Gastric Submucosal Research Articles

The effect of Channa striata extract and standard eradication regimen on asymmetric dimethylarginine in Helicobacter pylori gastritis rat model.

Background and Aim:The presence of gastric mucosa or submucosa inflammation due to Helicobacter pylori leads to histological changes. Gastric injury, pro-inflammatory factors, and oxidative stress in H. pylori infection produce asymmetric dimethylarginine (ADMA), which are a competitive inhibitor of nitric oxide synthase. Investigations were carried out aimed at finding new drugs derived from natural products for the treatment of H. pylori. Channa striata is known to have in vitro anti-inflammatory and antimicrobial properties. This study aimed to investigate the effect of C. striata extract and a standard eradication regimen on ADMA levels and histological changes in the H. pylori gastritis rat model.Materials and Methods:Thirty-five male rats were randomly and equally divided into five groups. Group-1 was the negative control group and Groups-2 to 5 were H. pylori-infected groups. Groups-3 to 5 were administered C. striata extract, a standard eradication regimen, and a combination of standard eradication regimen and C. striata extract, respectively. Histological examination and serum ADMA levels were analyzed. The difference between groups was analyzed using the Kruskal–Wallis and one-way analysis of variance tests. The significance was p<0.05.Results:Serum ADMA levels and severity of gastritis were higher in infected groups compared to the negative control group (p<0.05). The severity of gastritis and mean ADMA levels in the group that received a single administration of the C. striata extract was higher than the others (p<0.05). Serum ADMA levels and severity of gastritis were significantly reduced in the group that received a combination of standard eradication regimen and C. striata extract (p<0.05).Conclusion:Single administration of C. striata extract worsens the severity of gastritis and increased serum ADMA levels in the H. pylori gastritis rat model. The administration of a combination of standard eradication regimen and C. striata extract reduces serum ADMA levels and significantly improves the severity of H. pylori gastritis rat model.

Current State and Problems of Gastric Endoscopic Submucosal Dissection in Elderly Patients Aged ≥85 Years in a Regional Core Hospital

Current State and Problems of Gastric Endoscopic Submucosal Dissection in Elderly Patients Aged ≥85 Years in a Regional Core Hospital

IgG4-related Sclerosing Disease Forming a Gastric Submucosal Tumor Diagnosed after Laparoscopic Endoscopic Cooperative Surgery—Report of a Case—

IgG4-related Sclerosing Disease Forming a Gastric Submucosal Tumor Diagnosed after Laparoscopic Endoscopic Cooperative Surgery—Report of a Case—

Gastric gastrointestinal stromal tumours (2-5 cm): Correlation of CT features with malignancy and differential diagnosis

PurposeThe purpose of this study was to investigate the computed tomography (CT) features of 2−5 cm gastric gastrointestinal stromal tumors (GISTs), schwannomas and leimyomas which have close relationship with malignancy evaluation and differential diagnosis. MethodSeventy-six patients with pathologically confirmed gastric submucosal tumors (SMTs) between 2−5 cm were included in this study, including 60 GISTs, 10 schwannomas and 6 leiomyomas. CT imaging features were reviewed and quantitative parameters including CT values during nonenhanced phase (CTV-N), portal phase (CTV-P) and delayed phase (CTV-D) were recorded. The association of CT features with mitotic counts of GISTs and the significantly different CT features between GISTs and benign SMTs were analyzed. ResultsThe lobulated contour was significantly more common in GISTs with high mitoses (P < 0.05). The value of CTV-D/CTV-P was significantly lower in GISTs with high mitoses (P < 0.05) and it was an independent predictor for high-mitosis GISTs (P = 0.049, odds ratio [OR] = 186.445) with an area under the curve (AUC) of 0.722. CT features including heterogeneous enhancement and presence of necrosis or cystic degeneration were significantly suggestive of GISTs instead of benign SMTs (P < 0.05). The value of CTV-D/CTV-P was significantly higher in schwannomas than that in GISTs (P < 0.05) with an AUC of 0.853. The value of CTV-P/CTV-N was significantly lower in leiomyomas than that in GISTs (P < 0.05) with an AUC of 0.883. ConclusionsSome qualitative and quantitative parameters on contrast-enhanced CT can be helpful in preoperative diagnosis and risk stratification of 2−5 cm gastric GISTs.

Incidence of Delayed Bleeding among Patients Continuing Antithrombotics during Gastric Endoscopic Submucosal Dissection.

objective In patients continuing antithrombotics, delayed bleeding after gastric endoscopic submucosal dissection (ESD) is a severe complication. Vonoprazan (VPZ) exerts a rapid, potent, and long-lasting antacid effect compared with traditional proton-pump inhibitors (PPIs). This study aimed to compare the incidence of delayed bleeding after gastric ESD between the use of VPZ and PPIs in patients continuing antithrombotics. Methods In this retrospective analysis, we examined 71 patients with 101 lesions treated with traditional PPIs (PPI group) and 59 patients with 90 lesions treated with VPZ (VPZ group). After 2 days (day 0 and 1) of intravenous PPI administration, either an oral PPI or VPZ was administered from postoperative day 2 to 8 weeks after ESD. We assessed the incidence of overall delayed bleeding as well as bleeding that occurred from day 2 until 8 weeks after ESD. Results There was no significant difference in the use of antithrombotic agents between the groups. Overall delayed bleeding occurred 13 times (18%) in 9 patients in the PPI group and 18 times (31%) in 17 patients in the VPZ group (p=0.10). Bleeding from day 2 until 8 weeks after ESD occurred 12 times (17%) in 9 patients in the PPI group and 8 times (14%) in 8 patients in the VPZ group. Conclusion Even with a potent antacid agent, such as VPZ, the incidence of delayed bleeding was high in patients undergoing ESD with continuous antithrombotic agents.

2735 Phlegmonous Gastritis

INTRODUCTION: Phlegmonous gastritis (PG) is a rare cause of abdominal infection with a mortality rate up to 42%. PG presents a diagnostic and therapeutic challenge given the low incidence and non-standardized treatment options. We present a case of PG successfully treated with early antibiotic therapy. CASE DESCRIPTION/METHODS: A 47-year-old man with uncontrolled type 2 diabetes mellitus presented with four days of subjective fevers, abdominal pain, and vomiting. The patient was tachycardic (122 beats/min) and had epigastric tenderness without guarding or rebound. Initial studies revealed leukocytosis (30,000/mm³) and Gram-positive bacteremia, later identified as ß-hemolytic group A Streptococcus. The stomach was diffusely thickened to 16 mm on contrast-enhanced computed abdominal tomography (Figure 1). Endoscopy revealed diffuse gastric thickening with erythema and a nonbleeding 6 mm ulcer on the lesser curvature of the gastric body. Deep biopsy of the ulcer by cold forceps produced a purulent drainage (Figure 2). Subsequent endoscopic ultrasonography (EUS) found a 12 mm thickened gastric wall involving the deep mucosa, thus further biopsy was obtained. The biopsies from both endoscopy and EUS showed acute neutrophilic inflammation with micro-abscesses; Helicobacter pylori was not identified. The patient received three days of piperacillin/tazobactam followed by seven days of ampicillin/sulbactam, with resolution of symptoms. DISCUSSION: PG is a rapidly progressive and frequently fatal bacterial infection of the gastric wall. The etiology of PG remains unclear, but can be caused by local or hematogenous spread of infection. Streptococcusspp. accounts for 70% of cases, and up to one-third of infections are polymicrobial. Risk factors include gastric mucosal injury, diabetes mellitus, and alcoholism. Diagnosis is commonly delayed as clinical manifestations are nonspecific. High clinical suspicion and early radiographic testing are important to identify gastric wall thickening, which is supportive of the diagnosis. PG primarily affects the gastric submucosa but may extend to deeper layers. Histopathology is of limited benefit, as standard forceps biopsy collects insufficient submucosal tissue. Optimal treatment is not known. When diagnosis is delayed, surgical intervention is often required. Medical therapy alone has been associated with increased mortality rates; however, in cases of early diagnosis and empiric antibiotic treatment, medical therapy alone may be sufficient.

2740 IgG₄-Related Disease: A Gastric Mass With an IgG4 Surprise

INTRODUCTION: IgG₄-related disease is a rare autoimmune syndrome that causes fibrosis of glands, most commonly of the pancreas and biliary tract1,3. The overall prevalence is unknown, with an estimated less than 1:100,000 of the general population typically found in middle-aged males2,3. Diagnosis is made with IgG₄ levels at least 2x the upper limit of normal and dense lymphoplasmacytic infiltrate, however, it may be seen with normal IgG₄ levels6. Although rare, it can present similar to GI malignancies and should be considered in the differential for patients with autoimmune disease1,3,4,5. Here we present one of those unusual cases. CASE DESCRIPTION/METHODS: A 65-year-old lady with PMH of DM2 and Sjogren's Syndrome (SS) who presented to the hospital with intractable nausea, vomiting, and failure to thrive for over 1 month. The physical exam, labs that included CMP, LFTs, and serology was unremarkable; previous EGD revealed diffuse thickening of the gastric submucosa. Biopsy via open gastrectomy revealed chronic inflammation with multiple IgG₄ plasma cells and no signs of lymphoma, suspicious for IgG₄-RD. After the partial gastrectomy, serum Na levels were 162, which improved with DDAVP and was later confirmed to be diabetes insipidus (DI). Further workup and imaging were negative and baseline IgG and IgG₄ levels were 1178 and 61, respectively. Treatment included steroid therapy and DDAVP which improved her symptoms and preceded an uneventful hospital course. DISCUSSION: IgG₄-RD is a disease with numerous presentations based on the organs involved. It presents as a GI-specific illness due to its affinity for the pancreas and biliary tract1,2,3. As seen in our patient, although rare, it may also affect the stomach, form mass lesions and cause symptomatology similar to a GI malignancy3,5. In patients with autoimmune diseases, where GI malignancy is considered, it is reasonable to include IgG₄-RD in the differential. IgG₄-RD may mimic symptoms of SS, and therefore case-patients with SS should also be considered for IgG₄-RD. This patient also experienced DI which may be a manifestation of IgG₄-RD, as the syndrome may affect the pituitary4. This case is one of the few instances reported to have pituitary involvement after the onset of multiorgan involvement4. Like other autoimmune disorders, IgG₄-RD is responsive to steroid therapy or rituximab. Therefore, a timely diagnosis can help slow down or prevent symptomatic manifestations, as seen in the case. Clinicians should be aware of this clinical presentation.

1306 Endoscopic Mucosal Resection of Pancreatic Rest Presenting as a Submucosal Nodule in the Gastric Antrum

INTRODUCTION: Pancreatic rest (PR) is defined as ectopic pancreatic tissue outside the normal pancreatic parenchyma, with a vascular and nerve supply separate from the pancreas itself and has a prevalence of 0.55-14%. It is believed to arise during rotation of the foregut, when fragments of the pancreas become separated from the main body and are deposited at ectopic sites. CASE DESCRIPTION/METHODS: An 82-year-old male with a history of GERD presented with episodes of epigastric abdominal pain of 2 month duration that did not improve despite PPI therapy. He denied any other symptoms such as bleeding, weight loss or change in bowel habits. Physical examination revealed a non-distended abdomen and mid-epigastric tenderness. An EGD performed for evaluation of GERD 3 years prior found an antral nodule. A repeat EGD was done this time for evaluation of the epigastric pain and showed a mobile submucosal nodule in the antrum measuring 7-8 mm, unchanged from before. EUS was performed for further evaluation and showed a hypoechoic gastric submucosal lesion, arising from the muscularis mucosa, 8 mm in size. No high-risk features were present. The area was resected using EMR and the defect was closed with clips. The EUS also showed a cystic dilation of the pancreatic duct in the pancreatic head measuring 5 mm, suspicious for main duct IPMN. Results from the EMR biopsy demonstrated heterotopic pancreatic tissue with focal low grade pancreatic intraepithelial neoplasia (PanIN), with clear margins and reactive gastropathy with focal intestinal metaplasia. There was resolution of the abdominal pain after the procedure. A repeat EGD/EUS will be done in 1 year. MRI will be performed in 6 months for surveillance of the pancreatic duct dilation. DISCUSSION: PR can be found virtually anywhere along the GI tract, but they are typically found in the stomach along the greater curvature and antrum. Although usually asymptomatic, the most reported symptom is mid abdominal pain. Complications of gastric ectopic pancreas include acute or chronic pancreatitis, necrosis, pseudocyst, gastric outlet obstruction and rarely carcinoma. PanIN is neoplastic epithelial proliferation that occurs in the small caliber pancreatic ducts; it is divided in 3 degrees based on architectural and nuclear atypia and has potential progression to invasive ductal adenocarcinoma. In our case, PanIN 1 was found on histology and the lesion was completely resected. PR should always be considered when evaluating a submucosal lesion of the GI tract.

Renal Dysfunction is a Risk Factor of Death after Gastric Endoscopic Submucosal Dissection in Elderly Patients Aged ≥80 Years.

Introduction Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is well accepted. However, its adaptation for elderly patients is unclear. This study aimed to investigate the prognosis and long-term outcomes of ESD for EGC in elderly patients aged ≥80 years by comparing their findings to the findings of patients aged <80 years. Materials and Methods The study included 533 patients (632 lesions). The patients were divided into an elderly group (age, ≥80 years; 108 patients; 128 lesions; mean age, 83.4 ± 2.7 years) and a nonelderly group (age, <80 years; 425 patients; 504 lesions; mean age, 69.6 ± 7.9 years). We compared patient and lesion characteristics, overall survival (OS), and disease-specific survival (DSS) between the 2 groups retrospectively. Multivariate analysis was performed to clarify the risk factors of death after ESD. Results The rate of curative resection and adverse events was not significantly different between the groups. The mean survival time periods with regard to OS/DSS in the elderly and nonelderly groups were 75.8 ± 5.9 and 122.8 ± 2.6 months (P < 0.05)/120.0 ± 3.0 and 136.4 ± 0.6 months (not significant), respectively. In the elderly group, eGFR <30 ml/min/1.73 m2 was an independent risk factor of death (hazard ratio = 5.32; 95% confidence interval = 1.39–20.5; P=0.015). Conclusion ESD for EGC can be performed safely and can achieve high curability with good prognosis in elderly patients aged ≥80 years. After ESD, close attention should be paid to elderly patients with severe chronic kidney disease.

Clinical Usefulness of Dual Red Imaging in Gastric Endoscopic Submucosal Dissection: A Pilot Study.

Background/AimsDual red imaging (DRI) is a new, image-enhanced endoscopy technique. There are few reports about the usefulness of DRI during gastric endoscopic submucosal dissection (ESD). We aimed to examine the usefulness of DRI in endoscopic hemostasis during gastric ESD. MethodsWe enrolled a total of 20 consecutive patients who underwent gastric ESD. Five endoscopists compared DRI with white light imaging (WLI) for the visibility of blood vessels and bleeding points while performing endoscopic hemostasis. ResultsThe visibility of blood vessels was increased in 56% (19/34) of the cases, and the visibility of bleeding points was improved in 55% (11/20) of the cases with the use of DRI compared with the use of WLI. ConclusionsDRI improved the visibility of blood vessels and bleeding points in cases with oozing bleeding, blood pooling around the bleeding points, and multiple bleeding points.

Images of the month 2: A rare case of haematemesis from a gastric submucosal lesion

A 93-year-old male presented to the emergency department with haematemesis along with symptoms of lethargy and decreased appetite. Following fluid resuscitation, an upper gastrointestinal endoscopy was performed. A large submucosal lesion with ulceration and oozing blood was observed in the gastric

Value and limitation of endoscopic ultrasonography on the diagnosis of gastrointestinal submucosal tumor prior to endoscopic resection

Objective To investigate the efficacy and limitation of endoscopic ultrasonography(EUS) on the diagnosis of gastrointestinal submucosal tumor (SMT) prior to endoscopic resection. Methods Data of 211 patients, who were confirmed as gastrointestinal SMT before operation and received endoscopic resection for gastrointestinal submucosal tumor at Department of Gastroenterology, Shanghai Ruijin Hospital from January 2016 to December 2018 were analyzed. The value and limitation of EUS for SMT were investigated according to the final pathology. Results For the lesion distribution, 66 were in esophagus, 108 in stomach, 2 in duodenum and 35 in rectum. The accuracy of tumor origin by EUS was 99.5% (210/211). The accuracy of tumor nature by EUS was 75.8% (160/211). For the lesions originated from different locations, the diagnostic accuracy for lesion originated from esophageal mucosa/submucosa, esophageal muscularis propria, gastric mucosa/submucosa, gastric muscularis propria, duodenal submucosa, rectal mucosa/submucosa by EUS were 90.0%(54/60), 83.3%(5/6), 31.0%(13/42), 89.4%(59/66), 50.0%(1/2), 82.9%(29/35), respectively. With respect to hypoechoic lesions, leiomyoma, leiomyoma/gastrointestinal stromal tumor, and neuroendocrine tumor were the predominant type of tumor originated from esophageal mucosa, gastrointestinal muscularis propria and rectal mucosa/submucosal, respectively. Conclusion Although EUS is indispensible for the diagnosis of gastrointestinal submucosal tumor, it plays a limited role in the differential diagnosis of various lesions originated from gastric mucosa and submucosa. Since part of the submucosal tumors may be potential for malignant development, an diagnosis made by EUS should be more careful. Key words: Endoscopy; Endoscopic ultrasonography; Submucosal tumor

Cytomorphological features of glomus tumors arising in the stomach: A series of two cases diagnosed on FNA

• Gastric glomus tumors are rare mesenchymal tumors that should be included in the differential of gastric submucosal masses. • Cytologic features of glomus tumors are distinctive, but immunohistochemistry is required to help ascertain the diagnosis. • Endoscopic ultrasound-guided fine-needle aspiration can be used in the diagnosis of gastric intramural or submucosal lesions.

Comparison of Nonexposed Endoscopic Wall-Inversion Surgery with Endoscopic-Navigated Laparoscopic Wedge Resection for Gastric Submucosal Tumours: Results of a Two-Centre Study.

Introduction The aim of this study was to compare the indications, operative details, and clinical outcomes of nonexposed endoscopic wall-inversion surgery with endoscopic-navigated laparoscopic wedge resection of gastric submucosal tumours. Methods Medical records were reviewed for patients who underwent nonexposed endoscopic wall-inversion surgery (NEWS) at the Faculty Hospital Kralovske Vinohrady and endoscopic-navigated laparoscopic wedge resection (LWR) at the Kepler University Hospital. Demographic, tumour, surgical, perioperative, and follow-up data were collected and compared. Results Eleven patients underwent NEWS and twelve patients underwent LWR. NEWS was associated with a longer operating time and more frequent suture line bleeding (3 cases in the NEWS group versus 1 case in the LWR group). Negative resection margins were achieved in all NEWS procedures and in 11 of the LWRs. The difference in size between the tumour and the resected specimen was smaller in the NEWS group. Length of hospitalisation was similar between the two groups (NEWS = 6.8 days, LWR = 6.5 days). Follow-up gastroscopies at 12 months postoperatively revealed no signs of recurrence in any of the patients. Conclusion Nonexposed endoscopic wall-inversion surgery is a new technique for the treatment of gastric tumours. It allows for more precise resections with more frequent achievement of negative resection margins than LWRs. Additionally, it may allow for better preservation of gastric function and limit communication between the gastric lumen and peritoneal cavity. The longer operating time and more frequent complications associated with the NEWS reflects the limited experience with these new techniques.

EndoClot®SIS Polysaccharide Injection as a Submucosal Fluid Cushion for Endoscopic Mucosal Therapies: Results of Ex Vivo and In Vivo Studies.

There are many studies on submucosal injection materials, but their clinical use is restricted for various reasons. The objective of this study was to compare the feasibility and safety of injected EndoClot®SIS polysaccharide as a submucosal injection material (SFC) in ESD in the pig stomach to that of injected sigMAVisc™ or Eleview™. Four pig stomachs were used for the ex vivo study. Eighteen pigs were used for the in vivo study. In the ex vivo study, four injections were made in the gastric submucosa to induce submucosal uplift and extend its duration. Tissue change was observed. The in vivo study was performed in 2 steps. First, 3 injections were made in the esophageal mucosa to induce submucosal uplift and extend its duration. Histological change was observed. Second, ESD was performed in the stomach by injecting EndoClot®SIS polysaccharide, sigMAVisc™, or Eleview™ (each, n = 6) as an SFC. The effects of these agents on wound healing were examined. We evaluated the efficacy and safety of endoscopic surgery after EndoClot®SIS polysaccharide injection. EndoClot®SIS polysaccharide produced a longer-lasting elevation with clearer margins than was achieved by sigMAVisc™, Eleview™, or 0.9% NaCl and thereby enabled precise ESD without complications, such as bleeding and perforation. No obvious histopathological damage was observed at the injection site on endoscopy and histology. Submucosally injected EndoClot®SIS polysaccharide increased the effective separation of the mucosa and submucosa and reduced surgical complications. Hence, EndoClot®SIS polysaccharide injection is a safe and effective submucosal injection material.

Endoscopic Resection of Gastric Submucosal Masses by a Dental Floss Traction Method.

Background and Aims ESE (endoscopic submucosal excavation) is widely used for the treatment of digestive diseases. The dental floss traction (DFT) method has been successfully used to facilitate ESE to resect mucosal lesions such as early gastric cancer. DFT has not been used in ESE to remove submucosal masses. This study aimed to examine the efficacy of DFT-assisted ESE (DFT- ESE) for the removal of submucous masses. Methods From March 2017 to May 2017, a total of 12 patients with gastric submucosal masses at the First Affiliated Hospital of Nanchang University, Jiangxi, China, were enrolled. The tumor characteristics, en bloc resection rates, complications, and outcomes on follow-up were evaluated for all patients. Results The 12 submucosal tumors were completely removed by DFT- ESE. Nine were gastrointestinal stromal tumors. Two were Schwannoma, located in the greater curvature of the gastric corpus. One was gastric ectopic pancreas. All the resected tumors were removed completely with intact tumor capsules. There was no more bleeding or perforation after the endoscopic closure of the perforation or the wound after the DFT-ESE, and no recurrences were identified at the time of follow-up. Conclusions The DFT method efficiently and safely facilitated the ESE procedure during the resection of gastric submucosal tumors. This study was registered with Chinese Clinical Trial Registry under Registration number ChiCTR-OOC-15005833).

Examine the Availability and Safety of Mucosal Cutting Biopsy Technique for Diagnosis of Gastric Submucosal Tumor.

Objectives Differentiating gastrointestinal stromal tumor (GIST) from other submucosal tumors (SMTs) is important in diagnosing SMT. GIST is an immunohistological diagnosis that cannot be made from images alone. Tissue sampling of tumor sites is thus becoming increasingly important. In this study, the utility and associated complications of mucosal cutting biopsy (MCB) for gastric SMTs were investigated. Methods This was a case series study. The subjects were patients aged ≥20 years old in whom an SMT was seen on esophagogastroduodenography and who underwent MCB between January 2012 and December 2016. Patient information, endoscopy findings, gastric SMT size, pathological diagnosis, and other information were gathered from medical records. The SMT size was the maximum diameter that could be visualized on EUS. The pathological diagnosis was made with hematoxylin-eosin staining, with immunostaining added to diagnose GIST. The endpoint was the histopathological diagnostic yield. Risk assessment using the Miettinen classification and modified Fletcher classification was also done for GISTs treated with surgery. Results The mean tumor diameter was 15.4 mm. The tumor diameter was ≥20 mm in seven patients and <20 mm in 23 patients. The tissue-acquiring rate was 93.3%. A histological diagnosis could not be made in two patients. The only complication was that bleeding required endoscopic hemostasis during the procedure in one patient, but no subsequent bleeding or no postoperative bleeding was seen. Conclusions MCB is an appropriate and safe procedure in the diagnosis of gastric SMTs. Many hospitals will be able to perform MCB if they have the environment, including skills and equipment, to perform endoscopic submucosal dissection.

Su1312 – Abnormal Bioelectrical Slow-Wave in Patients with Gastric Submucosal Tumor, Defined by In-Vivo Laparoscopic High-Resolution Electrical Mapping

Su1312 – Abnormal Bioelectrical Slow-Wave in Patients with Gastric Submucosal Tumor, Defined by In-Vivo Laparoscopic High-Resolution Electrical Mapping

Early gastric cancer with multiple submucosal heterotopic gastric gland: A case report.

A case of early gastric cancer involving multiple submucosal gastric glands that was treated by distal gastrectomy was described in the present case report. An 85-year-old man was referred to our hospital for the treatment of gastric cancer. Esophagogastroduodenoscopy revealed an irregular, nodular, elevated lesion on the posterior wall of the middle third of the stomach, and biopsy specimens indicated well-differentiated tubular adenocarcinoma. Submucosal tumor (SMT)-like lesions were detected in the area adjacent to the nodular lesion, in the anterior wall side of the middle third of the stomach. Abdominal contrast-enhanced computed tomography showed cystic lesions in the middle part of the stomach, and no mass lesions in the liver. The patient underwent distal gastrectomy with regional lymphadenectomy. Macroscopic examination of the resected specimen showed an SMT-like lesion measuring 2.8×2.6 cm in contact with a superficial, depressed lesion measuring 1.7×0.9 mm in the middle third of the stomach, and another SMT-like lesion measuring 1.5×1.4 cm in diameter, which was also in the middle third of the stomach. The pathological diagnosis was well-differentiated tubular adenocarcinoma invading the gastric submucosal layer without lymph node metastasis, but with nearby submucosal heterotopic gastric gland (SHGG) detected. Following surgery, the patient remained symptom-free without evidence of recurrence for 3 months. The finding of SHGG remains a rare entity, and further studies are warranted to clarify the association between these submucosal lesions and the development of cancer.

Feasibility and safety of third-space endoscopic full-thickness resection in ex vivo and in vivo porcine models.

Background and study aims Endoscopic full-thickness resection (EFTR) involves several technical issues that need to be addressed. We devised a novel technique termed third-space EFTR and investigated its feasibility and safety in animal models. Methods Third-space EFTR was performed in three isolated porcine stomachs (ex vivo) and four live pigs (in vivo, 1-week survival). The technique involved a circumferential mucosal incision, submucosal tunnelling on the proximal side, endoscopic suturing of the surrounding mucosa, a circumferential seromuscular incision in the submucosal tunnel, transoral retrieval and entry site closure of the tunnel. The technical outcomes were investigated. Results In the ex vivo study, the procedure was successfully completed with R0 resection. In the in vivo study, the procedure was completed in all pigs; however, R0 resection failed in one pig owing to snaring resection. All pigs survived without severe adverse events. Conclusions Our findings indicate that third-space EFTR is feasible and safe. This technique may be useful as a minimally invasive endoscopic option for reliable treatment of small gastric submucosal tumours.