Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. In recent years, endoscopic therapy has emerged as a key complement to surgery, particularly for gastric GISTs confined to the superficial layers of the gastric wall and exhibiting predominantly endoluminal growth. Endoscopic resection offers significant advantages, including organ preservation, reduced length of hospital stay, and improved cost-effectiveness. However, adequate exposure of the submucosal space remains challenging. Unlike surgical interventions, where independent traction and counter-traction facilitate dissection, conventional endoscopy is largely limited to axial force transmission. Gravity often works against the operator; once the incision is made, the lesion may collapse into the field of view and obscure the dissection line. Several strategies have been proposed to overcome these limitations. Among them, the double-clip-and-rubber-band technique has been developed as an internal traction system that provides stable, directional traction on the lesion, but it has been applied mainly in colorectal endoscopic submucosal dissection series.

We describe a novel application of the double-clip-and-rubber-band traction technique to facilitate endoscopic resection of gastric GISTs. The tumour insertion on its layer of origin is approached through circumferential submucosal dissection. A first clip grasping a rubber band is anchored to the tumour edge. The rubber band is then grasped with a second clip, which is deployed on the opposite gastric wall. With this method, the traction force can be modulated by adjusting the distance between the two clips, which directly determines the elastic tension applied. This technique allows optimal and constant exposure of the submucosal layer for GISTs confined to the submucosa, and of the muscular insertion site for GISTs arising from the muscularis propria. At the end of the procedure, the clip attached to the contralateral gastric wall is removed using biopsy forceps.

This technique was successfully applied in three consecutive patients with gastric GISTs arising from the submucosa or muscularis propria, with a mean lesion size of 26 mm. En bloc resection was achieved in 100% of cases. The elastic traction created by the rubber band provided optimal visualisation of the serosal layer, helping to prevent inadvertent injury to surrounding extra-gastric structures. All procedures were performed with a GIF-EZ1500 gastroscope (Olympus, Tokyo, Japan) and a monopolar endoscopic knife (Gold Knife 4-mm T-type, Micro-Tech, Nanjing, China). Mean procedure time was 88 minutes (from the initial mucosal incision to placement of the final clip). No intraoperative complications occurred. Gastric wall defects were successfully closed with through-the-scope clips when the defect was limited to the muscularis propria and with over-the-scope clips when full-thickness resection was performed. Patients resumed oral intake on postoperative day 2 and were discharged after a mean of 5 days. Histopathological examination confirmed GIST in all cases, with negative resection margins (R0). No recurrence was observed at 6-month follow-up.

The application of the double-clip-and-rubber-band traction technique to the endoscopic treatment of gastric GISTs proved to be a safe and effective adjunct, facilitating exposure of the dissection plane and enabling reliable en bloc resection. In our experience, this traction strategy optimised procedural control without increasing adverse events, supporting its role as a valuable tool in the endoscopic management of appropriately selected gastric GISTs.