Minimally Invasive Options for Gastric Subepithelial Tumors Continue to Expand, Review Finds

Advances in therapeutic endoscopy are steadily reshaping how gastric subepithelial tumors (G-SETs) are managed, with a growing array of endoscopic and hybrid techniques offering alternatives to traditional surgery for selected patients. A comprehensive narrative review published in Gastroenterology Insights synthesizes more than a decade of evidence, outlining where these minimally invasive approaches fit within current clinical practice—and where important limitations remain .

G-SETs are lesions that arise beneath the gastric mucosa, most commonly from the submucosa or muscularis propria, and are often discovered incidentally during endoscopy. While many are benign, some—particularly gastrointestinal stromal tumors (GISTs)—carry malignant potential, making accurate characterization and appropriate management essential.

The review evaluates conventional endoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), alongside newer “third-space” methods including submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR). According to the authors, EMR and its variants have a limited role, largely restricted to very small, superficial lesions, due to concerns about incomplete resection and histologic accuracy.

ESD, by contrast, achieves high en bloc and R0 resection rates for intraluminal tumors arising from the submucosa, particularly in experienced centers. The authors highlight the increasing use of traction techniques—such as clip-and-line or rubber-band systems—which have been shown to improve visualization, shorten procedure time, and reduce adverse events. However, ESD remains technically demanding and is associated with higher risks of bleeding and perforation when tumors originate from the muscularis propria or are located near the esophagogastric junction.

For deeper lesions, EFTR has emerged as a key option. Pooled data summarized in the review suggest that exposed EFTR can achieve complete resection rates approaching 100%, with low rates of major complications when reliable defect closure techniques are used. STER offers another organ-sparing strategy, particularly well suited for tumors near the esophagogastric junction, although its applicability is generally limited to lesions smaller than 3–3.5 cm.

The review also examines hybrid laparoscopic–endoscopic approaches, such as laparoscopic and endoscopic cooperative surgery (LECS) and non-exposure variants. These techniques combine endoscopic precision with laparoscopic closure, minimizing gastric wall resection and reducing the risk of contamination. While outcomes are favorable in expert centers, evidence is largely derived from retrospective cohorts, and the procedures require close multidisciplinary coordination.

Despite promising results, the authors emphasize that surgery remains the reference standard for large, extraluminal, or anatomically prohibitive tumors. They also note that most data supporting advanced endoscopic and hybrid approaches come from high-volume centers, underscoring the importance of expertise, training, and careful patient selection.

Overall, the review portrays a rapidly evolving field in which minimally invasive strategies are increasingly viable for selected G-SETs, while calling for more prospective studies and standardized training pathways to support broader, safe adoption.