Name: Evaluation of the Effectiveness of Longitudinal Incision for Endoscopic Submucosal Excavation of Gastric Subepithelial Lesions (Video) | JoVE Journal
Uploaded: 2026-04-28T12:35:00.000+00:00
Duration: 4 min 8 s
Description: Learn longitudinal incision endoscopic submucosal excavation for gastric subepithelial lesions ≤2 cm. This technique reduces operative time and simplifies defect closure compared to circular incision methods.

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5 minutes

This work was supported by a grant from the Medical Scientific Research Foundation of Guangdong Province, China (Grant number B2024163). No relevant financial activities outside the submitted work.

This study retrospectively analyzed patients diagnosed with gastric SELs who underwent endoscopic surgery at the Digestive Endoscopy Center. The study was approved by the Ethics Committee of the First Affiliated Hospital of Jinan University (approval number: KY-2025-323), complies with the Declaration of Helsinki, and all patients have provided informed consent.
NOTE: Figure 1 shows a typical endoscopic image of gastric SELs.
1. Patient selection
<ol>
	<li>Inclusion criteria: Include patients with a preoperative diagnosis of gastric SELs by endoscopic ultrasound (EUS) or computed tomography (CT); maximum lesion diameter &#8804; 2 cm; absence of high-risk endoscopic features (including irregular border, ulceration, heterogeneous echogenicity, cystic spaces, or hyperechoic nodules).</li>
	<li>Exclusion criteria: Exclude patients with lesions preoperatively assessed to involve the serosal layer or significantly protrude outward, making endoscopic treatment unfeasible; evidence of lymph node or distant metastasis; severe primary diseases of the heart, cerebrovascular system, liver, kidneys, or hematopoietic system; severe gastrointestinal bleeding or life-threatening perforation requiring immediate surgical intervention.</li>
</ol>
2. Patient preparation
<ol>
	<li>Conduct preoperative evaluations
	<ol>
		<li>Perform blood tests, including a complete blood count, coagulation profile, liver and kidney function tests, electrolyte panel, and screenings for infectious diseases (Hepatitis B/C, HIV, Syphilis). These assess bleeding risk, coagulation status, and the patient&#39;s general health.</li>
		<li>Obtain an electrocardiogram to evaluate cardiac function and rule out severe arrhythmia or other contraindications to surgery.</li>
		<li>Acquire a chest X-ray&#8203; to establish a baseline assessment of cardiopulmonary status.</li>
	</ol>
	</li>
	<li>Preoperative informed consent
	<ol>
		<li>The attending physician must explain in detail the procedure&#39;s necessity, process, and expected outcomes to the patient and family. Discuss potential risks and complications, such as bleeding, perforation, infection, and incomplete resection or recurrence of the lesion.</li>
		<li>Have the patient or their legal representative sign the procedural and anesthesia consent forms&#8203; after ensuring they fully understand the information provided.</li>
	</ol>
	</li>
	<li>Prepare the patient
	<ol>
		<li>Instruct the patient to fast&#8203; for 8-12 h and refrain from clear liquids for 4-6 h prior to the procedure to ensure an empty stomach.</li>
	</ol>
	</li>
	<li>Operating setting and anesthesia
	<ol>
		<li>Position the patient in the left lateral decubitus position under general anesthesia with endotracheal intubation. Use carbon dioxide for endoscopic insufflation during the operation.</li>
	</ol>
	</li>
</ol>
3. Surgical methods16,17
<ol>
	<li>For the improved group, perform endoscopic resection using a novel longitudinal incision. For the conventional group, perform endoscopic resection using the conventional circular incision.</li>
	<li>Marking
	<ol>
		<li>Mark several dots along the lesion margin using a single-use electrosurgical knife, forming a circular pattern 3-5 mm outside the lesion edge to define the resection boundaries. Set the high-frequency electrosurgical system to: Forced Coag, Effect 2, 20 W. 
		CAUTION: Improper use of the high-frequency electrosurgical system may cause serious injury to patients and staff. Always inspect the return electrode and cable before each use.</li>
	</ol>
	</li>
	<li>Submucosal injection
	<ol>
		<li>Prepare a mixture of 250 mL of normal saline and 2 mL of 0.2% indigo rouge.</li>
		<li>Using a 23G single-use injector with a 4 mm needle, perform the injection from distal to proximal at an angle of 15&#176; to 30&#176;. Place injections just outside the pre-marked dots to achieve maximum elevation directly adjacent to the markings.</li>
		<li>Advance the needle deep into the tissue, then inject while slowly withdrawing to ensure the tip remains within the mid-submucosal layer. The mucosal surface should elevate rapidly, uniformly, and persistently, forming a smooth, dome-shaped mucosal elevation. This ensures adequate lifting of the lesion from the underlying muscle layer, creating a safety cushion to prevent perforation. 
		NOTE: The blue dye enhances visualization of the submucosal layer throughout the procedure.</li>
	</ol>
	</li>
	<li>Mucosal incision
	<ol>
		<li>Improved group: Make a longitudinal incision through the mucosa and submucosa along the central axis of the lesion using the single-use electrosurgical knife, ensuring it surpasses the lesion&#39;s entire longitudinal dimension.</li>
		<li>Conventional group: Make a circular incision approximately 3 mm outside the pre-marked points. Fully incise the submucosal tissue to expose the lesion.</li>
		<li>Set the high-frequency electrosurgical system to: Endo Cut Q, Effect 3, Cut Duration 2, Cut Interval 4; Forced Coag, Effect 2, 50 W.</li>
	</ol>
	</li>
	<li>Submucosal excavation
	<ol>
		<li>Carefully dissect and separate the submucosal connective tissue beneath the lesion using the electrosurgical knife.</li>
		<li>Fully expose the lesion and completely free it from its attachments, while preserving the underlying muscle layer as much as possible.</li>
		<li>If bleeding is detected during the separation process, use the knife to coagulate minor bleeding vessels.</li>
	</ol>
	</li>
	<li>Hemostasis
	<ol>
		<li>Thoroughly inspect the resection defect for active bleeding or visible vessels. Treat any bleeding points or high-risk vessels with the single-use electrosurgical hemostatic forceps to prevent delayed bleeding. Set the high-frequency electrosurgical system to: Soft Coag, Effect 2, 80 W.</li>
	</ol>
	</li>
	<li>Defect closure
	<ol>
		<li>First, moderately aspirate intragastric gas to approximate the defect edges and reduce the tissue gap for clipping. Engage the mucosal edge on the proximal side of the defect with one jaw of the clip and then hook the distal mucosal edge with the opposite jaw. Close the clip while maintaining continuous suction.</li>
		<li>Next, apply clips sequentially to approximate the mucosal edges until the entire defect is fully apposed.</li>
		<li>For larger defects, consider combined techniques using a single-use ligating device with clips for complete closure. If hemostasis or defect closure is ineffective, refer the patient for laparoscopic intervention.</li>
	</ol>
	</li>
	<li>Specimen management
	<ol>
		<li>Retrieve the resected specimen using a snare or retrieval net. Figure 2 and Figure 3 show the endoscopic resection procedure.</li>
		<li>Fix the specimens in 10% formaldehyde solution for 24h and send for pathological examination, including HE staining and immunohistochemistry (for CD117, CD34, DOG-1, Ki-67, actin, S-100, desmin, vimentin, and other indicators). 
		CAUTION: Formaldehyde is a hazardous chemical used for tissue fixation. It is a known carcinogen, sensitizer, and irritant. Handle formaldehyde solutions only in a well-ventilated area.</li>
		<li>Use closed-system containers for specimen transfer and storage whenever possible. Wear appropriate chemical-resistant gloves when handling formaldehyde.</li>
	</ol>
	</li>
</ol>
4. Postoperative management
<ol>
	<li>Monitor vital signs, symptoms, and abdominal signs postoperatively.</li>
	<li>Maintain patient fasting for the first day, then provide a semiliquid diet for 3 days, and gradually advance to a normal diet within 2 weeks.</li>
	<li>For patients who experienced perforation or full-thickness resection during surgery, advise fasting for 3 days postoperatively and resume oral intake gradually based on clinical condition.</li>
	<li>Routinely administer proton pump inhibitors (PPIs) and gastric mucosal protectants intravenously.</li>
	<li>Administer antibiotics in cases of intraoperative perforation or full-thickness resection to prevent infection.</li>
	<li>Provide symptomatic treatment for postoperative pain, fever, or other complaints.</li>
</ol>

<ol><li>Deprez, P. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+management+of+subepithelial+lesions+including+neuroendocrine+neoplasms%3A+European+Society+of+Gastrointestinal+Endoscopy+%28ESGE%29+Guideline+%5BTitle%5D)+AND+%22Endoscopy%22%5BJournal%5D)">Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline .</a> Endoscopy. 54 (4), 412-429 (2022).</li>
<li>Endoscopic Surgery Group, C.S. of D.E.C.M.A., NOTES Group, C.S. of D.E.C.M.A., Digestive Endoscopy Spcialty Comite, E.P.B. of C.M.D.A., Gastrointestinal Surgery Group, C.S. of S.C.M.A., Pinghong, Z., Zhaoshen, L. Chinese consensus on endoscopic diagnosis and managment of gastrointestinal submucosal tumors(version 2023). <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Chinese+J+Digestive+Endoscopy%22">Chinese J Digestive Endoscopy</a>. 40 (4), 253-263 (2023).</li>
<li>Jacobson, B. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((ACG+Clinical+Guideline%3A+Diagnosis+and+Management+of+Gastrointestinal+Subepithelial+Lesions%5BTitle%5D)+AND+%22Am+J+Gastroenterol%22%5BJournal%5D)">ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions.</a> Am J Gastroenterol. 118 (1), 46-58 (2023).</li>
<li>Kim, G. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+Resection+of+Subepithelial+Tumors%5BTitle%5D)+AND+%22Clin+Endosc%22%5BJournal%5D)">Endoscopic Resection of Subepithelial Tumors.</a> Clin Endosc. 45 (3), 240-244 (2012).</li>
<li>Humphris, J. L., Jones, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Subepithelial+mass+lesions+in+the+upper+gastrointestinal+tract%5BTitle%5D)+AND+%22J+Gastroenterol+Hepatol%22%5BJournal%5D)">Subepithelial mass lesions in the upper gastrointestinal tract.</a> J Gastroenterol Hepatol. 23 (4), 556-566 (2008).</li>
<li>Polkowski, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+ultrasound+and+endoscopic+ultrasound-guided+fine-needle+biopsy+for+the+diagnosis+of+malignant+submucosal+tumors%5BTitle%5D)+AND+%22Endoscopy%22%5BJournal%5D)">Endoscopic ultrasound and endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of malignant submucosal tumors.</a> Endoscopy. 37 (7), 635-645 (2005).</li>
<li><a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22National+Comprehensive+Cancer+Network+NCCN+Clinical+Practice+Guidelines+in+Oncology%3A+Gastrointestinal+Stromal+Tumors%22">National Comprehensive Cancer Network NCCN Clinical Practice Guidelines in Oncology: Gastrointestinal Stromal Tumors</a>. Version 1.2023, (2023).</li>
<li>Casali, P. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Gastrointestinal+stromal+tumours%3A+ESMO%E2%80%93EURACAN%E2%80%93GENTURIS+Clinical+Practice+Guidelines+for+diagnosis%2C+treatment+and+follow-up%5BTitle%5D)+AND+%22Ann+Oncol%22%5BJournal%5D)">Gastrointestinal stromal tumours: ESMO–EURACAN–GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up.</a> Ann Oncol. 33 (1), 20-33 (2022).</li>
<li>Xu, H. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+different+endoscopic+resection+techniques+for+submucosal+tumors+originating+from+muscularis+propria+at+the+esophagogastric+junction%5BTitle%5D)+AND+%22BMC+Gastroenterol%22%5BJournal%5D)">Comparison of different endoscopic resection techniques for submucosal tumors originating from muscularis propria at the esophagogastric junction.</a> BMC Gastroenterol. 19 (1), 174(2019).</li>
<li>Ponte Neto, F. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+resection+of+esophageal+and+gastric+submucosal+tumors+from+the+muscularis+propria+layer%3A+submucosal+tunneling+endoscopic+resection+versus+endoscopic+submucosal+excavation%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Endoscopic resection of esophageal and gastric submucosal tumors from the muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation: A systematic review and meta-analysis.</a> Surg Endosc. 35 (12), 6413-6426 (2021).</li>
<li>Dalal, I., Andalib, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Advances+in+endoscopic+resection%3A+a+review+of+endoscopic+submucosal+dissection+%28ESD%29%2C+endoscopic+full+thickness+resection+%28EFTR%29+and+submucosal+tunneling+endoscopic+resection+%28STER%29%5BTitle%5D)+AND+%22Transl+Gastroenterol+Hepatol%22%5BJournal%5D)">Advances in endoscopic resection: a review of endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER).</a> Transl Gastroenterol Hepatol. 7, 19(2022).</li>
<li>Chen, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+outcomes+of+submucosal+tunneling+endoscopic+resection+for+upper+gastrointestinal+submucosal+tumors%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Long-term outcomes of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors.</a> Ann Surg. 265 (2), 363-369 (2017).</li>
<li>An, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+submucosal+dissection+for+gastric+gastrointestinal+stromal+tumors%3A+a+retrospective+cohort+study%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Endoscopic submucosal dissection for gastric gastrointestinal stromal tumors: a retrospective cohort study.</a> Surg Endosc. 31 (11), 4522-4531 (2017).</li>
<li>Guoen, L. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+value+of+longitudinal+incision+in+endoscopic+submucosal+excavation+for+treating+submucosal+tumors+of+the+upper+gastrointestinal+tract%5BTitle%5D)+AND+%22J+Digest+Oncol%22%5BJournal%5D)">Clinical value of longitudinal incision in endoscopic submucosal excavation for treating submucosal tumors of the upper gastrointestinal tract.</a> J Digest Oncol. 8 (2), 7276(2016).</li>
<li>Zhou, P., Zhang, Y., Yao, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Application+and+evaluation+of+the+new+technique+of+minimal+endoscopic+dissection+for+gastrointestinal+tract+submucosal+tumor%5BTitle%5D)+AND+%22Chinese+J+Gastrointest+Surg%22%5BJournal%5D)">Application and evaluation of the new technique of minimal endoscopic dissection for gastrointestinal tract submucosal tumor.</a> Chinese J Gastrointest Surg. 16 (5), 406-410 (2013).</li>
<li>National Clinical Research Center for Digestive Diseases, Digestive Endoscopy Branch of Chinese Medical Association Perioperative guideline for endoscopic submucosal dissection for gastric lesions (2025 edition). <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Chinese+J+Digest+Endos%22">Chinese J Digest Endos</a>. 42 (6), 421-437 (2025).</li>
<li>Libânio, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+submucosal+dissection+techniques+and+technology%3A+European+Society+of+Gastrointestinal+Endoscopy+%28ESGE%29+Technical+Review%5BTitle%5D)+AND+%22Endoscopy%22%5BJournal%5D)">Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review.</a> Endoscopy. 55 (4), 361-389 (2023).</li>
<li>Li, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+and+safety+of+endoscopic+resection+for+small+submucosal+tumors+originating+from+the+muscularis+propria+layer+in+the+gastric+fundus%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Efficacy and safety of endoscopic resection for small submucosal tumors originating from the muscularis propria layer in the gastric fundus.</a> Surg Endosc. 33 (8), 2553-2561 (2019).</li>
<li>Jian, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+clinical+value+of+endoscopic+longitudinal+incision+and+excavation+for+gastrointestinal+submucosal+tumors%5BTitle%5D)+AND+%22Chinese+Digest+Med+Imageol%22%5BJournal%5D)">The clinical value of endoscopic longitudinal incision and excavation for gastrointestinal submucosal tumors.</a> Chinese Digest Med Imageol. 1 (1), 22-24 (2011).</li>
<li>Kaltenbach, T., Friedland, S., Barro, J., Soetikno, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clipping+for+upper+gastrointestinal+bleeding%5BTitle%5D)+AND+%22Am+J+Gastroenterol%22%5BJournal%5D)">Clipping for upper gastrointestinal bleeding.</a> Am J Gastroenterol. 101 (5), 915-918 (2006).</li>
<li>Li, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((New+devices+and+techniques+for+endoscopic+closure+of+gastrointestinal+perforations%5BTitle%5D)+AND+%22World+J+Gastroenterol%22%5BJournal%5D)">New devices and techniques for endoscopic closure of gastrointestinal perforations.</a> World J Gastroenterol. 22 (33), 7453-7462 (2016).</li>
<li>Gong, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((New+endoscopic+closure+technique%2C+%E2%80%9Cinternal+traction%E2%80%93assisted+suspended+closure%2C%E2%80%9D+for+GI+defect+closure%3A+a+pilot+study+%28with+video%29%5BTitle%5D)+AND+%22Gastrointest+Endosc%22%5BJournal%5D)">New endoscopic closure technique, “internal traction–assisted suspended closure,” for GI defect closure: a pilot study (with video).</a> Gastrointest Endosc. 99 (2), 186-192.e1 (2024).</li>
</ol>

The authors have nothing to disclose.

The critical determinants of success in endoscopic treatment for SELs are the completeness of lesion resection, the ability to effectively close the resulting defect, and the capacity to manage complications such as bleeding and perforation endoscopically9,18. This study focused on comparing a conventional circular incision ESE with a modified longitudinal incision ESE.
The key procedural innovation of the longitudinal incision techniq...

Subepithelial lesions (SELs) of the gastrointestinal tract originate from the deep layers beneath the mucosa1,2. Although SELs can be found throughout the digestive tract, they are most commonly detected in the stomach during routine endoscopy3,4,5. Histologically, most SELs are benign6; however, neuroendocrine tumors (NETs) and gastrointestinal stromal tumors (GISTs) possess malignant potential2,7. With advances in endoscopic technology and increased public health awareness, the detection rate of SELs has risen significantly. Standardized endoscopic minimally invasive treatment can improve patients&#39; quality of life, alleviate the burden on families and society, and conserve medical resources. According to the National Comprehensive Cancer Network (NCCN) guidelines for GIST management, lesions smaller than 2 cm without high-risk features may not require immediate resection7. In contrast, the European Society for Medical Oncology (ESMO) recommends excision of all GISTs&#8212;even those under 2 cm in diameter8. Nevertheless, long-term follow-up entails substantial economic and time costs, and a growing number of small lesions have been shown to harbor malignant potential2,7. Therefore, surgical resection is increasingly preferred when feasible. Current endoscopic treatments for SELs include snare resection, endoscopic submucosal excavation (ESE), submucosal tunnel endoscopic resection (STER), endoscopic full-thickness resection (EFTR), and natural orifice transluminal endoscopic surgery (NOTES)2,9,10,11,12. Among these, STER requires the creation of a submucosal tunnel, which limits its application to favorable anatomical locations like the esophagus and cardia11. EFTR, while versatile, involves full-thickness wall resection and presents considerable technical difficulties, particularly in achieving reliable defect closure11. On the other hand, ESE is considered feasible for intracavitary SELs &#8804; 2 cm. Conventional ESE follows the principles of endoscopic submucosal dissection (ESD), employing a circular incision around the lesion to remove the overlying mucosa, fully expose the lesion, and achieve complete resection9. Nonetheless, the substantial mucosal defects created by conventional ESE pose a significant challenge for closure13, leading to extended operative times9,14 and greater utilization of closure devices15. The circular incision creates a defect with circumferential tension, which often requires multiple clips or advanced closure techniques. In contrast, longitudinal incision follows the natural axial alignment of the gastrointestinal tract, where tissue mobility and biomechanical properties may facilitate easier apposition of the defect edges with less tension10,11,14. Therefore, there is a clinical need to develop a more convenient, straightforward, effective, and safe endoscopic closure technique.
In this study, we propose an improved technique, longitudinal incision endoscopic submucosal excavation for gastric SELs, in which a longitudinal incision is made through the mucosa and submucosa above the lesion, followed by lesion removal and defect closure with metal clips. The aim of this study is to evaluate the feasibility and technical outcomes of longitudinal incision ESE.

<table><tbody><tr><td>Disposable Distal Attachment</td><td>Olympus, Japan</td><td>D-201-11804</td><td>Transparent cap for mucosal dissection and traction</td></tr><tr><td>Endoscope</td><td>Fujinon, Japan</td><td>&amp;nbsp;EG-580RD</td><td>Therapeutic gastroscope with a 3.2 mm working channel</td></tr><tr><td>Endoscope host: Fujinon&amp;nbsp;</td><td>Fujinon, Japan</td><td>ELUXEO 7000</td><td>Video processor system</td></tr><tr><td>High-frequency Electrosurgical System</td><td>Erbe Elektromedizin GmbH, Germany</td><td>VIO 200D</td><td>Used for all cutting and coagulation procedures, including mucosal incision, submucosal dissection, and hemostasis. Specific modes (Endo Cut Q, Forced Coag, Soft Coag) and power settings were applied as per the protocol.</td></tr><tr><td>Indigo Rouge</td><td>Nanwei Medical, China</td><td>MTN-DYZ-15</td><td>0.2% indigo carmine solution for submucosal staining</td></tr><tr><td>Metal clip</td><td>Anri Medical, China</td><td>AMH-HCG-165-135</td><td>Rotatable; Defect closure</td></tr><tr><td>Single Use Electrosurgical Hemostatic Forceps</td><td>Olympus, Japan</td><td>FD-410LR</td><td>Hemostasis and defect managemen</td></tr><tr><td>Single Use Electrosurgical Knife</td><td>Olympus, Japan</td><td>KD-655L;KD-611L</td><td>Include needle knife and IT knife; Mucosal incision and submucosal dissection</td></tr><tr><td>Single Use Injector</td><td>Olympus, Japan</td><td>NM-400U-0423</td><td>23G, 4mm needle length for submucosal injection</td></tr><tr><td>Single Use Ligating Device</td><td>Olympus, Japan</td><td>HX-400U-30</td><td>Nylon loop for large defect closure or purse-string suture</td></tr></tbody></table>

evaluation of the effectiveness of longitudinal incision for endoscopic submucosal excavation of gastric subepithelial lesions

Evaluation of the Effectiveness of Longitudinal Incision for Endoscopic Submucosal Excavation of Gastric Subepithelial Lesions

Endoscopic submucosal excavation (ESE) is an established technique for managing gastric subepithelial lesions (SELs). This article presents a detailed protocol for an improved technique: longitudinal incision ESE. The core innovation involves making a straight-line incision along the central axis of the lesion, rather than a conventional circumferential one, followed by lesion retrieval and primary defect closure with metal clips. The protocol&#39;s feasibility and technical outcomes are supported by a retrospective study of 52 patients, where the longitudinal incision group (n=21) showed a 100% procedural success rate and a significantly shorter mean operation time compared to the conventional circular incision group (51.43 &#177; 5.56 min vs. 70.00 &#177; 6.96 min, P=0.0179). Furthermore, the longitudinal incision appeared to reduce the necessity for advanced closure devices (5% vs. 28%) and was associated with a low complication profile. This protocol highlights that the longitudinal incision technique may be a safe, effective, and feasible treatment for patients with gastric intracavitary SELs &#8804; 2 cm, potentially offering distinct practical advantages in operative efficiency, defect management, and consumable usage.

Demographic and clinical characteristics of patients 
Quantitative data are presented as mean ± standard deviation, and between-group comparisons were made using the t-test. Qualitative data are presented as numbers (percentages) and compared using the Chi-squared test or Fisher's exact test, as appropriate. A two-tailed p-value &lt; 0.05 was considered statistically significant.
A total of 52 patients were included in this study. There were 21 patients in the improved grou...

This protocol describes longitudinal incision endoscopic submucosal excavation, a technique designed to facilitate the resection and defect closure of gastric subepithelial lesions.

Endoscopic submucosal excavation (ESE) is an established technique for managing gastric subepithelial lesions (SELs). This article presents a detailed ...

This research compares longitudinal versus circular incision for endoscopic submucosal excavation to determine which is faster and safer. Circular incision creates large defects that are hard to close. Longitudinal incision simplifies closure and shortens operative time.This technique is ideal for endoscopic removal of small gastric subepithelial lesions measuring two centimeters or less. To begin, using a single-use electrosurgical knife, mark several dots along the lesion margin in a circular pattern, three to five millimeters outside the lesion edge, to define the resection boundaries. For submucosal injection of indigo rouge, advance the needle deep into the tissue.Inject while slowly withdrawing to ensure that the tip remains within the mid-submucosal layer. Confirm that the mucosal surface elevates rapidly, uniformly, and persistently to form a smooth, dome-shaped mucosal elevation. Next, using the single-use electrosurgical knife, make a longitudinal incision through the mucosa and submucosa along the central axis of the lesion, ensuring that it surpasses the entire longitudinal dimension of the lesion.Carefully dissect and separate the submucosal connective tissue beneath the lesion using the electrosurgical knife. Next, fully expose the lesion and completely free it from its attachments while preserving the underlying muscle layer as much as possible. If bleeding is detected during the separation process, use the electrosurgical knife to coagulate minor bleeding vessels.Thoroughly inspect the resection defect for active bleeding or visible vessels. Treat any bleeding points or high-risk vessels with single-use electrosurgical hemostatic forceps to prevent delayed bleeding. To close the defect, first, moderately aspirate intragastric gas to approximate the defect edges and reduce the tissue gap for clipping.Engage the mucosal edge on the proximal side of the defect with one jaw of the clip. Then hook the distal mucosal edge with the opposite jaw. Close the clip while maintaining continuous suction.Next, apply clips sequentially to approximate the mucosal edges until the entire defect is fully apposed. No statistically significant differences were found in most baseline demographic and clinical variables between the improved group and the conventional group. The improved group had a significantly shorter mean operation time compared to the conventional group.No serious postoperative complications, such as perforation, abdominal abscess, fever, or severe abdominal pain, occurred in either group. The incidence of major complications was 0%in both groups, and no statistically significant difference was found. This protocol allows precise measurement of operative time, success rates, and complications between the two incision techniques.The key challenge is ensuring the longitudinal incision is exactly centered over the lesion's long axis.

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In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

This study reports a successful method of endoscopical adipose tissue-derived stromal cell (ADSC)-sheet transplantation for esophageal stricture prevention after an extended endoscopic submucosal dissection (ESD) in a swine model.

ADSC-sheet Transplantation to Prevent Stricture after Extended Esophageal Endoscopic Submucosal Dissection

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

Here, we performed a systematic evaluation of patients diagnosed with gastric low-grade intraepithelial neoplasia by previous endoscopic biopsy and obtained a pathological diagnosis by complete resection of the lesion by endoscopic submucosal dissection (ESD), analyzing factors that potentially increase the risk of pathological escalation.

Establishment and Evaluation of a Risk Prediction Model for Pathological Escalation of Gastric Low-Grade Intraepithelial Neoplasia

This study details a standardized PCM-ESD protocol for resecting large rectal LSTs, aiming to enhance dissection speed and prevent transmural perforation via submucosal tunneling.

The Pocket-Creation Procedure of Endoscopic Submucosal Dissection for Large Rectal Laterally Spreading Tumors

This protocol describes a self-made multiring thread method to provide controlled internal traction during gastric endoscopic submucosal dissection. The technique facilitates effective mucosal flap traction in desired directions and forces, enabling easy, safe, and cost-effective dissection.

Self-Made Internal Traction Method For Endoscopic Submucosal Dissection of Early Gastric Cancer

We demonstrate how to perform macrophage MR imaging using ultrasmall superparamagnetic contrast agent (USPIO) in septic arthritis, allowing an initial and longitudinal in vivo non-invasive evaluation of macrophages infiltration and an assessment of therapy efficacy.

In vivo Macrophage Imaging Using MR Targeted Contrast Agent for Longitudinal Evaluation of Septic Arthritis

Ex vivo analysis of arterial lesions from animal models of cardiovascular disease classically relies on histological and immunohistochemical techniques. These provide 2-dimensional measurements in 3-dimensional lesions. This manuscript describes the generation of arterial lesions for quantitative analysis in 3-dimensions using optical projection tomography.

Generation and 3-Dimensional Quantitation of Arterial Lesions in Mice Using Optical Projection Tomography

We describe methods for longitudinal monitoring of the efficacy of therapeutics for the treatment of colonic pathologies in mice using a rigid endoscope. This protocol can be readily used for the characterization of the therapeutic response of an individual tumor in live mice and also for monitoring potential disease relapse.

Non-invasive Assessment of the Efficacy of New Therapeutics for Intestinal Pathologies Using Serial Endoscopic Imaging of Live Mice

We describe a simple approach for diagnosis of halitosis in dogs as well as a dietary approach for its management. This protocol may be extended to the management of halitosis in humans in the near future.

Therapeutic Effectiveness of a Dietary Supplement for Management of Halitosis in Dogs

Learn longitudinal incision endoscopic submucosal excavation for gastric subepithelial lesions ≤2 cm. This technique reduces operative time and simplifies defect closure compared to circular incision methods.

Evaluation of the Effectiveness of Longitudinal Incision for Endoscopic Submucosal Excavation of Gastric Subepithelial Lesions

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