LAUSR

Endoscopic full-thickness resection (EFTR) has been developed to treat gastrointestinal stromal tumors (GISTs) of < 3 cm [1]. The challenges were to secure the surgical field and to establish a reliable endoscopic closure method [2]. Therefore, we have developed a novel strategy of traction-assisted EFTR followed by O-ring band [3] and over-thescopeclipclosure throughananimal study [4]. We describe a clinical case in which this strategywas feasible (▶Video 1). A man in his 40 s presented with an intraextraluminal mixed-growth type GIST (22mm in diameter) located in the middle stomach. First, a single port aimed at pneumoperitoneal control was created. Then, a whole circumferential submucosal incision was performed around the lesion, followed by 5-mm perforations at both central ends. A 4-cm loop of suture was anchored on the muscle– serosal layer at both perforation sites (▶Fig. 1). After EFTR of the distal half, the proximal half was resected using clip-line traction (▶Fig. 2). After the lesion was retrieved orally, the anchored loop was grasped and pulled into the endoscopic variceal ligation hood (MD48720U; Sumius, Tokyo, Japan), and then the anchor clips at both ends were ligated with an O-ring band [3] and an endoloop snare (HX-400U-30; Olympus, Tokyo, Japan) (▶Fig. 3). This procedure enabled the full-thickness defect to be reduced and the surgical field to be secured. After the two defects around the band ligation were approximated using Twin Grasper forceps (Ovesco Endoscopy, Tübingen, Germany), full-thickness inverted closure was completed by deploying the over-the-scope clips (▶Fig. 4). Laparoscopic observation revealed no leakage on indigo carmine air leak test and confirmed inverted full-thickness closure (▶Fig. 5). The procedure time was 80 minutes for traction-assisted EFTR and 35 minutes for O-ring and overthe-scope clip closure. No complications occurred. Histological examination confirmed curative resection of low risk GIST. Traction-assisted EFTR followed by O-ring and over-the-scope clip closure were clinically feasible.