Combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique (CLEAN-NET) for gastric submucosal tumors: updated advantages and limitations

Complete surgical resection is currently considered the first choice of treatment for patients with resectable gastric submucosal tumors (SMTs) including gastrointestinal stromal tumors (GISTs) (1-3). For complete surgical en bloc resection of gastric SMTs, an adequate safety margin should be secured without injuring the pseudocapsule of the SMTs during resection (1). Laparoscopic gastric surgery has been advanced and standardized worldwide. Furthermore, laparoscopic wedge resection for gastric SMTs has also been reported to be safe, oncologically feasible, and with a decrease in the length of hospital stay and blood loss (4-6). For SMTs with extraluminal growth, laparoscopic wedge resection is easier to detect, however, when they grow in the intra-lumen, identification and determination of appropriate free margin of the SMT from the outside of the stomach is difficult, sometimes resulting in postoperative gastroparesis due to excessive resection, deformity or stenosis of the stomach