Introduction

Gastric Gastrointestinal Stromal Tumors (GISTs) are among the most common mesenchymal tumors arising in the gastrointestinal tract. Despite many international guidelines, the treatment of GISTs with tumor diameters less than 50 mm remains controversial. Although surgical resection is indicated for histologically diagnosed GISTs, endoscopic resection has recently been reported. However, endoscopic resection, mainly Endoscopic submucosal dissection (ESD), often requires a full-layer resection of the gastric wall, which requires extensive suturing. Therefore, we have developed an ESD technique for endoscopic resection of the gastric wall that uses a threaded clip and a detachable snare to strangulate the muscle layer prior to resection and allows safe and easy complete resection without perforation (EISMR: Endoscopic inversion and strangulation of the muscle layer and resection). We now report seven cases of EISMR for gastric GISTs.

Aims & Methods

We evaluated the safety and efficacy of EISMR for GISTs. Seven gastric GISTs (4 males and 3 females) with tumor diameters of 50 mm or less for which we performed EISMR were included in this study, and the en bloc resection rate, R0 resection rate, procedure time, and complications were investigated. All patients underwent EUS and abdominal CT scan before treatment to confirm that the pathological diagnosis was GIST, that the tumor diameter was less than 50 mm, and that the tumor was intraluminal growth type.
In the EISMR procedure, sodium hyaluronate solution was first injected into the submucosal layer of the lesion to dissect the submucosa as in ESD. After a yellowish GIST continuity with the muscularis propria is observed, the submucosa and muscle layer are dissected to expose as much of the submucosa as possible without damaging the tumor. Next, a threaded clip is attached to the tumor and pulled in order to invert the muscle layer. The muscle layer is then retracted into the gastric lumen to form a polyp-like shape, and the base of the muscle layer is strangulated using an detachable snare (PolyLoop Ligating Device, Olympus). The upper margin of the strangulated area is then incised to complete the resection. After confirming that there is no perforation, the strangulated area is additionally sutured with a clip.

Results

All seven cases could be resected en bloc, with a median time of 90.5 minutes (58-120). Of the seven EISMR cases, five cases were performed by experts and two by non-experts. All patients were discharged on postoperative day 5 or 6 without adverse events. Pathology results showed complete resection in the low-risk GIST group. Upper endoscopy 3-6 months after EISMR showed no tumor recurrence and only scarring.

Conclusion

EISMR for gastric GISTs is potentially safe, easy and useful without excessive invasion.

Introduction

Endoscopic Submucosal Dissection (ESD) is the best endoscopic technique that enables en bloc resection of superficial colorectal neoplasms.Despite its effectiveness, ESD is not very widespread in Western countries due to technical complexity, long procedure times, and a steep learning curve. These barriers have created a significant gap in adoption and outcomes between Eastern and Western centers. Underwater ESD (U-ESD) has been introduced to simplify the procedure. This study aimed to evaluate the effectiveness of U-ESD versus conventional gas-based ESD (G-ESD) in a Western center, focusing on procedural efficiency and safety.

Aims & Methods

This is a single-center, prospective randomized controlled trial conducted at Fondazione Campus Bio-Medico in Rome between December 2024 and April 2025.Forty patients with non-pedunculated colorectal lesions were randomly assigned in a 1:1 ratio to undergo either Underwater ESD (U-ESD) or conventional ESD with insufflation of Carbon Dioxide (CO2) (G-ESD).The primary outcome was total procedure time. Secondary outcomes included dissection speed, en bloc and R0 resection rates, use of hemostatic forceps, and the incidence of adverse events such as delayed bleeding, perforation, and post-ESD coagulation syndrome (PECS).

Results

A total of 40 patients referred to our endoscopic unit for ESD between December 2024 and April 2025. The mean size of the colorectal lesions was 57.4 mm and 40.7 mm in the U-ESD and G-ESD groups. The location of the lesions was in the rectum in 15% and 55% of the U-ESD and C-ESD groups, respectively; in the right side of the colon in 35% and 20% of the U-ESD and G-ESD groups, respectively. The morphology of LST was classified as LST-nongranular in 20 % and 25% of the U-ESD and G-ESD groups, respectively; as LST granular in 60% and 35% of the U-ESD and G-ESD groups, respectively. Fibrosis (grade 1 and 2) was present in 45% and 30% of the U-ESD and G-ESD groups, respectively. The mean total procedure time was shorter in the U-ESD group compared with the G-ESD group (53.3 ±33 minutes vs 78.7 ± 25.6 minutes; mean difference,–25.4 minutes; P=0.009).Mean dissection speed was faster in the U-ESD group compared with the G-ESD group (42 ± 26.3 mm2/min vs 13.3 ± 8 mm2/min; mean difference, 28.7 mm2/min; P= 0.001). En bloc and R0 resection rates in both groups were 100%. The use of a hemostatic forceps was significantly lower in U-ESD compared G-ESD (40% vs 90%, P= 0.001). Delayed bleeding occurred in only one patient in G-ESD group and was managed successfully by endoscopic clipping. No perforations occurred in either group. PECS was noted in only one patient in the G-ESD group.

Conclusion

UESD has shown a significantly shorter procedure time and faster dissection speed compared with GESD. These both empower the possibility of considering U-ESD as the preferred colorectal ESD method for colorectal lesions.

Introduction

Although endoscopic balloon dilation (EBD) remains the standard intervention for Crohn’s disease (CD)-associated strictures, its efficacy is limited by high recurrence and surgery rates. Retrospective analyses suggest endoscopic stricturotomy (ES) may offer superior outcomes, particularly in anastomotic strictures. However, no randomized trials have directly compared EBD and ES for short CD-related strictures.

Aims & Methods

This single-center, randomized controlled trial (August 2022–March 2025) enrolled adult CD patients (18–65 years) with symptomatic, predominantly fibrotic or mixed, short strictures (<3 cm), including both de novo and anastomotic types, accessible via standard endoscopy. Patients with multiple (>2) strictures, strictures beyond endoscopic reach, or prior stricturotomy were excluded. Participants were randomized to undergo either EBD or ES. The primary outcome was clinical recurrence at 1 year. Secondary outcomes included re-intervention, surgery, emergency visits, hospitalization, technical success, and adverse events.

Results

Out of 70 randomized patients, 69 were analyzed (EBD: 35; ES: 34). Baseline characteristics were comparable between groups. Technical success was similar (EBD: 91.4%, ES: 94.1%). On time to event analysis, clinical recurrence was significantly lower in the ES group (OR=0.343, 95% CI: 0.134–0.881; p=0.026). Re-intervention rates favored ES (EBD: 25.7%, ES: 8.8%; OR=0.337, 95% CI: 0.131–0.870; p=0.025). Surgery rates were numerically lower with ES (EBD: 11.4%, ES: 5.9%) but not statistically significant (p=0.581). Hospitalization was significantly more frequent in the EBD arm (OR=0.276, 95% CI: 0.091–0.840; p=0.023). ED visits also trended lower with ES, though not statistically significant (p=0.062) (see table). Adverse events occurred in 25.7% of EBD patients (bleeding n=3 [1 hemoclip], pain with admission n=3, micro-perforation n=1, post-procedure pain n=2) and 14.7% of ES patients (bleeding n=3 [1 self-limited, 1 coagrasper, 1 hemoclip], none required transfusion, suspected perforation n=1, mild pain n=1).

Conclusion

In this interim analysis, ES was associated with significantly lower clinical recurrence, re-intervention, and hospitalization compared to EBD for short CD-related strictures, with similar safety outcomes. These findings support ES as a potentially superior first-line endoscopic strategy over EBD in selected patients with Crohn’s disease strictures. (NCT05521867)

References

Lan N, Shen B. Endoscopic Stricturotomy Versus Balloon Dilation in the Treatment of Anastomotic Strictures in Crohn's Disease. Inflamm Bowel Dis. 2018 Mar 19;24(4):897-907. doi: 10.1093/ibd/izx085. PMID: 29546384.