Fig. 1. Flowchart of patient inclusion. SET, subepithelial tumor; ER, endoscopic resection; GIST, gastrointestinal stromal tumor; NIH, National Institute of Health; STER, submucosal tunneling endoscopic resection; EUS, endoscopic ultrasonography; ESD, endoscopic submucosal dissection; cc-EFTR, clip-and-cut endoscopic full-thickness resection.

Fig. 2. (A–H) Case illustration of endoscopic submucosal dissection. (A) A subepithelial tumor (SET) in the distal antrum. (B) After marking around the lesion with an endoscopic knife, submucosal injection is administered. (C–F) Circumferential incision followed by submucosal dissection is performed. (G) After removing the SET, hemostasis is performed with coagulation forceps. (H) The removed gastric SET is displayed. (I–P) Case illustration of clip-and-cut endoscopic full-thickness resection. (I) A SET in the fundus is displayed. (J) Submucosal injection and circumferential incision are performed. (K) A clip with dental floss is applied to the mucosa above the SET for traction. (L) Sentinel clips are placed on both sides of the resected area to anchor the muscularis propria layer. (M) Transmural resection is performed using continuous traction to pull the SET into the stomach. (N) Transmural resection and perforation closure with clips are carried out simultaneously. (O) After the SET is completely excised, additional clipping is performed to strengthen the closure site. (P) The removed gastric SET is displayed.

Fig. 3. Differences between the resection margin status and procedure time according to location. To investigate the efficacy of endoscopic submucosal dissection (ESD) and clip-and-cut endoscopic full-thickness resection (cc-EFTR) according to location, the state of resection margin and procedure time are compared between the upper third and middle plus lower third groups. Unlike the middle plus lower third group, which had no differences in resection margin and procedure time, the R0 resection rate is significantly high in cc-EFTR in the upper third groups. (A, B) Resection margin status of upper third and middle plus lower third. (C, D) Procedure time of upper third and middle plus lower third.

Fig. 4. Clinical outcomes of the endoscopic resection methods. Summary of each treatment’s oncologic follow-up. ESD, endoscopic submucosal dissection; cc-EFTR, clip-and-cut endoscopic full-thickness resection.

Graphical abstract