LAUSR

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. 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. 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.