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A 63-year-old man presented with a gastric subepithelial tumor, incidentally detected on screening endoscopy. A subepithelial tumor, approximately 30mm in size and with a positive cushion sign, was observed on the greater curvature of the gastric lower body (▶Fig. 1). Severe erythema and hemorrhagic spots were seen on its surface. On endoscopic ultrasonography, the lesion was anechoic, mainly confined to the submucosal layer, and had a small branch-shaped hypoechoic portion in the cystic wall (▶Fig. 2). Endoscopic submucosal dissection (ESD) was suggested in order to prevent bleeding (▶Video 1). After marking the tumor borders, a 0.9% saline solution with epinephrine and indigo carmine was injected into the submucosal layer. Subsequently, a circumferential mucosal incision wasmadewith a dual knife and submucosal dissection was performed with an insulated-tipped knife. During dissection, the tumor was tightly attached to the proper muscle layer; therefore, a clip attached with dental floss was deployed to secure the dissection plane between the tumor andmuscle layer (▶Fig. 3). The tumor was safely and completely resected (▶Fig. 4). Histopathologically, the cystic lesion was lined with columnar epithelial mucosa and had its own muscle layer, and ectopic pancreatic tissue of acinar structure was present in the cystic wall (▶Fig. 5). The patient did not develop any adverse events and was discharged after 2 days. Gastric duplication cysts comprise about 2%–9% of gastrointestinal duplication cysts [1]. Most are cystic, occurring along the greater curvature of the stomach without communicating with it [2]. Ectopic pancreatic tissue is found in the wall in up to 37% [3]. The conventional treatment for removal is surgical resection; ESD is an alternative modality. Due to the tight attachment of the cyst to the muscle layer, dental floss and clip traction is an efficient and safe method for en bloc resection.

Endoscopic submucosal dissection for gastric duplication cyst with heterotopic pancreas