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The management of small gastrointestinal subepithelial tumors (SETs) considers periodic endoscopic surveillance vs. endoscopic removal for entities with malignant potential such as neuroendocrine tumor (NET), gastrointestinal stromal tumor or others [1]. Excision by ligationassisted endoscopic mucosal resection (EMR) is an option for small SETs [2]. In a 57-year-old woman undergoing periodic endoscopic surveillance for chronic atrophic gastritis, three small grade 2 (Ki-67, 3%) NETs were identified in the gastric body (▶Fig. 1). Indication for endoscopic excision was agreed by consensus in a multidisciplinary committee. EMR using a specific mucosectomy device (Captivator; Boston Scientific, Quincy, Massachusetts, USA) was proposed. During NET banding, two technical incidents occurred: 1) the transparent cap of the device was not optimally attached to the tip of the gastroscope (the blue rubber bands should not be observed in the endoscopic view); and 2) two bands, instead of one, were deployed when the first NET was ligated. During resection of the first NET using an electrocautery snare (ERBE, 40W cut, 30W coagulation; ERBE Elektromedizin GmbH, Tübingen, Germany), immediate gastric perforation occurred (▶Fig. 2). The wall defect was effectively closed during the same procedure by endoscopic clipping using eight clips (Resolution clip; Boston Scientific) (▶Fig. 3). Endoscopic band ligation (EBL) without resection was decided for the other two NETs, avoiding the resection technique. The patient did well after the procedure, requiring a 7-day hospital stay. Endoscopic surveillance after 10 months and 2 years showed a fibrous scar and one remaining clip from the first resected NET (pathological biopsy examination confirmed fibrous tissue) (▶Fig. 4), and the disappearance of the other two NETs (▶Video 1). Ligation-assisted EMR is associated with a non-negligible rate of adverse events such as perforation [2, 3]. EBL without resection is an apparently safe and effective option for management of small SETs [4, 5].

Gastric perforation during ligation-assisted endoscopic mucosal resection of a neuroendocrine tumor: banding without resection may be a safer option