2125 Overcoming the Challenge of Full Thickness Resection of Gastric Lesions Using Colonic Full Thickness Resection Device (FTRD): Novel Technique

Abstract

INTRODUCTION: Colonic FTRD (over the scope full thickness resection device) is safe, feasible and approved for colorectal lesions. However, it’s role for upper gastrointestinal (UGI) lesions resection need to be further studied. Colonic FTRD system’s cap diameter is 21 mm which makes it very challenging to insert through the mouth for UGI lesions. We present a case of endoscopic full thickness resection (eFTR) of stomach lesion using colonic FTRD using a novel technique for upper esophagus dilation to assist in the insertion of colonic FTRD through the mouth. CASE DESCRIPTION/METHODS: Case Presentation A 49-year-old female was referred to us for endoscopic resection of submucosal lesion suspected for gastric stromal tumor (GIST) prior to bariatric gastric bypass surgery. EGD revealed the lesion in the gastric body. Endoscopic ultrasound (EUS) confirmed it as well demarcated hypoechoic lesion measuring 0.8 cm × 0.8 cm arising from the intersection of submucosal layer and muscularis layer without adjacent lymphadenopathy. FTRD under general anesthesia was planned. eFTR technique: To assist the insertion of colonic FTRD, upper esophagus was dilated with savory dilator size 51 French for 1 minute, then with 55 French for 1 minute and then with 60 French for 5 minutes. Pediatric colonoscope installed with FTRD was gently advanced into the stomach lumen. Circumferential marking of the lesion was done using FTRD marking probe. Favorable positioning was achieved. FTRD grasper was used to grasp and mobilize the tissue into the cap. Clip was applied and snare was hooked to high frequency generator performing high frequency snare resection. Endoscope was removed along with resection specimen. Histopathology revealed fibrotic nodule with complete resection (R0). Endoscopy at 3-month revealed no recurrence. DISCUSSION: UGI FTRD is not yet approved in the US. Our case illustrates that colonic FTRD can be used for UGI lesion. Our novel technique of serial esophageal dilation before insertion of larger size FTRD is unique. Similar technique can be used for insertion of future UGI FTRD system as well as its cap diameter is still larger at 19.5 mm which can still be challenging in patients with small upper GI caliber. Since muscularis propria was missing in resected tissue, it opens up a question if device is only capable of eFTR in lower GI tract (thin GI wall as compared to upper GI wall) or if it can achieve similar results with respect to true “full thickness resection” as eFTR in lower GI tract.