Gastric perforation during ligation-assisted endoscopic mucosal resection of a neuroendocrine tumor: banding without resection may be a safer option

The management of small gastrointestinal subepithelial tumors (SETs) considers periodic endoscopic surveillance vs. endoscopic removal for entities with malignant potential such as neuroendocrine tumor (NET), gastrointestinal stromal tumor or others [1]. Excision by ligation-assisted endoscopic mucosal resection (EMR) is an option for small SETs [2].

In a 57-year-old woman undergoing periodic endoscopic surveillance for chronic atrophic gastritis, three small grade 2 (Ki-67, 3 %) NETs were identified in the gastric body ([Fig. 1]). Indication for endoscopic excision was agreed by consensus in a multidisciplinary committee. EMR using a specific mucosectomy device (Captivator; Boston Scientific, Quincy, Massachusetts, USA) was proposed.

Fig. 1 Endoscopic view of one (arrow) of the three neuroendocrine tumors.

During NET banding, two technical incidents occurred: 1) the transparent cap of the device was not optimally attached to the tip of the gastroscope (the blue rubber bands should not be observed in the endoscopic view); and 2) two bands, instead of one, were deployed when the first NET was ligated. During resection of the first NET using an electrocautery snare (ERBE, 40 W cut, 30 W coagulation; ERBE Elektromedizin GmbH, Tübingen, Germany), immediate gastric perforation occurred ([Fig. 2]). The wall defect was effectively closed during the same procedure by endoscopic clipping using eight clips (Resolution clip; Boston Scientific) ([Fig. 3]). Endoscopic band ligation (EBL) without resection was decided for the other two NETs, avoiding the resection technique.

Fig. 2 Neuroendocrine tumor resection with electrocautery snare after band ligation.

Fig. 3 Wall defect closure by endoscopic clipping.

The patient did well after the procedure, requiring a 7-day hospital stay. Endoscopic surveillance after 10 months and 2 years showed a fibrous scar and one remaining clip from the first resected NET (pathological biopsy examination confirmed fibrous tissue) ([Fig. 4]), and the disappearance of the other two NETs ([Video 1]).

Fig. 4 Remaining clip in the fibrous scar of the first resected neuroendocrine tumor.

Video 1 Intraprocedure adverse event during ligation-assisted endoscopic mucosal resection: gastric perforation.

Ligation-assisted EMR is associated with a non-negligible rate of adverse events such as perforation [2] [3]. EBL without resection is an apparently safe and effective option for management of small SETs [4] [5].

Endoscopy_UCTN_Code_TTT_1AO_2AC

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2020

• References

• 1 Faulx AL, Kothari S, Acosta RD. et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117-1132
• 2 Hwang JH, Konda V, Abu Dayyeh BK. et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
• 3 Zang D, Lin Q, Shi R. et al. Ligation-assisted endoscopic submucosal resection with apical mucosal incision to treat gastric subepithelial tumors originating from the muscularis propria. Endoscopy 2018; 50: 1180-1185
• 4 Binmoeller KF, Shah JN, Bhat YM. et al. Suck-ligate-unroof-biopsy by using a detachable 20-mm loop for the diagnosis and therapy of small subepithelial tumors (with video). Gastrointest Endosc 2014; 79: 750-755
• 5 Bas-Cutrina F, Consiglieri CF, Bosch-Schips J. et al. Endoscopic band ligation plus single-incision needle-knife biopsy for small subepithelial deep-layer tumor: easy and effective. Endoscopy 2019; 51: E191-192