What alternative tools can be used to remove a gastric Gastrointestinal Stromal Tumor (GIST) when it cannot be pulled into the cap using a tissue holder with a Full-Thickness Resection Device (FTRD)?

Alternative Tools for Gastric GIST Removal When FTRD Tissue Holder Fails

When the tissue holder of a Full-Thickness Resection Device (FTRD) fails to pull a gastric GIST into the cap, you should switch to a submucosal tunneling endoscopic resection (STER) technique or consider an exposed endoscopic full-thickness resection approach.

Understanding the Limitations of FTRD for Gastric GISTs

• FTRD has significant limitations for gastric subepithelial lesions (SELs), particularly with firm grasp and retrieval of the lesion into the cap, as slippage often occurs underneath the overlying mucosa 1
• While FTRD can achieve technical success rates up to 93% for small gastric SELs (<15mm), complete (R0) resection rates are considerably lower (68-76%) 1
• Bulky SELs are especially challenging to manage with FTRD due to difficulties manipulating the lesion into the cap 1

Alternative Approaches When FTRD Fails

1. Submucosal Tunneling Endoscopic Resection (STER)

• STER is ideal for gastric fundus and cardia lesions where scope manipulation for other techniques may be difficult 1
• The technique creates a submucosal tunnel 3-5cm proximal to the lesion, allowing dissection around the SEL and extraction through the tunnel 1
• Advantages include:
  • Provides scope stability and traction on the lesion within the confined tunnel space 1
  • The mucosal flap minimizes extravasation of luminal contents during dissection 1
  • Easier closure of the mucosal entry point compared to full-thickness defects 1
• Size limitations: STER is most effective for lesions <3-4cm; larger lesions are difficult to remove through the tunnel 1

2. Exposed Endoscopic Full-Thickness Resection (EFTR)

• Consider exposed EFTR for gastric lesions that cannot be reliably excised by other methods due to size or location 1
• This technique is particularly suitable for gastric lesions as the clinical consequences of a leak are less severe than in the esophagus or duodenum 1
• Requires advanced equipment including:
  • Dual-channel gastroscope
  • Dedicated electrosurgical knives
  • Hemostatic forceps
  • Closure devices (over-the-scope clips, through-the-scope clips, suture devices)
  • Peritoneal needles for decompression 1
• Note: This approach should be performed in hospital endoscopy units with readily available surgical support 1

3. Adjunctive Techniques to Improve FTRD Success

• Unroofing of the SEL before FTRD application may improve grasp and retrieval 1
• This involves partial removal of the overlying mucosa to better expose the lesion for grasping 1
• However, these strategies have limited evidence and require further study 1

Efficacy and Safety Considerations

• STER has demonstrated high success rates with pooled en bloc and complete resection rates of 95% and 98%, respectively 1
• Potential complications of STER include:
  • Air leakage (subcutaneous emphysema and pneumomediastinum) in 15% of cases 1
  • Perforation rate of 5.6% 1
• For upper GI FTRD procedures, technical success rates of 93% have been reported, but R0 resection rates are lower at 68% 2
• Complication rates for upper GI FTRD are approximately 21% for mild to moderate adverse events 2

Important Caveats

• Always use carbon dioxide insufflation (mandatory) given its faster absorption compared to air and lower risk for adverse events 1
• Administer prophylactic intravenous antibiotics during the procedure due to potential risk of peritoneal contamination 1
• For lesions >3cm, consider surgical referral as endoscopic approaches become technically challenging and have higher complication rates 1
• The choice of technique should consider lesion size, location, and operator expertise 1