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are the most common mesenchymal tu− mors of the gastrointestinal tract. It has been debated whether the morbidity and mortality associated with surgery are acceptable when removing these lesions, which have a low potential for malignan− cy. Endoscopic submucosal dissection (ESD) enables en−bloc resection of such lesions regardless of their size and shape. However, ESD is associated with a risk of perforation of up to 5%, depending on the size and location of the lesion. In order to maintain better visualization during ESD, the Fujinon FlushKnife (Fujinon, Willich, Germany) has been recently developed [1 ±3]. The case presented here involved a 58− year−old man with a gastric GIST (l" Fig. 1). Tumor resection was per− formed by means of FlushKnife ESD (l" Fig. 2) following submucosal injection of 30 ml saline containing epinephrine 1 :10 000. GIST enucleation was per− formed endoscopically within 32 min− utes. After ESD it became obvious that the gastric wall had been perforated, with air leakage and visible abdominal distension. Endoscopic full−thickness suturing of the perforation site was at− tempted to avoid surgical intervention (l" Fig. 3 and 4, l" Video 1). The endo− scopic suturing time was 12 minutes and an adequate suturing result was con− firmed endoscopically. Enteral feeding was reestablished within 48 hours, and control gastroscopy at 72 hours after treatment confirmed complete closure of the perforation before the patient was discharged (l" Fig. 5 and 6). The NDO Plicator device (NDO Surgical Inc., Mansfield, Massachusetts, USA), which enables endoscopic transmural su− turing, was initially developed for the treatment of gastroesophageal reflux dis− ease. Limited experience of using this de− vice for closure of gastrointestinal wall defects has been reported elsewhere [4± 6]. The resultant sealing is composed of the edges of the former defect bound with a nonabsorbable, pledgeted trans− mural suture (l" Fig. 4). A negative aspect of the transmural procedure is the risk of blindly incorporating or damaging adja− cent organs. In addition, the risk of fistu− lation and migration of the nonresorbable pledgeted sutures is unknown at present. Nevertheless, the Plicator might be a use− ful endoscopic suturing device allowing surgical intervention to be avoided if per− foration occurs.

Endoscopic GIST resection using FlushKnife ESD and subsequent perforation closure by means of endoscopic full-thickness suturing