ENDOSCOPY TO ENDOSURGERY: ENDOSCOPIC ENUCLEATION OF GASTRIC GIST

According to recent National Comprehensive Cancer Network guidelines, gastrointestinal (GI) stromal tumors (GISTs) bigger than 2 cm should be removed, while smaller incidental GISTs with no signs of malignancy can be removed or active surveilled. However, a small tumor size does not exclude the potential for malignancy in GIST. So, Japanese guidelines recommends resection even if the tumor is small. Here the case of a 72-year-old man, with an history of coronary artery disease, recent pulmonary embolism requiring long-term anticoagulant therapy, who underwent upper GI endoscopy for anemia. A 10 mm sub-epithelial mass was found in posterior wall of gastric antrum. The patient underwent endoscopic ultrasonography (GF-UCT180; Olympus), that showed a hypoechoic homogeneous intramural mass arising from the muscularis propria, with mild hypervascular pattern after contrast-enhanced study, suspected for GIST. In order to achieve a definitive diagnosis, fine needle aspiration was performed using a 22-gauge needle (Expect-SlimLine; Boston Scientific). Histology and immunehistochemical staining revealed a low-risk GIST (low mitotic index, positive reactions for CD117, CD34, DOG-1). CT scan excluded metastatic disease. Because patient's anxiety about possible disease progression and the high anesthesiological risk, after multidisciplinary evaluation, an endoscopic enucleation was performed, using CO₂ and under deep sedation. Marking dots around the lesion and submucosal dissection were performed using T-type Hybrid-Knife (ERBE Elektromedizin GmbH). After submucosal dissection, the lesion was enucleated. However, due to the deeper location of the tumor into the muscular layer, 3 iatrogenic perforations occurred. Owing to the thinness of the remnants tissues surrounding the leakages, the deployment of through-the-scope clips wasn't enough to achieve complete closure. So, double over-the-scope clips were placed, gaining technical and clinical success, as demonstrated by contrast medium injection. The procedure took about 60 min, resulting in an en-bloc resection. Low molecular weight heparin was reintroduced 24 hours after the procedure. Upper GI endoscopy with contrast medium injection after 5 days excluded perforations and the patient was discharged. The latest endoscopic control 3 months later revealed regular scar. Even challenging, this case illustrates the feasibility and safety of endoscopic enucleation of gastric GIST, in a high-risk patient who was receiving anticoagulant therapy.