Endoscopic band ligation plus single-incision needle knife biopsy for small subepithelial deep-layer tumor: easy and effective

A 61-year-old man was referred for an iron-deficiency anemia diagnostic process. Upper gastrointestinal endoscopy was performed and fortuitously revealed a small gastric subepithelial lesion. Endoscopic ultrasound (EUS) characterization revealed a solid lesion, with fusiform morphology, well-defined by smooth edges and an hypoechoic homogeneous internal pattern, measuring 12.3 × 5.8 mm, and originating in the muscularis propria layer, which confirmed a subepithelial tumor ([Fig. 1]). With the aim of avoiding EUS surveillance of the subepithelial tumor, a minimally invasive removal technique was planned [1] [2] [3].

Fig. 1 Endoscopic ultrasound view of a small gastric subepithelial tumor, seen fortuitously during a diagnostic process for iron-deficiency anemia.

Endoscopic band ligation of the subepithelial tumor was done using a Captivator endoscopic mucosal resection standard gastroscope device (Boston Scientific, Quincy, Massachusetts, USA) combined with a single-incision needle knife (SINK) biopsy (XL Triple-lumen needle knife; Boston Scientific; and pure-cut 90-W, Beamer CE600; ConMed, Utica, New York, USA). A standard videogastroscope was used, and four biopsy samples were obtained (Radial Jaw large capacity biopsy forceps; Boston Scientific) ([Fig. 2]). The patient remained in hospital for 24 hours and was called at 48 hours and 7 days after the procedure, with no incidents or adverse events being reported ([Video 1]).

Fig. 2 a Subepithelial tumor: endoscopic view of single-incision needle knife (SINK) biopsy. b Use of biopsy forceps to obtain samples for anatomopathological study.

Video 1 Endoscopic band ligation without resection, plus single-incision needle knife biopsy, for a gastric subepithelial tumor.

Pathological and immunohistochemistry examination revealed a fascicular proliferation of fusiform eosinophilic cells, negative for CD117 (c-kit) and DOG1, and positive for desmin and caldesmon, corresponding to the diagnosis of a leiomyoma ([Fig. 3]).

Fig. 3 Immunohistochemistry markers confirming a leiomyoma.

The first EUS control, at 5 weeks after the procedure, revealed a complete disappearance of the subepithelial tumor features, showing a discreet eschar (simple biopsy with 4 samples, showing normal gastric mucosa). Long-term EUS control at 1 year showed that the subepithelial tumor had vanished, confirming the successful result and allowing discontinuation of endoscopic surveillance ([Fig. 4]).

Fig. 4 Endoscopic view of gastric wall 1 year after the procedure, showing no sign of the subepithelial tumor.

Endoscopic band ligation combined with SINK biopsy seems to be an effective minimally invasive technique that is safer than endoscopic resection for treating a gastric subepithelial tumor originating in the muscularis propria [4] [5].

Endoscopy_UCTN_Code_TTT_1AO_2AG

Competing interests

None

• 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 Arezzo A, Verra M, Miegge A. et al. Loop-and-let-go technique for a bleeding, large sessile gastric gastrointestinal stromal tumor (GIST). Endoscopy 2011; 43: E18-19
• 3 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
• 4 Hwang JH, Konda V, Abu Dayyeh BK. et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
• 5 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