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.
