Published online May 21, 2026. doi: 10.3748/wjg.v32.i19.112955
Revised: January 24, 2026
Accepted: March 12, 2026
Published online: May 21, 2026
Processing time: 280 Days and 19.5 Hours
Gastric subepithelial tumors (SETs), commonly encountered in gastrointestinal practice, require precise and complete resection to prevent recurrence and malignant transformation.
To compare efficacy, safety, and clinical outcomes between traction-preclosure (TPC)-assisted endoscopic full-thickness resection (EFTR) and conventional EFTR for gastric SETs.
We retrospectively analyzed 214 patients who underwent EFTR for gastric SETs, assigning them to the conventional EFTR (n = 129) or TPC-EFTR (n = 85) group. Primary outcomes were complete and en bloc resection rates. Secondary outcomes included procedural efficiency (operation time, closure time, time to resumption of diet and defecation), safety (adverse events, blood parameters, pneumoperitoneum), and clinical efficacy (pain scores, EuroQol visual analogue scale, health utility values, recurrence rate). Recurrence-free survival was assessed by Kaplan-Meier analysis.
Compared to the conventional EFTR group, the TPC-EFTR group had a higher complete resection rate (95.3% vs 86.8%, P = 0.041), shorter operation time [60.0 (40.0) minutes vs 70.0 (39.5) minutes, P = 0.047], shorter closure time (13.0 ± 4.5 minutes vs 14.3 ± 4.5 minutes, P = 0.044), and lower pneumoperitoneum incidence (4.7% vs 14.0%, P = 0.033). The TPC-EFTR group showed higher postoperative EuroQol visual analogue scale scores [79.9 (7.6) vs 79.3 (2.0), P = 0.001] and health utility values [95.0 (4.0) × 10-2 vs 92.0 (14.0) × 10-2, P = 0.002]. Kaplan-Meier curves showed comparable median recurrence-free survival between the two groups [not reached (95% confidence interval: 26.0-not reached) months vs 75.0 (95% confidence interval: 60.0-75.0) months, P = 0.770].
TPC-EFTR is safe and effective strategy gastric SETs, enhancing procedural efficiency and postoperative quality of life while potentially achieving comparable or superior long-term oncological outcomes vs conventional EFTR.
Core Tip: This retrospective cohort study compared traction-preclosure-assisted endoscopic full-thickness resection (EFTR) with conventional EFTR for gastric subepithelial tumors. traction-preclosure-EFTR improved complete resection rates, shortened operation and closure times, and reduced pneumoperitoneum incidence while enhancing postoperative quality of life (higher EuroQol visual analogue scale and health utility values) without increasing recurrence risk, demonstrating superior efficacy and safety.
- Citation: Li X, Zhang RY, Wen XD, Li XQ, Liu WH. Traction-preclosure-assisted vs conventional endoscopic full-thickness resection for gastric subepithelial tumors: Safety, efficacy in a retrospective cohort (with video). World J Gastroenterol 2026; 32(19): 112955
- URL: https://www.wjgnet.com/1007-9327/full/v32/i19/112955.htm
- DOI: https://dx.doi.org/10.3748/wjg.v32.i19.112955
Gastric subepithelial tumors (SETs) are frequently encountered in gastroenterology and pose a significant clinical challenge[1]. Although often benign, their malignant potential requires complete en bloc resection to avert recurrence or progression[2]. Traditional treatments include laparoscopic surgery and endoscopic techniques, with endoscopic full-thickness resection (EFTR) favored for its minimal invasiveness[3]. However, EFTR faces technical hurdles in deep-seated lesions, where inadequate exposure and unstable closure margins may result in tumor displacement, peritoneal contamination, or the requirement for salvage surgery. While purse-string suturing or device-assisted closure techniques can address these issues, their technical complexity and cost limit widespread adoption.
To overcome these limitations, our team developed traction-preclosure (TPC)-EFTR for gastric SETs, with success demonstrated in individual cases[4] and demonstrable adaptability to challenging anatomical stromal tumors[5]. This combined approach improves the visualization and maneuverability of deep-seated SETs during endoscopic procedures. Although earlier case reports have demonstrated improved exposure and closure, systematic evaluation of efficacy and safety remains lacking. The present study fills this gap by standardizing TPC-EFTR and validating its advantages in a large-scale cohort, advancing endoscopic management of gastric SETs.
This retrospective cohort study analyzed consecutive cases of patients with gastric SETs who underwent EFTR from January 1, 2020, to March 31, 2025, at the Department of Gastroenterology of Sichuan Provincial People’s Hospital. The clinical data of 280 patients were collected based on the inclusion criteria.
Inclusion criteria: (1) Age ≥ 18 years; (2) Gastric SETs with intraluminal or intramural growth confirmed by endoscopy, endoscopic ultrasonography, computed tomography (CT), or histopathology; (3) Informed of the surgical risks and actively requested EFTR; (4) No severe cardiovascular or cerebrovascular disease; and (5) Provided written informed consent.
Exclusion criteria: (1) SETs exhibiting extraluminal growth, diameter > 5 cm or dissemination on endoscopic ultrasonography; (2) History of postoperative tumor recurrence; (3) Severe comorbidities precluding surgery (e.g., decompensated organ failure); (4) Active psychiatric disorders (e.g., acute psychotic episodes or severe schizophrenia exacerbations) impairing the ability to provide informed consent; (5) Absolute surgical contraindications (e.g., esophageal stenosis, pregnancy); or (6) Insufficient key clinical data (e.g., resection status, postoperative outcomes).
Patient assignment: As this is a registered retrospective cohort study, patients were not randomized or blinded. The choice of EFTR [conventional group (CG)] and TPC-EFTR [experimental group (EG)] was determined based on patient’s preference after preoperative counseling. Of 280 enrolled patients, 66 cases were excluded (CG = 40, EG = 26). The final analysis included 214 cases (CG = 129, EG = 85), achieving > 80% statistical power using G*Power 3.1 software (Heinrich Heine University Düsseldorf, Düsseldorf, Germany) (α = 0.05, effect size = 0.5). A post hoc power analysis confirmed sufficient power (> 80%). The study flowchart is shown in Supplementary Figure 1.
Two surgical approaches were employed: EFTR and TPC-EFTR. All patients received thorough preoperative counseling through multidisciplinary consultation and selected their treatment method after providing written informed consent.
Conventional EFTR technology: Under general anesthesia, endoscopy was performed to inspect the gastric cavity. The tumor was identified, and a transparent distal cap exposed the lesion-mucosa interface. The tumor was completely resected using standard endoscopic techniques, and the gastric wall defect was closed using a purse-string suture with clips and an endoloop ligation device (Figure 1).
TPC-EFTR technology: Under general anesthesia, the tumor was located endoscopically and marked using a dual knife (Olympus Corporation, Tokyo, Japan). A clip-and-line traction device grasped the mucosa at the marked area, providing traction in the oral direction. With the endoscope retroflexed orally, the incision began at the distal margin. Upward traction fully exposed the tumor for precise complete full-thickness resection. Once adequate tumor mobilization had been achieved, the traction device lifted the lesion to convert the large defect into a more linear shape, enabling pre-resection closure, followed by en bloc resection and final closure (Figure 2; Video). Additional demonstrations of TPC-EFTR for SETs in various gastric regions are provided in Supplementary Figure 2. The endoscope was oriented orally before traction, with the clip securing the anal-side edge and tension adjusted for optimal exposure (Supplementary Figure 3).
The total operation time is defined as the time from gastroscope insertion to completion of the procedure. En bloc resection refers to the removal of the tumor in a single piece with macroscopically clear lateral margins[6]. Complete resection means R0 (histologic negative margins) and requires en bloc as a prerequisite[7]. Numeric rating scale scores for pain assessment are categorized as follows: No pain = 0, mild pain = 1-4, moderate pain = 5-6, and severe pain = 7-10[8]. The American Society of Anesthesiologists (ASA) physical status classification includes grades I to V, with anesthetic risk categorized as mild (I-II) or severe (III-V). The AGREE grading system for adverse events is as follows: No adverse events; grade I, requiring no intervention; grade II, requiring pharmacologic treatment; grade III, requiring endoscopic, radiologic, or surgical intervention; grade IV, involving organ dysfunction requiring intensive care; and grade V, representing death[9].
Closure performance was evaluated through key metrics such as closure time (from initiating defect closure to confirming integrity), number of clips, procedure-ending leak test (assessing closure integrity via air insufflation), pneumoperitoneum (intraperitoneal free air on abdominal CT for persistent postoperative abdominal pain), and the need for rescue closure (secondary techniques for incomplete sealing, persistent leakage, or technical difficulties).
A median follow-up of 20 months was conducted after surgery to assess tumor recurrence and quality of life (QOL). Recurrence was evaluated by postoperative gastroscopy. QOL was assessed using the five-level European QOL Five-Dimensional Questionnaire (EQ-5D-5 L; five dimensions and five levels) and the EuroQol visual analogue scale (EQ-VAS; 0-100)[10]. Health utility values were calculated using the China-specific EQ-5D-5 L scoring algorithm (range: < 0 to 1, Supplementary Table 1)[11]. The health utility value = 1 - (sum of dimension-specific weights).
Clinical data, retrieved from the hospital’s electronic medical record system, included demographics, comorbidities, blood test parameters, tumor characteristics, intraoperative metrics (e.g., total operation time, closure time, and resection rate), and postoperative follow-up data (e.g., pain score, complications, EQ-5D-5 L health utility values, and recurrence rate). All collected indicators were classified into primary and secondary outcomes.
Complete and en bloc resection rates.
Secondary outcomes were assessed across three domains: Efficiency (total operation time, closure time, time to diet resumption, time to first defecation, and length of postoperative hospitalization), safety (adverse events, blood test indicators, procedure-ending leak test, and pneumoperitoneum), and clinical efficacy (pain scores, EQ-VAS, health utility values, and recurrence). Baseline clinical characteristics were compared to ensure group comparability, followed by assessments of differences in primary and secondary outcomes.
Long-term outcomes, including recurrence rate and recurrence-free survival (RFS), were evaluated using follow-up data to compare oncological outcomes between the two surgical techniques.
Statistical analyses were conducted using SPSS version 25.0 (IBM Corp., Armonk, NY, United States). Categorical variables (e.g., sex, ASA classification) are presented as n (%) and were compared using the χ2 test or Fisher’s exact test (for expected cell counts < 5). Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed data (e.g., weight, body mass index) are reported as mean ± SD and were compared with Student’s t-tests. Non-normally distributed data (e.g., age, tumor size) are expressed as median (interquartile range) and were analyzed with the Mann-Whitney U test (reported as Z-values). Sensitivity analyses included: (1) Symptomatic subgroup assessment of CT-detected free air [Fisher’s exact test with odds ratio and 95% confidence interval (CI)]; and (2) QOL covariate adjustment via multiple linear regression (baseline scores, age, comorbidities, and tumor size). RFS was evaluated using the Kaplan-Meier method, and differences between groups were compared using the log-rank test. A two-tailed P value < 0.05 was considered statistically significant (all CIs at 95%).
A total of 214 patients were retrospectively enrolled, with a median age of 56.0 years (interquartile range: 12.0), including 66 men and 148 women. No significant differences were observed between the two groups in baseline characteristics including age, sex, weight, body mass index, ASA classification, comorbidities, tumor size and location, or pathological type. These results indicate that the two groups were comparable at baseline (Table 1).
| Clinical characteristics | Control group (n = 129) | Experimental group (n = 85) | χ2/t/Z | P value |
| Age, years, median (IQR) | 56.0 (12.5) | 56.0 (11.0) | Z = 0.621 | 0.535 |
| Sex | χ2 = 0.946 | 0.331 | ||
| Male | 43 (33.3) | 23 (27.1) | ||
| Female | 86 (66.7) | 62 (72.9) | ||
| Weight, kg, median (IQR) | 60.0 (14.0) | 60.0 (13.5) | Z = 0.165 | 0.869 |
| BMI, kg/m2, mean ± SD | 23.0 ± 2.9 | 23.4 ± 3.4 | t = -1.096 | 0.274 |
| ASA classification | χ2 = 0.183 | 0.669 | ||
| I/II | 119 (92.2) | 77 (90.6) | ||
| III/IV | 10 (7.8) | 8 (9.4) | ||
| Comorbidities | χ2 = 1.633 | 0.201 | ||
| Yes | 28 (21.7) | 25 (29.4) | ||
| No | 101 (78.3) | 60 (70.6) | ||
| Size of tumor, cm, median (IQR) | 1.5 (1.0) | 1.2 (1.0) | Z = 1.765 | 0.078 |
| Site of tumor | χ2 = 6.661 | 0.084 | ||
| Cardia | 17 (13.2) | 5 (5.9) | ||
| Fundus | 56 (43.4) | 39 (45.9) | ||
| Gastric body | 44 (34.1) | 38 (44.7) | ||
| Antrum | 12 (9.3) | 3 (3.5) | ||
| Pathological types | χ2 = 1.691 | 0.429 | ||
| Stromal tumor | 111 (86.0) | 74 (87.1) | ||
| Leiomyoma | 11 (8.5) | 4 (4.7) | ||
| Alternative | 7 (5.4) | 7 (8.2) |
The EG achieved a significantly higher complete resection rate compared to the control group (95.3% vs 86.8%, P = 0.041). However, the en bloc resection rate was comparable between groups (98.8% vs 98.4%, P > 0.999).
In terms of procedural efficiency, the operation time [60.0 (40.0) minutes vs 70.0 (39.5) minutes, P = 0.047] and the closure time (13.0 ± 4.5 minutes vs 14.3 ± 4.5 minutes, P = 0.044) were significantly shorter in the EG than the control group (Tables 2 and 3). Regarding safety, the incidence of pneumoperitoneum was lower in the EG (4.7% vs 14.0%, P = 0.033; Table 3), while no significant differences were observed in perioperative blood test parameters (Figure 3; Supplementary Table 2). In the sensitivity analysis restricted to patients undergoing postoperative CT (control: n = 64; TPC-EFTR: n = 46), the incidence of pneumoperitoneum was significantly lower with TPC-EFTR (8.7%, 4/46) vs conventional EFTR (28.1%, 18/64; odds ratio = 0.24, 95%CI: 0.07-0.78, P = 0.019).
| Procedural characteristics | Control group (n = 129) | Experimental group (n = 85) | χ2/t/Z | P value |
| En bloc resection rate | χ2 = 0.000 | > 0.999 | ||
| Yes | 127 (98.4) | 84 (98.8) | ||
| No | 2 (1.6) | 1 (1.2) | ||
| Complete resection rate | χ2 = 4.156 | 0.041 | ||
| Yes | 112 (86.8) | 81 (95.3) | ||
| No | 17 (13.2) | 4(4.7) | ||
| Operation time, minutes, median (IQR) | 70.0 (39.5) | 60.0 (40.0) | Z = 1.985 | 0.047 |
| NRS pain score | χ2 = 1.735 | 0.188 | ||
| Mild pain | 83 (64.3) | 62 (72.9) | ||
| Moderate pain | 46 (35.7) | 23 (27.1) | ||
| Adverse events | χ2 = 0.284 | 0.867 | ||
| Grade I | 7 (5.4) | 4 (4.7) | ||
| Grade II | 8 (6.2) | 4 (4.7) | ||
| None | 114 (88.4) | 77 (90.6) | ||
| Hospitalization expenses, thousand yuan, median (IQR) | 12.9 (11.4) | 11.3 (14.0) | Z = 1.614 | 0.107 |
| Postoperative time to resume defecation, hours, median (IQR) | 19.0 (6.5) | 19.0 (6.0) | Z = 0.534 | 0.593 |
| Postoperative time to resume diet, hours, median (IQR) | 56.0 (24.0) | 56.0 (24.0) | Z = 0.291 | 0.771 |
| Postoperative hospitalization time, days, median (IQR) | 5.0 (2.0) | 5.0 (2.0) | Z = 1.494 | 0.135 |
| Procedural characteristics | Control group (n = 129) | Experimental group (n = 85) | χ2/t/Z | P value |
| Closure time, minutes, mean ± SD | 14.3 ± 4.5 | 13.0 ± 4.5 | t = 2.030 | 0.044 |
| Number of clips, mean ± SD | 7.2 ± 3.3 | 6.4 ± 2.9 | t = 1.788 | 0.075 |
| Procedure-ending leak test | χ2 = 2.005 | 0.157 | ||
| Positive | 3 (2.3) | 0 (0.0) | ||
| Negative | 126 (97.7) | 85 (100.0) | ||
| Rescue closure | χ2 = 1.330 | 0.249 | ||
| Yes | 2 (1.6) | 0 (0.0) | ||
| No | 127 (98.4) | 85 (100.0) | ||
| Pneumoperitoneum | χ2 = 6.833 | 0.033 | ||
| Yes | 18 (14.0) | 4 (4.7) | ||
| No | 46 (35.7) | 42 (49.4) | ||
| Not examined | 65 (50.4) | 39 (45.9) |
During a median follow-up of 20 months, the recurrence rate did not differ significantly between the two groups (1.2% vs 4.7%, P = 0.315). However, the EG demonstrated significantly higher postoperative EQ-VAS scores [79.9 (7.6) vs 79.3 (2.0), P = 0.001] and health utility values [95.0 (4.0) × 10-2 vs 92.0 (14.0) × 10-2, P = 0.002] than the control group (Table 4). Additionally, the adjusted differences in change in the EQ-VAS score and the health utility value between groups were 2.14 (95%CI: 0.49-3.79, P = 0.011) and 2.58 × 10-2 (95%CI: 1.26-3.90, P < 0.001), respectively. Sensitivity analysis revealed that EG patients had higher postoperative EQ-VAS scores (increase of 2.1 points, P = 0.011) and health utility values (increase of 0.03 points, P < 0.001) (Supplementary Table 3).
| Procedural characteristics | Control group (n = 129) | Experimental group (n = 85) | χ2/t/Z | P value |
| Follow-up duration, months | 20.0 (20.0) | 19.0 (15.0) | Z = 1.810 | 0.070 |
| Recurrence rate | χ2 = 1.011 | 0.315 | ||
| Yes | 6 (4.7) | 1 (1.2) | ||
| No | 123 (95.3) | 84 (98.8) | ||
| Preoperative EQ-VAS score | 79.3 (2.0)a | 79.3 (2.4)b | Z = 1.368 | 0.171 |
| Postoperative EQ-VAS score | 79.3 (2.0)a | 79.9 (7.6)b | Z = 3.214 | 0.001 |
| Preoperative health utility values, × 10-2 | 91.0 (13.0)c | 93.0 (9.0)d | Z = 1.657 | 0.098 |
| Postoperative health utility values, × 10-2 | 92.0 (14.0)c | 95.0 (4.0)d | Z = 3.167 | 0.002 |
Kaplan-Meier curves with log-rank testing demonstrated comparable RFS between groups [median RFS: Not reached (95%CI: 26.0-not reached) months vs 75.0 (95%CI: 60.0-75.0) months, P = 0.770] (Figure 4). Notably, the EG did not reach the median RFS during the follow-up period. Additionally, we have included survival rates and restricted mean survival time at specific time points (e.g., 12 months, 24 months, and 36 months), with no statistically significant differences observed (Supplementary Table 4).
SETs, encompassing benign lesions such as leiomyomas and potentially malignant entities like gastrointestinal stromal tumors, pose diagnostic and therapeutic challenges due to their heterogeneous presentation and unpredictable clinical course[12]. Historically, surgical resection served as the mainstay therapy, though it was associated with considerable invasiveness and procedural risk[13]. EFTR has transformed the therapeutic landscape by enabling precise en bloc lesion removal and allowing thorough pathological assessment[14]. However, challenges persist in exposing deep-seated tumors and securing post-resection gastric wall defects[15,16]. The integration of traction and pre-closure techniques into EFTR marks a significant advancement, and the following discussion will elaborate on these benefits.
The application of traction in EFTR enhances dissection precision by improving exposure of the lesion and surrounding normal tissue, thereby accelerating the procedure and minimizing unintended injury to adjacent structures[17]. The application of upward traction on the lesion allows more controlled separation of the tumor from the gastric wall, decreasing operative time and improving visual exposure. This study demonstrated a significantly shorter operation time in the TPC-EFTR group [60.0 (40.0) minutes vs 70.0 (39.5) minutes, P = 0.047], supporting the technique’s ability to enhance procedural efficiency and intraoperative visibility. These advantages contribute to improved resection quality. By maintaining tumor capsule integrity and reducing malignant cell dissemination, the traction-assisted method achieved a higher complete resection rate (95.3% vs 86.8%, P = 0.041).
Comparison between conventional EFTR and other traction-assisted methods, such as snare-assisted traction, highlights the superiority of traction in improving surgical performance. Reported data indicated significantly higher operative success rates (95.6% vs 72.2%, P = 0.001) and shorter procedure durations (53.6 ± 16.6 minutes vs 67.7 ± 33.4 minutes, P < 0.001) with traction-assisted approaches[18]. Studies have consistently reported that traction enhances resection outcomes, with complete resection and en bloc resection rates reaching 100%, further supporting the present findings[19,20]. However, a limitation of our study is that the findings mainly apply to intraluminal and intramural lesions; the applicability of TPC-EFTR to predominantly extraluminal SETs requires further investigation.
Closure of the post-resection defect remains a critical step in preventing complications such as pneumoperitoneum and peritonitis[21]. The pre-closure technique with upward traction improves closure efficiency by approximating the defect edges and maintaining alignment until secure clip placement is achieved. This approach shortened the closure time (13.0 ± 4.5 minutes vs 14.3 ± 4.5 minutes, P = 0.044) and significantly reduced postoperative pneumoperitoneum incidence (4.7% vs 14.0%, P = 0.033). All procedure-ending leak tests were negative in the EG (100%), whereas leak-positive cases in the control group recovered after rescue closure. The higher pneumoperitoneum incidence in the CG may be partly attributed to prolonged procedure times, causing greater gas accumulation, and to the inclusion of imaging-detected cases without clinical relevance. All pneumoperitoneum events in both groups were mild and self-limiting, and managed conservatively without paracentesis, surgery, or prolonged hospitalization, with comparable clinical severity and recovery outcomes. Despite potential detection bias from symptom-triggered CT imaging underestimating pneumoperitoneum incidence, sensitivity analysis robustly supported the findings by demonstrating TPC-EFTR’s 4.17-fold risk reduction and mitigation of this bias.
A retrospective study comparing pre-resection closure using over-the-scope clips vs post-resection closure in EFTR demonstrated that pre-closure achieved faster defect closure and greater security, evidenced by a pneumoperitoneum rate of 0% compared to 16.7%[22]. Our study adopted the pre-closure approach to leverage its safety and efficiency, avoiding the technical challenges of complex devices like over-the-scope clips, thereby achieving a streamlined and easily applicable closure process[23,24].
The TPC-EFTR technique also optimizes the biomechanical environment of defect closure, reducing postoperative physiological stress. The EG showed lower inflammatory markers (e.g., white blood cell count) and more favorable liver and renal function profiles than controls, though the differences were not significant (P > 0.05), possibly due to insufficient statistical power. Future research should enroll patients through multi-center trials, extend study duration for comprehensive data collection, and apply selective inclusion criteria to minimize confounding factors and enhance validity.
The TPC-EFTR approach improved postoperative QOL, as reflected by higher EQ-VAS scores [79.3 (2.0) vs 79.9 (7.6), P = 0.001] and health utility values [92.0 (14.0) × 10-2 vs 95.0 (4.0) × 10-2, P = 0.002] compared with the control group. Sensitivity analysis demonstrated that the QOL improvement attributable to the TPC-EFTR technique was robust and not driven by differences in baseline characteristics (e.g., age, comorbidities). Additionally, the adjusted differences in change in the EQ-VAS score and the health utility value between groups were 2.14 (95%CI: 0.49-3.79, P = 0.011) and 2.58 × 10-2 (95%CI: 1.26-3.90, P < 0.001), respectively. These improvements likely result from procedural advantages, including shorter operative time, reduced pneumoperitoneum, and a higher complete resection rate. Although the between-group differences in postoperative scores were statistically significant, the absolute differences were small, and their clinical significance requires further investigation.
Conversely, the full-thickness resection device is limited in upper gastrointestinal applications due to its large outer diameter (21 mm), often requiring upper esophageal sphincter dilation and risking mucosal injury. Its use remains restricted to clinical trials or individualized consent protocols, with high device and consumable costs further limiting accessibility[25]. Hospitalization expenses showed a downward trend in the EG [11300 (14000) CNY vs 12900 (11400) CNY, P = 0.107], although this was not statistically significant. This finding aligns with previous reports indicating that TPC-EFTR shortens operative time and improves resection efficiency while maintaining cost neutrality, an important consideration in resource-limited healthcare settings[26]. Overall, the evidence supports TPC-EFTR as a minimally invasive, effective, and economically viable option for gastric SETs.
Our study highlights the clinical value of a combined diagnostic-therapeutic strategy for small gastric SETs (median size: 1.5 cm; range: 1.0-2.0 cm). Although current guidelines recognize the controversy surrounding the management of lesions smaller than 2 cm, emerging evidence supports individualized resection in selected cases with high-risk features (e.g., irregular borders, cystic spaces, echogenic foci, or heterogeneity per American College of Gastroenterology/National Comprehensive Cancer Network guidelines[27,28]), predictors of progression (size ≥ 1 cm, muscularis propria origin, and mucosal changes), or patient-specific needs[29]. The European Society of Gastrointestinal Endoscopy recommends multidisciplinary evaluation to balance the burden of surveillance (repeated endoscopies, diagnostic uncertainty) against patient anxiety and preferences[30]. Technically, TPC-EFTR enables en bloc resection of challenging lesions (e.g., gastroesophageal junction, muscularis propria origin) while providing definitive histopathology, thereby resolving diagnostic ambiguity and avoiding prolonged surveillance[31]. By offering both definitive diagnosis and curative treatment in a single session, TPC-EFTR aligns with guideline-supported individualized care pathways and represents a practical, patient-centered solution for small lesions with suspicious features or urgent clinical indications.
Long-term outcomes serve as the definitive benchmark for evaluating tumor treatment efficacy. A meta-analysis of 15 studies involving 1133 patients, using a random-effects model, included 887 patients with follow-up data and reported a recurrence rate of 0.7% (95%CI: 0.002-0.013; P < 0.001) within 3 to 36 months after surgery[32]. Other meta-analyses of EFTR procedures have documented recurrence rates ranging from 8.5% to 12.6%, supporting the feasibility and safety of EFTR[33,34]. Additionally, a systematic review and meta-analysis of EFTR for upper gastrointestinal tumors revealed only two cases of recurrence (1.4%) in patients without R0 resection during 3-6 months of follow-up[35]. However, re
In this study, with a median follow-up duration of 20 months, recurrence rates were comparable between the two groups (1.2% vs 4.7%). Kaplan-Meier survival analysis with log-rank testing demonstrated comparable RFS between the two groups [median RFS: Not reached (95%CI: 26.0-not reached) months vs 75.0 (95%CI: 60.0-75.0) months, P = 0.770], with the median RFS in the EG not reached. Additionally, we have included survival rates and restricted mean survival time at specific time points, with no statistically significant differences observed. These findings indicate that the TPC technique may achieve long-term oncologic outcomes comparable to or potentially better than those of conventional EFTR, although future studies with larger sample sizes and longer follow-up periods are warranted for further validation.
As a single-center retrospective study with a limited sample size, and consequently missing effect sizes for variables, potential biases, like detection bias from symptom-triggered CT possibly underestimating pneumoperitoneum incidence and non-standardized QOL assessment timepoints, may compromise the findings’ validity and generalizability. For greater statistical power, larger prospective multi-center collaborations should recruit sufficient patients across subgroups. This will ensure thorough data collection, enabling comprehensive, robust statistical analyses and enhancing the clinical interpretability of the findings. Such studies should prolong duration, employ selective criteria for stratification, and reduce confounders while verifying benefits and long-term outcomes. The current findings apply to intraluminal/intramural lesions; TPC-EFTR’s role in extraluminal SETs needs future study.
The TPC-EFTR technique provides a safe and effective strategy for gastric SETs, and enhances procedural efficiency and postoperative QOL, while potentially achieving comparable or superior long-term oncological outcomes relative to conventional EFTR. Further high-quality studies are required to validate these results and refine endoscopic protocols for gastric SETs management.
We express our gratitude to Professor Li-Na Ren, Department of Transfusion Medicine, The General Hospital of Western Theater Command, Chengdu, China, for her assistance in revising the manuscript.
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