopic submucosal tunnelling releases the large tumor from the cardia and facilitates
easy insertion of a laparoscopic stapling device via a gastrostomy on the anterior
gastric wall.
