Review Article| Volume 54, ISSUE 6, P729-736, June 2022

Exposed endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors: A systematic review and pooled analysis

Published:October 12, 2021DOI:



      Exposed endoscopic full-thickness resection (Eo-EFTR) is emerging as a promising minimally invasive alternative to surgery for the treatment of deep gastric submucosal tumors (G-SMTs). However, literature concerning this subject is heterogeneous and data mostly come from relatively small retrospective studies.


      We aimed to perform a pooled analysis of published data with regard to gastric Eo-EFTR, providing a pooled estimate of technical and clinical outcomes.


      The protocol was registered in PROSPERO. MEDLINE and EMBASE databases were searched for studies published from 1998 to 2020. The primary outcomes were complete resection and surgical conversion rates. The secondary outcomes were overall and selected major adverse events rates. The Forest plots on primary and secondary endpoints were produced based on fixed and random effect models.


      Nineteen studies including 952 Eo-EFTR-treated G-SMTs were included. The pooled estimate of the complete resection rate and surgical conversion rates was 99.3% and 0.09%, respectively. The pooled estimate of overall major adverse events, delayed bleeding, delayed perforation and peritonitis, abdominal abscess and/or abdominal infection was 0.29%, 0.14%, 0.14%, and 0.12%, respectively.


      Gastric Eo-EFTR has a high rate of complete resection with a low surgical conversion rate. It appears to be relatively safe and might represent a non-inferior minimally invasive alternative to surgery in selected cases.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Digestive and Liver Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • NCCN
        Clinical practice guidelines in oncology.
        Soft Tissue Sarcoma. (NCCN Guidelines), 2018 (Version 2[cited 2021 Jan 22]. Available from:)
        • Granata A.
        • Martino A.
        • Amata M.
        • et al.
        Efficacy and safety of gastric exposed endoscopic full-thickness resection without laparoscopic assistance: a systematic review.
        Endosc Int Open. 2020; 8: E1173-E1182
        • Wang C.
        • Gao Z.
        • Shen K.
        • et al.
        Safety and efficiency of endoscopic resection versus laparoscopic resection in gastric gastrointestinal stromal tumours: a systematic review and meta-analysis.
        Eur J Surg Oncol. 2020; 46: 667-674
        • Suzuki H.
        • Okuwaki S.
        • Ikeda K.
        • et al.
        Endoscopic full-thickness resection (EFTR) and waterproof defect closure (ENDC) for improvement of curability and safety in endoscopic treatment of early gastrointestinal malignancies (in Japanese, English abstract).
        Prog Dig Endosc. 1998; 52: 49-53
        • Suzuki H.
        • Ikeda K.
        Endoscopic mucosal resection and full thickness resection with complete defect closure for early gastrointestinal malignancies.
        Endoscopy. 2001; 33: 437-439
        • Ikeda K.
        • Mosse C.A.
        • Park P.O.
        • et al.
        Endoscopic full-thickness resection: circumferential cutting method.
        Gastrointest Endosc. 2006; 64: 82-89
        • Zhou P.H.
        • Yao L.Q.
        • Qin X.Y.
        • et al.
        Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria.
        Surg Endosc. 2011; 25: 2926-2931
        • Aslanian H.R.
        • Sethi A.
        • et al.
        • ASGE Technology Committee
        ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection.
        VideoGIE. 2019; 4: 343-350
        • Cai M.Y.
        • Martin Carreras-Presas F.
        • Zhou P.H.
        Endoscopic full-thickness resection for gastrointestinal submucosal tumors.
        Dig Endosc. 2018; 30: 17-24
        • Mori H.
        • Kobara H.
        • Nishiyama N.
        • et al.
        Current status and future perspectives of endoscopic full-thickness resection.
        Dig Endosc. 2018; 30: 25-31
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        Ann Intern Med. 2009; 151: 65-94
        • Slim K.
        • Nini E.
        • Forestier D.
        • et al.
        Methodological index for non-randomized studies (minors): development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Shi Q.
        • Chen T.
        • Zhong Y.S.
        • et al.
        Complete closure of large gastric defects after endoscopic fullthickness resection, using endoloop and metallic clip interrupted suture.
        Endoscopy. 2013; 45: 329-334
        • Dong H.Y.
        • Wang Y.L.
        • Jia X.Y.
        • et al.
        Modified laparoscopic intragastric surgery and endoscopic full-thickness resection for gastric stromal tumor originating from the muscularis propria.
        Surg Endosc. 2014; 28: 1447-1453
        • Ye L.P.
        • Yu Z.
        • Mao X.L.
        • et al.
        Endoscopic fullthickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria.
        Surg Endosc. 2014; 28: 1978-1983
        • Feng Y.
        • Yu L.
        • Yang S.
        • et al.
        Endolumenal endoscopic full-thickness resection of muscularis propria-originating gastric submucosal tumors.
        J Laparoendosc Adv Surg Tech A. 2014; 24: 171-176
        • Wu C.R.
        • Huang L.Y.
        • Guo J.
        • et al.
        Clinical control study of endoscopic full-thickness resection and laparoscopic surgery in the treatment of gastric tumors arising from the muscularis propria.
        Chin Med J. 2015; 128 (Engl): 1455-1459
        • Yang F.
        • Wang S.
        • Sun S.
        • et al.
        Factors associated with endoscopic full-thickness resection of gastric submucosal tumors.
        Surg Endosc. 2015; 29: 3588-3593
        • Lu J.
        • Jiao T.
        • Li Y.
        • et al.
        Facilitating retroflexed endoscopic full-thickness resection through loop-mediated or rope-mediated countertraction (with videos).
        Gastrointest Endosc. 2016; 83: 223-228
        • Wang H.
        • Feng X.
        • Ye S.
        • et al.
        A comparison of the efficacy and safety of endoscopic full-thickness resection and laparoscopic-assisted surgery for small gastrointestinal stromal tumors.
        Surg Endosc. 2016; 30: 3357-3361
        • Shi D.
        • Li R.
        • Chen W.
        • et al.
        Application of novel endoloops to close the defects resulted from endoscopic full-thickness resection with single-channel gastroscope: a multicenter study.
        Surg Endosc. 2017; 31: 837-842
        • Hu J.W.
        • Ge L.
        • Zhou P.H.
        • et al.
        A novel grasp-and-loop closure method for defect closure after endoscopic full-thickness resection (with video).
        Surg Endosc. 2017; 31: 4275-4282
        • Sun M.
        • Song J.
        • Song X.
        • et al.
        Endoscopic full-thickness resection for gastric subepithelial tumors originating from the muscularis propria: a 69-case series.
        Surg Laparosc Endosc Percutan Tech. 2018; 28: e12-e17
        • Abe N.
        • Takeuchi H.
        • Ohki A.
        • et al.
        Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor.
        Dig Endosc. 2018; 30: 7-16
        • Wu N.
        • Liu S.
        • Chen M.
        • et al.
        The prepurse-string suture technique for gastric defect after endoscopic full-thickness resection (with video).
        Medicine. 2018; 97 (Baltimore): e12118
        • Li B.
        • Shi Q.
        • Qi Z.P.
        • et al.
        The efficacy of dental floss and a hemoclip as a traction method for the endoscopic full-thickness resection of submucosal tumors in the gastric fundus.
        Surg Endosc. 2019; 33: 3864-3873
        • Xiu H.
        • Zhao C.Y.
        • Liu F.G.
        • et al.
        Comparing about three types of endoscopic therapy methods for upper gastrointestinal submucosal tumors originating from the muscularis propria layer.
        Scand J Gastroenterol. 2019; 54: 1481-1486
        • Zhao Y.
        • Pang T.
        • Zhang B.
        • et al.
        Retrospective comparison of endoscopic full-thickness versus laparoscopic or surgical resection of small (≤ 5cm) gastric gastrointestinal stromal tumors.
        J Gastrointest Surg. 2020; 24: 2714-2721
        • Liu S.
        • Zhou X.
        • Yao Y.
        • et al.
        Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients' tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection.
        Surg Endosc. 2020; 34: 4053-4064
        • Hu J.
        • Ge N.
        • Wang S.
        • et al.
        Direct endoscopic full-thickness resection for submucosal tumors with an intraluminal growth pattern originating from the muscularis propria layer in the gastric fundus.
        BMC Gastroenterol. 2020; 20: 70