Giant gastric leiomyoma excision using endoscopic submucosal dissection with dental floss clip traction technique: a case report

Abstract

For gastric leiomyomas measuring ≥5 cm, endoscopic resection is necessary. The larger size of these tumors significantly impairs the resection field of view, increasing the risk of intraoperative bleeding and perforation and potentially leading to incomplete tumor removal. The combination of dental floss and tissue clip traction techniques is commonly used for resecting mucosal lesions but is rarely reported for submucosal tumors. We recently completed a case of endoscopic resection of a giant gastric leiomyoma in the body of the stomach, approximately 7 cm in length, using endoscopic submucosal dissection with dental floss clip traction. The dissection was carefully controlled within the muscularis propria layer, avoiding damage to the serosa. No bleeding or perforation occurred. A special technique was employed to avoid damage to the muscle layer. By combining this technique with tissue forceps, better traction stability may have been achieved. During the traction process, slight tension was consistently maintained between the swelling and the muscle layer, preventing perforation due to traction. The resection field remained clear throughout the procedure, which lasted 50 minutes in total. The final outcome was satisfactory. This method may be worthy of clinical application.

Introduction

Gastric leiomyoma is a benign submucosal tumor composed of smooth muscle cells, accounting for 2.5% of all gastric tumors.^1,2 It is the most common submucosal tumor of the upper gastrointestinal tract.^3,4 Although malignant transformation is rare, some leiomyomas can gradually increase in size and may present with clinical symptoms such as bleeding, pain, or obstruction.^5,6 Therefore, large gastric leiomyomas should be resected. Currently, common endoscopic resection methods include endoscopic submucosal dissection (ESD), endoscopic mucosal resection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection.

It should be noted that there is no standardized method for the resection of giant submucosal leiomyomas. Because of the large size of the tumor, the field of view during resection is poor, and the incidence of complications is high. The tubular structure of the endoscope and the non-axial operation mode increase the difficulty of resection and may prolong surgery time. ⁷ For operators with limited experience, resecting tumors through endoscopic submucosal excision can be challenging. A large meta-analysis has shown that traction-assisted ESD can shorten the operation time, increase the R0 resection rate, and reduce the risk of perforation. ⁸ However, the use of a suture-combined tissue clamp traction technique for the resection of giant gastric leiomyomas has not been reported.

Case report

A 40-year-old woman was admitted to the Department of Gastroenterology at Shenzhen Second People’s Hospital, Shenzhen, Guangdong, on 20 January 2024 with a 3-year history of abdominal pain and a 2-month history of noticeable gastric mass. Given the patient’s abdominal pain, the large tumor size, and her strong willingness for surgery, endoscopic mass resection was performed. White light endoscopy (GIF-Q260J; Olympus, Tokyo, Japan) revealed a long, strip-like raised mass on the posterior wall of the upper stomach body, measuring approximately 7 cm in length. No marking was performed because of the distinct visibility of the mass, and submucosal injection was administered prior to mucosal incision (Figure 1(a)). Ultrasound endoscopy showed that the lesion appeared as hypoechoic changes originating from the muscularis propria (Figure 1(b)). A mucosal incision knife (2.0 mm with IT-NANO functionality) was used to incise the surface mucosa of the mass, exposing the tumor body, which was then dissected along its edges (Figure 1(c)). During the operation, suture traction was applied (Figure 1(d)), and the mass was carefully excised while maintaining tension on the leiomyoma to avoid inadvertent traction on the muscular layer, thus preventing perforation (Figure 1(e)). The wound surface was closed with one three-arm clip and multiple tissue clips (Figure 1(f)), and the postoperative specimen is shown in Figure 1(g). The postoperative pathological diagnosis confirmed leiomyoma. This study adheres to the CARE guidelines. ⁹

Figure 1.

Endoscopic resection of a large gastric leiomyoma using the suture-combined tissue clamp traction technique. (a) White light endoscopy shows a long strip-like raised mass on the posterior wall of the upper stomach body, measuring approximately 7 cm in length. (b) Ultrasound endoscopy reveals hypoechoic changes in the lesion, originating from the muscularis propria. (c) A mucosal incision knife (Woodpecker Knife, 2.0 mm) is used to cut the surface mucosa of the mass, exposing the tumor body, which is then peeled off along its edges. (d) Suture traction is used during the operation. (e) The mass is completely excised. (f) The wound surface is sutured with one three-arm clip and multiple tissue clips and (g) postoperative specimen.

Discussion

Gastric leiomyomas are benign tumors, most of which originate from the muscularis propria. They can be found in any part of the stomach and can grow extraluminally or intraluminally. The prevalence of gastric leiomyomas is approximately 2.4% of all gastric tumors. They are more common in women aged 50 to 59 years. ¹⁰ Most gastric leiomyomas are asymptomatic and are often discovered incidentally during other surgeries. ¹¹ Some leiomyomas can enlarge, and in severe cases, clinical symptoms such as bleeding, pain, and obstruction may occur.^5,6 In traditional ESD, unclear visualization may lead to difficulty in resection. Traction-assisted resection techniques are methods that can provide tissue tension within the submucosal layer and facilitate resection under direct vision. Existing assistive resection techniques include magnetic anchor-guided ESD, the use of dual endoscopes, and clip-assisted techniques. ¹² A meta-analysis of seven randomized controlled trials showed that for the treatment of superficial gastrointestinal tumors, traction-assisted ESD is more effective than traditional ESD. ¹³

A randomized controlled trial demonstrated that auxiliary traction techniques are more suitable for lesions located in the upper or middle stomach with larger curvature. However, the efficacy of traction techniques in gastric ESD varies significantly depending on the lesion’s location, the degree of submucosal fibrosis, and the equipment used. ¹⁴ Previous studies have indicated that the suture traction method can successfully expose the edges of tumors originating from the mucosa for resection. Its three main advantages are as follows: the preparation and use of the suture-combined tissue clamp are simple and convenient; if bleeding occurs, hemostasis can be achieved through compression and/or electrocoagulation to expose the bleeding point; and the use of sutures can make the surgery faster and safer.^15,16 A retrospective study showed that suture traction-assisted ESD for small submucosal tumors originating from the muscularis propria of the gastric fundus is safe and effective and promotes postoperative recovery. ¹⁷ To date, there have been no case reports on the resection of giant gastric leiomyomas using suture traction.

In this case, we used a suture-combined tissue clamp traction technique to resect a large gastric leiomyoma measuring ≥5 cm, simplifying the procedure and enhancing stability compared with previous methods. Our approach, which incorporated tissue forceps with suture traction, addressed the technical challenges of clip placement and suture management, potentially reducing the risk of bleeding and shortening surgery time. This innovative technique offers a more efficient and safer alternative for the resection of large submucosal gastric tumors.^18–20

We present the first reported case of using the suture-combined tissue clamp traction technique to remove a gastric body leiomyoma measuring approximately 7 cm in length. No adverse events occurred during the resection process, which lasted 50 minutes, and the tumor was completely excised. This case demonstrates the feasibility of using this technique to remove gastric leiomyomas measuring ≥5 cm.

For gastric leiomyomas measuring ≥5 cm, endoscopic resection is necessary. The suture-combined tissue clamp traction technique offers advantages such as operational simplicity, lower complication rates, and shorter surgery times. However, further observation and investigation through larger-scale case studies are needed to validate its safety and effectiveness.

In conclusion, the combination of dental floss and tissue clip traction techniques demonstrated potential efficacy as an ancillary approach for the resection of large gastric submucosal tumors in this case. This method warrants further exploration and evaluation in future studies to determine its broader applicability and safety profile.