Endoscopic tunneling and subserosal dissection using a natural orifice transluminal endoscopic surgery approach for a...

Gastric subepithelial lesions (SELs) may be endophytic or exophytic. Although endoscopic resection is increasingly being used for endophytic lesions, surgery is recommended for exophytic lesions. Endoscopic full-thickness resection and submucosal tunneling endoscopic resection are established techniques for resection of endophytic SELs. This video demonstrates the technique of endoscopic tunneling subserosal dissection (ETSSD) for an exophytic subserosal gastrointestinal stromal tumor (GIST) using a natural orifice transluminal endoscopic surgery approach.

A 74-year-old woman presented with a gastric subepithelial lesion, which was confirmed as a GIST by endoscopic ultrasound-guided fine-needle biopsy. Preprocedural neoadjuvant imatinib was administered for 3 months. Using a submucosal tunneling approach and through-the-tunnel full-thickness myotomy, we entered the peritoneal cavity and approached the lesion from the serosal side to coagulate subserosal vessels and perform omental adhesiolysis. Thereafter, the lesion was enucleated and resected, with subsequent mucosal incision closure.

The patient recovered well after the procedure. Follow-up esophagogastroduodenoscopy at 1 month showed complete healing, and a contrast-enhanced CT scan at 6 months confirmed no recurrence.

ETSSD is safe and feasible for treatment of exophytic gastric subepithelial lesions.