No-touch endoscopic full-thickness resection technique matches the surgical concept as far as possible

We would like to thank Wang et al. for their comments regarding our paper [1]. The no-touch endoscopic full-thickness resection (NT-EFTR) technique aims to match the surgical concept of achieving R0 resection. It should be emphasized that during the procedure, the integrity of the gastrointestinal tract should be restored before attempting to retrieve large tumors; therefore, after resection, the gastric wall defect is closed because the risk of tumor rupture increases during retrieval [2]. After satisfactory closure of the wall defect, large tumors could be safely retrieved, even when divided into two or more pieces. Notably, owing to individual differences, even GISTs with a large diameter can be retrieved successfully if the transverse diameter is appropriate (< 3.5 cm).

NT-EFTR is also suitable for large tumors with intraluminal growth when the layer of gastric muscle located at the tumor bed is very thin. It is very difficult to keep the integrity of the digestive tract using endoscopic submucosal excavation (ESE). Under this condition, the capsule of the tumor will be damaged, which deviates from the surgical concept and goal of R0 resection. In fact, ESE was found to be related to higher R1 rates in GISTs than EFTR [3]. Thus, NT-EFTR is safer than ESE for some large tumors with intraluminal growth.

The diameter of the gastric wall defect is usually not the same as the tumor size. During NT-EFTR, the stomach is dilated by carbon dioxide insufflation. After resection, the gastric defect is smaller, mainly because of stomach contraction. In addition, for intraluminal submucosal tumors, because the basal part is often significantly smaller than the tumor diameter, the wall defect after NT-EFTR is relatively smaller than the tumor.

Finally, we cannot but agree on the need for large prospective multicenter studies on the use of NT-EFTR for gastric GISTs in order to evaluate the long-term outcomes of this new technique.

^‡ These authors contributed equally.

Publication History

Article published online:
21 December 2023

• References

• 1 Chen T, Zhang YW, Lian JJ. et al. No-touch endoscopic full-thickness resection technique for gastric gastrointestinal stromal tumors. Endoscopy 2023; 55: 557-562
• 2 Chen T, Zhou PH, Chu Y. et al. Long-term outcomes of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors. Ann Surg 2017; 265: 363-369
• 3 Zhu Y, Xu MD, Xu C. et al. Microscopic positive tumor margin does not increase the rate of recurrence in endoscopic resected gastric mesenchymal tumors compared to negative tumor margin. Surg Endosc 2020; 34: 159-169