Gastrointestinal submucosal tumors (SMTs) mostly grew in the lumen, but also some of the lesions were extraluminal, in which the stomach was the most common site. Gastrointestinal stromal tumor account for a large proportion of SMT. Due to the deep lesion location of gastric SMT, endoscopic submucosal dissection related techniques are difficult to operate, while endoscopic full-thickness resection (EFTR) has been widely used in clinical practice because it is less invasive and can preserve the physiological structure and function of the stomach. However, complete closure of the gastrectomy site after EFTR is critical. If the closure is incomplete, it may cause peritonitis, late perforation and other conditions, and even require further surgical intervention. Although there are currently a number of suture devices and techniques that can be used to promote closure, they have the problem of requiring additional equipment or being inconvenient to use. Although metal clips are widely used, their effectiveness depends on the size and tension of the defect. Therefore, an effective and convenient endoscopic closure technique is urgently needed to solve the closure problem of gastric SMTs after treatment.

To investigate the effect of combined application of the preclosure technique and dental floss traction in gastric wound closure following EFTR.

In this study, the data of 94 patients treated for gastric SMTs at the Gastrointestinal Endoscopy Center of the Affiliated Union Hospital of Fujian Medical University from April 2022 to May 2023 were retrospectively analyzed. The patients were divided into a preclosure group (54 patients) and a non-preclosure group (40 patients) on the basis of the timing of wound closure with titanium clips after dental floss traction-assisted EFTR. Each patient in the preclosure group had their wounds preclosed with titanium clips after subtotal lesion resection, whereas each patient in the non-preclosure group had their wounds closed with titanium clips after total lesion resection. The lesion size, wound closure time, number of titanium clips used, incidence of postoperative complications, and postoperative hospitalization time were compared between the two groups.

The wound closure time was significantly shorter in the preclosure group than in the non-preclosure group (6.69 ± 2.109 minutes vs 11.65 ± 3.786 minutes, P < 0.001). The number of titanium clips used was significantly lower in the preclosure group (8.93 ± 2.231) than in the non-preclosure group (12.05 ± 4.495) (P < 0.001). There was no significant difference between the two groups in terms of the need for an indwelling gastric tube or the length of postoperative hospital stay (6.41 ± 1.31 vs 6.13 ± 1.06 days). For all patients in the preclosure group and the non-preclosure group, resection was completed successfully without bleeding, abdominal pain, abdominal distension, or other postoperative complications.

Application of the preclosure technique combined with dental floss traction can be used intraoperatively to effectively close the surgical wound in patients undergoing EFTR, reliably preventing the tumor from falling into the peritoneal cavity.

Aim: To explore the feasibility and effectiveness of snare-assisted traction endoscopic full thickness resection (EFTR) on gastric fundus submucosal tumors (SMTs). Methods: The clinical and pathological data of patients with gastric SMTs who underwent EFTR treatment at the Endoscopy Center of Kaifeng Central Hospital from January 2018 to June 2023 were collected. Among them, 36 patients underwent snare-assisted traction EFTR (SAT-EFTR) and 46 patients underwent standard EFTR (S-EFTR). The clinical baseline data, operative data, adverse events, and follow-up results of the two groups were collected and compared. Results: All patients successfully completed EFTR technique. There were 34 male and 48 female patients, with an average age of (56.62 ± 11.31) years. The average operation time was shorter in the snare-assisted EFTR group than the S-EFTR group (73.39 ± 31.33 minutes versus 92.89 ± 37.57 minutes, P = .014). In addition, the resection speed of the snare-assisted EFTR group was also significantly faster than that of the S-EFTR group (4.04 ± 2.23 versus 2.48 ± 0.93 mm2/min, P < .001). There was no statistically significant difference in the age, gender, lesion size, postoperative fasting duration, and postoperative hospitalization stay between the two groups (P > .05). One patient in the SAT-EFTR group developed delayed postoperative perforation which was close with purse‑string suture technique. All patients were discharged successfully, and there was no recurrence or metastasis during the follow-up period. Conclusion: Snare-assisted traction of EFTR could shorten the operation time, reduce the difficulty of the operation, and improve the efficiency of the operation. At the same time, this method is simple and easy to learn, more suitable for beginners, and worthy of clinical promotion and application.

With the advent of endoscopic submucosal dissection, a variety of endoscopic devices including knives and high-frequency electrosurgical unit have become available. In addition, the concept of natural orifice transluminal endoscopic surgery pushed flexible endoscopic surgery ahead. In this review, the birth of peroral endoscopic myotomy and its expansion into the field of submucosal endoscopy are reviewed.

Endoscopic submucosal dissection (ESD) is a method that can be used for en bloc resection, regardless of the size and form of the lesion. The special location of ileocecal tumors leads to insufficient counter-traction and poor field of vision, making ESD difficult. An S-O clip has been developed to simplify the attachment procedure, eliminating interference with the endoscope and improving accessibility.

The patient was a 70-year-old man who presented with abdominal pain and bloating. A colonoscopy revealed a flat-elevated-type lesion on the ileocecal valve, with the oral side of the lesion having progressed to the terminal ileum. The traction direction was adjusted from distal to proximal during the procedure using the S-O clip. Finally, with the help of the S-O clip, the tumor was safely removed and collected.

The S-O clip was successful in ESD of a colorectal tumor. By removing and re-anchoring the loaded ring, the S-O clips allowed the adjustment of traction direction from distal to proximal during ESD.

Endoscopic submucosal dissection (ESD) was developed in 2000s to overcome the limitations of endoscopic mucosal resection (EMR), especially to accomplish en-bloc resection, and it has been accepted worldwide in the past decades. Many ESD devices and diagnosis modalities are currently available, which include pit pattern and narrow band imaging (NBI) diagnoses to evaluate the depth of the tumor preoperatively with sensitivities of 70 to 90%. Depending on the Japanese colorectal guideline, the intramucosal cancer and shallow invasion of the submucosal layer are the main good indications of ESD; however, the ESD practices between Japan and Western countries still vary, including pathologic definition of cancer, tumor/node/metastasis classification, and handling of ESD specimen. In the United States, despite the large demand for treatment of colorectal neoplasm, pit pattern and magnified NBI diagnoses are not widely accepted yet, and piecemeal EMR is still the major method in most of the institutions. Moreover, the specific guideline of ESD is also not available yet. More new technologies are being developed other than conventional ESD methods in Eastern and Western countries, and ESD is now expected to change in the next generation. It is recommended that not only gastroenterologists but also colorectal surgeons have appropriate knowledge of colorectal lesions and their management to ensure current treatments is applied to patients.

In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.