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
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