This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Limitless. Endoscopic submucosal dissection of a giant gastric polyp. Authors declared no disclosure. Most of the gastric hyperplastic polyps identified incidentally. Polyps smaller than 1 cm are usually asymptomatic, where they might cause dyspeptic symptoms depending on size and location. Malign transformation risk for gastric hyperplastic polyp is approximately 5% and it increases with polyp size and accompanying comorbidities. ESD is an effective treatment method for large symptomatic gastric polyps without surgery and loss of organ function. It requires accurate planning and adequate experience. Objectives are to treat symptomatic gastric polyp via endoscope without major surgery while preserving organ and function. Also, secondary symptoms are aimed to treat without adverse events while accurately staging the lesion. 36-year-old female patient presented with dyspeptic complaints, nausea, vomiting, weight loss and iron deficiency anemia that required iron replacement therapy. Patient was evaluated 8 times with endoscopy in the last 3 months. On endoscopy, there was a giant polypoid mass observed on lesser curvature. On histopathology, the lesion was reported as hyperplastic polyp with indefinite dysplasia. On radiology and endoscopic ultrasonography, there was no abnormal finding other than increased mucosal wall thickness. Multidisciplinary tumor board decided in favor of surgical resection due to dysplasia suspicion of symptomatic polyp. At the end, ESD under general anesthesia was decided. Lesion starting from cardia extends through lesser curvature and reaches to posterior antrum. Our ESD strategy is that while the patient lying in supine position, gravity is towards here. At first, mucosal incision following submucosal injection should be made using endoscopic knife to oral side with a standard endoscope. Then, the tunnel is initiated towards anal side. Afterwards, the tunnel end reaches to anal side. At the next step, lateral border dissection is completed with using the help of gravity and the lesion is free to taken out and block. Lesion starting from cardia extends through lesser curvature and reaches to posterior antrum. As we shown in animation, submucosal injection is made towards oral side, then lateral mucosal incision is made via endoscopic knife, thus we entered submucosal layer. The tunnel under the lesion is made towards anal side. One of the advantages of tunnel method is safe isolation of main vascular structures, perforating arteries and veins, providing easy access for coagulation before bleeding. The endoscope is briefly removed from the tunnel frequently to check the color change of the mucosa to assess the correct direction of tunnel. Dissection is proceeded towards anal side until the distal end of the lesion. Because of failing injection, indigo carmine added hydroxyethyl starch solution is used. For dissection, 4.5 mm length endoscopic knife with injection capability is used. Then mucosal incision is made to distal end of the lesion. At this step, the tunnel is widened. Lateral incisions are made using the help of gravity for a more feasible dissection and better exposure, with a different endoscopic knife with safer and faster features. Last step, the counter-lateral side of the lesion against gravity is dissected. The lesion is N-block externalized orally with endoscopic smear, then fixated on a styrofoam plate. After procedure, there was a huge mucosal defect. Visible vascular spots are preventably coagulated. There was no muscular damage or perforation. The resection site is sutured endoscopically to shorten recovery time and to prevent adverse events such as delayed perforation or bleeding. For this lesion, three sutures have been used. The dimensions of the removed polyp are measured as 410 mm and 110 mm. All surgical margins were clear endoscopically. The duration of procedure was 192 minutes. Histopathologically, the lesion was reported as hyperplastic polyp without dysplasia. All surgical margins were clear. Patient was admitted to ward after ESC, discharged on day 3 postoperatively without observing any bleeding or delayed perforation. On 3-month follow-up endoscopic examination, there was no endoscopic or histopathological recurrence. All of the presenting symptoms, including iron deficiency anemia, were completely improved at 6 months. On 3-month follow-up, sutures are removed endoscopically and the resection site is observed to heal completely with fibrinic tissue. There was no endoscopic or histopathological recurrence or residual polyp. Precise and thorough planning before ESC is essential for en bloc resection of giant lesions to prevent the additional physical problems might occur for large lesions. The tunnel methods provide cleaner, faster, and safer dissection while providing easy isolation of main vascular structures and coagulation. For increased safety, efficacy, and speed in giant lesions, using gravity correctly is highly advantageous due to substantial weight of the lesion. Endoscopic suturing techniques are effective tools to shorten recovery time and tissue healing for giant lesions. Three patients with symptomatic hypoplastic polyps had been treated with this technique so far. All of the patients showed complete clinical improvement after the treatment. ESD can be the choice-to-go method for minimal invasive treatment for symptomatic benign polyps with malignant transformation risk. Symptomatic well-being while preserving the anatomy can be achieved with ESD. Tunneling methods can be used for an effective and controlled end-block dissection of giant lesions. Endoscopic suturing techniques can prevent adverse events such as delayed perforation and bleeding while providing fast clinical recovery. Thank you for watching.

endoscopic submucosal dissection

giant gastric polyp

hyperplastic polyp

dysplasia

tunnel method