Going Deep: Endoscopic Full-thickness Resection (EFTR) of a Gastric Schwannoma

Abstract

Endoscopic full-thickness resection (EFTR) is a less-invasive and potentially curative method of en bloc removal of gastrointestinal tumor. We present a case of young female found to have a 2cm mass along the anterior wall of the distal body treated successfully with Endoscopic Full-Thickness Resection. A 54 year old female underwent an upper endoscopy for chronic post prandial left upper quadrant pain with increased bloating and decreased appetite. Endoscopy at that time revealed 2x2 cm gastric mass. An EUS revealed the mass to be arising from the muscularis propria and FNA was performed that showed a spindle cell neoplasm but could not be fully described due to lack of specimen. On repeat endoscopy with curative intent 2.2 cm dimpled mass with ulceration was noted along the anterior wall in the gastric body as previously seen. The lesion was marked circumferentially with dual knife. Heleon was injected to lift the lesion. Using dual knife circumferential cutting around the mass was done. Then Using a hook knife, dual knife and IT2 knife the mass dissected to complete the full thickness resection. The mass was then retrieved using rothnet. The capsule was intact. Using Apollo suturing device, the defect in the gastric wall was closed in double layer. Pathology revealed a 2.5cm gastric submucosal schwannoma, 2.5 cm, completely resected. No necrosis was seen and mitotic rate is < 1 / 50 HPFs. Immunohistochemical staining for S-100 is strongly and diffusely positive in the tumor. Immunostains for c-kit (CD117), desmin and SMA are negative. Follow up swallowing studies revealed no defects or extravasation of contrast, and the patient was able to start clear liquids. She was discharged home and is currently doing well. This case illustrates that EFTR is a safe and effective method for removal of gastrointestinal masses. However, EFTR procedures are still limited to case reports and small, retrospective, or pilot series in the literature. We recommend larger multi center trials to fully investigate the role of endoscopic full-thickness resection.Figure 1