Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in early mucinous gastric cancer: Role of lymph node metastasis

BACKGROUND

Recent evidence showed that combining endoscopic submucosal dissection (ESD) and laparoscopic sentinel lymph node dissection may avoid unnecessary gastrectomy in treating early mucinous gastric cancer (EMGC) patients with risks of positive lymph node metastasis (pLNM).

AIM

To explore the predictive factors for pLNM in EMGC, and to optimize the clinical application of combing ESD and sentinel lymph node dissection in a proper subgroup of patients with EMGC.

METHODS

Thirty-one patients with EMGC who had undergone gastrectomy with lymph node dissection were consecutively enrolled from January 1988 to December 2016. Univariate and multivariate logistic regression analyses were used to estimate the association between the rates of pLNM and clinicopathological factors, providing odds ratio (OR) with 95% confidence interval. And the association between the number of predictors and the pLNM rate was also investigated.

RESULTS

Depth of invasion (OR = 7.342, 1.127-33.256, P = 0.039), tumor diameter (OR = 9.158, 1.348-29.133, P = 0.044), and lymphatic vessel involvement (OR = 27.749, 1.821-33.143, P = 0.019) turned out to be significant and might be the independent risk factors for predicating pLNM in the multivariate analysis. For patients with 1, 2, and 3 risk factors, the pLNM rates were 9.1%, 33.3%, and 75.0%, respectively. pLNM was not detected in seven patients without any of these risk factors.

CONCLUSION

ESD might serve as a safe and sufficient treatment for intramucosal EMGC if tumor size ≤ 2 cm, and when lymphatic vessel involvement is absent by postoperative histological examination. Combining ESD and sentinel lymph node dissection could be recommended as a safe and effective treatment for EMGC patients with a potential risk of pLNM.

Surgical options for submucosal tumors near the esophagogastric junction: does size or location matter?

Background

Submucosal tumors (SMTs) of different etiologies exist from esophagus to rectum. Esophagogastric junction (EGJ) is one of the known difficult locations for tumor resection. Although minimally invasive surgery (MIS) is a well-established approach for gastrointestinal surgery, there is no consensus that MIS for resection of SMTs around EGJ is superior to laparotomy. We tried to clarify the factors that determine the surgeons’ choices between these two approaches.

Methods

From January 2002 to June 2016, 909 patients with SMTs underwent resection in our department. Among them, 119 patients (13%) had SMTs around EGJ were enrolled by retrospective review. The clinicopathological features and tumor-related parameters were reviewed and analyzed.

Results

The cohort was stratified into three groups according to the extent of gastrectomy and surgical approaches. The three groups are as following: major gastrectomy (n = 13), minor gastrectomy by laparotomy (n = 51), and minor gastrectomy with MIS (n = 55). The average tumor size was significantly larger in the major gastrectomy group than in the two minor gastrectomy groups; however, there was no difference between the two minor gastrectomy groups (5.33 cm, 4.07 cm, and 3.69 cm, respectively). The minor gastrectomy with MIS required least hospital stay and operation duration also. We re-stratify the two minor gastrectomy groups (n = 106) according to the orientation of SMTs around the EGJ into 4 zones. Most of SMTs located on the greater curvature side of the EGJ were resected with MIS (82% versus 18%), whereas SMTs in the other zones were resected more often by laparotomy (59% versus 41%). There was no surgical mortality within the cohort, while minor gastrectomy with MIS yielded least number of leakages among the three groups.

Conclusions

For SMTs around the EGJ, larger tumors (diameter of more than 5 cm) are more likely to be resected with major gastrectomy. To resect SMTs around the EGJ in a wedge-like (minor gastrectomy) fashion, tumors located other than the greater curvature side were more often resected by laparotomy. However, MIS yielded acceptable safety and surgical outcomes compared to conventional laparotomy for SMTs around the EGJ of the same size.

Non-exposure Simple Suturing Endoscopic Full-thickness Resection with Sentinel Basin Dissection in Patients with Early Gastric Cancer: the SENORITA 3 Pilot Study

Purpose

Recently, non-exposure simple suturing endoscopic full-thickness resection (NESS-EFTR) was developed to prevent tumor exposure to the peritoneal cavity. This study aimed to evaluate the feasibility of NESS-EFTR with sentinel basin dissection for early gastric cancer (EGC).

Materials and Methods

This was the prospective SENORITA 3 pilot. From July 2017 to January 2018, 20 patients with EGC smaller than 3 cm without an absolute indication for endoscopic submucosal dissection were enrolled. The sentinel basin was detected using Tc^99m-phytate and indocyanine green, and the NESS-EFTR procedure was performed when all sentinel basin nodes were tumor-free on frozen pathologic examination. We evaluated the complete resection and intraoperative perforation rates as well as the incidence of postoperative complications.

Results

Among the 20 enrolled patients, one dropped out due to large tumor size, while another underwent conventional laparoscopic gastrectomy due to metastatic sentinel lymph nodes. All NESS-EFTR procedures were performed in 17 of the 18 other patients (94.4%) without conversion, and the complete resection rate was 83.3% (15/18). The intraoperative perforation rate was 27.8% (5/18), and endoscopic clipping or laparoscopic suturing or stapling was performed at the perforation site. There was one case of postoperative complications treated with endoscopic clipping; the others were discharged without any event.

Conclusions

NESS-EFTR with sentinel basin dissection is a technically challenging procedure that obtains safe margins, prevents intraoperative perforation, and may be a treatment option for EGC after additional experience.

Trial Registration

ClinicalTrials.gov Identifier: NCT03216174

Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract

BACKGROUND/AIMS

Endoscopic treatment (ET) has been applied for decades to treat subepithelial tumors, including gastrointestinal stromal tumors (GISTs). However, the efficacy of ET remains debatable. In this study, we evaluated the efficacy and safety of ET for GISTs in the upper gastrointestinal tract.

METHODS

This retrospective single-center study included 97 patients who underwent ET. All patients were enrolled from July 2014 to July 2018. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time, total cost, and follow-up were investigated and analyzed.

RESULTS

Our study achieved 100% en bloc resection and 77.4% (72/93) R0 resection. The most common location was the fundus with a mean tumor size of 2.1±1.43 cm. The mean age, procedure time, hospital stay, and cost were 59.7±11.29 years, 64.7±35.23 minutes, 6.8 days, and 5,337 dollars, respectively. According to National Institutes of Health classification, 63 (64.9%), 26 (26.8%), 5 (5.2%), and 3 (3.1%) patients belonged to the very low, low, intermediate, and high risk classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 21.3±13.0 months showed no recurrence or metastasis.

CONCLUSION

ET is effective and safe for curative removal of GISTs in the upper gastrointestinal tract, and it can be a treatment of choice for patients with no metastasis.

Laparoscopic and endoscopic cooperative surgery for cholecystogastric fistula: A case report

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Cholecystogastric fistula (CGF) is rarest form of cholecystoenteric fistula (CEF).

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Our patient had a CGF close to the pylorus.

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Laparoscopic and endoscopic cooperative surgery (LECS) was used to treat CGF.

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Intraoperative endoscopy helped see the margin between fistula suture and pylorus.

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LECS is a viable option to treat CGF, a rare CEF in biliary tract surgery.

Introduction

Cholecystoenteric fistula (CEF) is rare in biliary tract surgery, and cholecystogastric fistula (CGF) is the rarest form of CEF. Although open cholecystectomy with the closure of the fistula is the gold standard treatment for nonobstructing biliary-enteric fistulas, the optimal treatment for CGF has not been established. Laparoscopic and endoscopic cooperative surgery (LECS), a minimally invasive surgery for gastric submucosal tumors, reportedly helps achieve favorable postoperative outcomes. This report presents a case wherein CGF was treated with LECS.

Case presentation

An-84-year-old man with a history of chemotherapy for ileocecal diffuse large B cell lymphoma presented with fever and abdominal pain. He was diagnosed with cholangitis, and endoscopic lithotripsy was performed. Abdominal contrast-enhanced computed tomography revealed gastric wall thickening close to the gallbladder, indicating a malignant lymphoma. Esophagogastroduodenoscopy revealed a concavity on the anterior wall of the antrum of the stomach. Direct endoscopic cholangiography, which was performed by the injection of a contrast medium into the concavity, confirmed the concavity to be a CGF. Cholecystectomy with the closure of the fistula using the LECS was performed to check for suture line leakage and the positional relation of the suture line and the pylorus. The resected specimen showed acute and chronic cholecystitis without malignancy. The patient did not experience postoperative complications in the subsequent 3 months.

Discussion

Resection and closure of the fistula using LECS were performed successfully.

Conclusion

LECS can be performed for CGF. LECS enables intraoperative observation of the fistula and suture line, and thus reduces postoperative complications.

Laparoscopic and endoscopic cooperative surgery for gastric cancer mimicking a submucosal tumor

Abstract

Background

Gastric cancer that mimics a submucosal tumor (SMT) is infrequently encountered in routine clinical settings, and histopathological analysis is often negative for malignant cells. In such cases, excisional biopsy of the entire tumor may be necessary to make a definitive pathological diagnosis, and laparoscopic and endoscopic cooperative surgery (LECS) is a viable method of excisional biopsy.

Case presentation

An 80-year-old male patient diagnosed with stomach wall irregularities at routine medical check-up was referred to our facility, and consequent endoscopic examination detected a 20-mm protruded lesion in the greater curvature at the middle third of the stomach. Endoscopic ultrasound (EUS) showed a thick, low echoic lesion with an irregular margin in the second layer of the gastric wall. Further, a nodular part of the lesion had infiltrated into the submucosa, with an appearance similar to that of linitis plastica of the stomach. The lesion was highly suspected to be a gastric carcinoma with submucosal invasion. However, mucosal-incision-assisted biopsy revealed no malignant cells. Computed tomography (CT) identified no metastatic lymph nodes. Therefore, an excisional biopsy using LECS was performed, and to avoid peritoneal dissemination, we used a modified version, namely, combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET). The procedure ended without any complications, and post-operative course was uneventful. As histopathology returned a diagnosis of adenocarcinoma pT4a, we performed radical gastrectomy and D2 lymphadenectomy. Post-operative course was unremarkable and the patient underwent follow-up examinations without adjuvant chemotherapy because of old age.

Conclusions

Local resection using LECS for gastric tumors with a high suspicion of malignancy is useful and feasible. LECS could be used in similar cases.

Nonexposed wall-inversion surgery as a novel local resection method for neoplasms in the gastrointestinal tract

Nonexposed wall-inversion surgery was invented for the treatment of node-negative gastrointestinal tumors that are difficult to be resected using the endoluminal approach alone. The advantages of this surgery include 1. full-thickness resection procedure of gastrointestinal wall with minimum necessary tumor-negative margins and 2. less risk of bacterial contamination and tumor seeding into the abdominal cavity. We conducted a PubMed search to select relevant articles published until the end of October 2019 for pooled case analyses using the keyword "nonexposed wall-inversion surgery," Based on our search, we enrolled the data of 88 gastric lesions and 1 duodenal lesion retrieved from 7 case report articles and 4 original articles of clinical cases. The gastric lesions consisted of 59 gastrointestinal stromal tumors, 7 ectopic pancreases, 5 leiomyomas, 3 early gastric cancers, and 14 others, with a mean maximal tumor diameter of 25.0 mm. In 5 lesions (5.7%), intraoperative perforation was performed, and 2 lesions (2.3%) were retrieved by the transabdominal route. All 4 major postoperative complications (4.5%) were managed without resurgical interventions. The duodenal case, neuroendocrine tumor, measuring 13 mm in size, was curatively resected without complications. Nonexposed wall-inversion surgery appears to be an acceptable treatment for node-negative gastric and duodenal tumors; however, further accumulation of cases is necessary to confirm the feasibility.

Laparoscopy-assisted endoscopic full-thickness resection of upper gastrointestinal subepithelial tumors: A single-center early experience

Recently, there have been important developments in minimally invasive full-thickness resection of subepithelial tumors (SETs) of the upper gastrointestinal tract. However, there remain challenges with techniques such as laparoscopy-endoscopy cooperative surgery (LECS) and non-exposed endoscopic wall-inversion surgery (NEWS). The aim of the present study was to further investigate the feasibility, efficacy and safety of laparoscopy-assisted endoscopic full-thickness resection (ETFR) of SETs and to evaluate the clinical outcomes. This retrospective study included 16 patients with upper gastrointestinal SETs who underwent laparoscopy-assisted EFTR between July 2016 and December 2017. The patient characteristics, surgical outcomes, postoperative course, results of the histopathological examination and short-term outcomes were reviewed and analyzed. A total of 10 patients in the LECS group and 6 patients in the NEWS group presented with SETs in the stomach (15 cases) or duodenum (1 case). The mean tumor size in the LECS group (5.6 cm) was larger compared with that in the NEWS group (2.1 cm). R0 resection was achieved in all patients, without adverse events or tumor recurrence. The NEWS group exhibited a lower white blood cell count and C-reactive protein level on the first postoperative day, reflecting the less prominent inflammatory response, less bleeding and shorter hospitalization. Therefore, laparoscopy-assisted EFTR by LECS and NEWS is a feasible and safe minimally invasive treatment option for upper gastrointestinal SETs in selected patients.

Laparoscopic-endoscopic cooperative surgery for ileal lipoma: A case report

This is the first report of laparoscopic-endoscopic cooperative surgery (LECS) for an ileal tumor. A 50-year-old man was admitted to our hospital with a positive fecal occult blood test. Colonoscopy detected a submucosal tumor with intussusception located in the ileum, 10 cm oral from the Bauhin valve. On further examination, he was diagnosed with an ileal lipoma. There were no signs of malignancy. LECS was performed for the ileal tumor. After submucosal elevation by injecting saline solution, a mucosal incision was made circumferentially along the tumor. A full-thickness incision was created endoscopically and laparoscopically on the circumferential mucosal incisional line. The tumor was withdrawn intraluminally by endoscopy. The defect of the ileal wall was closed laparoscopically in an axial direction with linear staplers. Histologically, the tumor was a 25-mm ileal lipoma with negative resection margins and no malignancy.

A case of a gastric granular cell tumor preoperatively diagnosed and successfully treated by single-incision laparoscopic surgery

Background

Granular cell tumors (GCT) in the gastrointestinal tract are rare. Herein, we describe a case of a gastric GCT diagnosed preoperatively by endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) and successfully resected by single-incision laparoscopic surgery (SILS).

Case presentation

A 46-year-old Japanese woman had a tumor located in the angle of the stomach that was approximately 1.5 cm in diameter. Abdominal computed tomography (CT) revealed a submucosal tumor (SMT), which was finally diagnosed as a gastric GCT using EUS-FNAB. The tumor was not identified by CT 1 year and 4 months before diagnosis; therefore, because there was a possibility that the tumor was malignant, we performed surgical wedge resection using SILS. The patient had an uneventful recovery postoperatively and was discharged without complications 3 days after surgery. The tumor was pathologically diagnosed as a benign GCT that remained within the muscular layer. No recurrence or complications have occurred in the first 16 months since the surgery.

Conclusion

Because gastric GCTs are generally benign and are rarely associated with lymph node metastasis, SILS seems to be a safe and feasible surgical approach for treating GCTs.

Laparoscopic Transgastric Resection of a Gastrointestinal Stromal Tumor and Concomitant Sleeve Gastrectomy: a Case Report

BACKGROUND

Incidences of obesity, obesity surgeries, and gastric submucosal tumors (GST) have increased worldwide. This case report aims to demonstrate that concomitant laparoscopic transgastric resection (LTGR) of a gastrointestinal stromal tumor (GIST) near the esophagogastric junction (EGJ) can be performed safely and effectively in a patient with morbid obesity and scheduled sleeve gastrectomy (SG).

METHODS

The patient was planned to undergo SG surgery after the diagnosis of morbid obesity (BMI, 40.4 kg/m²). The routine preoperative endoscopic examination revealed a 4-cm diameter GIST-compatible lesion in the stomach near the EGJ. The LTGR with concomitant SG was scheduled for the patient.

RESULTS

The ports were placed for laparoscopic SG. Greater curvature and gastric fundus were fully mobilized. Along the greater curvature gastrotomy was performed, and thus the tumor was localized. The tumor was resected with a linear stapler by considering surgical margins. The frozen section examination showed no malignancy. The gastrotomy was closed, and the SG was performed via the orogastric tube (39F). In the postoperative passage X-ray, there was no stenosis or leaking, and the patient was externed on the third postoperative day. In the immunohistochemical examination, it was reported that the tumor was a GIST, and the surgical margins were negative.

CONCLUSION

The LTGR may help to protect the stomach or minimize the degree of partial resection in the treatment of especially GSTs near the EGJ.

Clinical outcomes of non-exposed endoscopic wall-inversion surgery for gastric submucosal tumors: long-term follow-up and functional results

BACKGROUND AND AIMS

To avoid the risk of iatrogenic dissemination during procedures, we have developed a combined laparoscopic and endoscopic surgery with a nonexposure technique for resection of gastric tumors. The study aim was to evaluate the feasibility and safety of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric submucosal tumors (SMTs).

METHODS

Between August 2013 and February 2018, NEWS was performed for 42 patients with gastric SMTs ≤ 3 cm in diameter at our institution. We retrospectively investigated the patients' backgrounds, operative and perioperative outcomes, tumor pathological characteristics, and follow-up data.

RESULTS

All tumors were resected with negative margins by NEWS. The median operation time was 198 min, and the median estimated blood loss was 5.0 mL. Adverse events occurred in one patient with pneumonia. All patients were alive without recurrence within the median follow-up period of 29.2 months. The average body weight loss rate was 0.3 ± 4.0%. No food residue was observed at endoscopic follow-up.

CONCLUSIONS

On the basis of slight body weight loss and the absence of food residue observed in the postoperative endoscopy, NEWS appeared to be safe and feasible for gastric SMTs and to preserve function of the remnant stomach.

The Efficacy of Autologous Myoblast Sheet Transplantation to Prevent Perforation After Duodenal Endoscopic Submucosal Dissection in Porcine Model

The recent advent of endoscopy has enabled the endoscopic submucosal dissection (ESD) of superficial nonampullary duodenal epithelial tumors. However, the substantially thin wall and presence of bile and pancreatic juice make it technically difficult to perform duodenal ESD without perforation, which leads to lethal complications. The present study evaluated the efficacy of autologous myoblast sheet transplantation for the prevention of late perforation after duodenal ESD in a porcine model. Two weeks before ESD, skeletal muscle was surgically excised from the femur of pigs, and myoblasts were isolated and seeded in temperature-responsive culture dishes to prepare sheets. Immediately after ESD, the autologous myoblast sheets were attached to the serosal surface at the ESD site with omentopexy. The pigs were divided into two groups: the autologous myoblast sheet group (n = 5), where the myoblast cell sheet was attached to the ESD ulcer part from the duodenal serous side, and the Omentum group (n = 5), where only the omentum was used. The pigs were sacrificed and analyzed macroscopically and histologically on postoperative day 3. The macroscopic examination of the abdominal cavity revealed perforation in the ESD ulcer area and leakage of bile in the Omentum group but no perforation in the Sheet group. A histopathological examination revealed that continuity of the duodenal wall at the ESD site was maintained with dense connective tissue in the Sheet group. In conclusion, autologous myoblast sheets were useful for preventing perforation after duodenal ESD.

Endoscopic trans gastric assisted surgery for gastric tumors: Case report and description of a new surgical technique

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Laparoscopic intragastric surgery is a possible management for gastrointestinal storm tumors(GIST) treatment.

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EPATS as percutaneous endoscopic intragastric surgery (PEIGS) can salvage the entire stomach of patients with sub epithelial lesions.

Background

Minimally invasive intragastric surgery [IGS] was first described by Ohashi in 1995 for early gastric cancer, with 3 trocars placed in the gastric lumen. Prior abdominal surgery is not a contraindication to IGS while the abdominal cavity is not explored, always that exist transilumination. But conversion to laparoscopic and open surgery can be challenging owing to the insufflated stomach and/or small bowel, although gas can be easily released via the gastrostomy.

Case presentation

A 53-year-old female patient, presented with a sub epithelial gastric antrum lesion confirmed by endoscopic ultrasonography managed with surgical endoscopic percutaneous assisted transgastric technique [EPATS] using a gastrostomy tube and the endoscope.

Discussion

We have been developing this operation since 2018. Nevertheless, we think EPATS is worthy to master, as PEIGS can salvage the entire stomach of patients with sub epithelial lesions in the lesser curve and in the esophagogastric junction, who otherwise would have to undergo total or proximal gastrectomy.

Conclusion

We need to perform more cases for future comparative studies with percutaneous endoscopic intragastric surgery [PEIGS] in terms of parameters as pain, inflammation, complications, stenosis, oncological results and cosmesis.

Laparoscopic and Endoscopic Cooperative Dissection for Small Gastric Gastrointestinal Stromal Tumor without Causing Injury to the Mucosa

Objective

To investigate the feasibility of laparoscopic and endoscopic cooperative dissection (LECD) for small gastric gastrointestinal stromal tumors (GISTs) without causing injury to the mucosa, compared with ESD surgery which is widely used now.

Methods

A total of 25 patients with small gastric GISTs who underwent LECD and 20 patients with small gastric GISTs who underwent ESD between October 2014 and June 2016 were included in this study. All patients underwent curative resection for pathologically diagnosed small gastric GISTs. Patients' clinical data were retrospectively analyzed.

Results

In LECD group, the operation was successfully performed in all patients. However, in the ESD group, three patients were transferred to laparoscopic surgery due to intraoperative massive bleeding or intraoperative perforation. No additional targeted chemotherapy drugs for interstitial tumors were prescribed in two groups. There was no difference in the complete tumor capsule rate (100% vs. 90%, p = 0.11), operation time (80.76 ± 13.86 ml vs. 84.05 ± 15.33 ml, p = 0.45), major intraoperative bleeding (0 vs. 5%, p = 0.26), postoperative bleeding (0 vs. 10%, p = 0.11), and postoperative infection (0 vs. 10%, p = 0.11) between the two groups. Compared to ESD (endoscopic submucosal dissection), LECS patients had shorter postoperative indwelling gastric tube (1.04 ± 0.98 d vs. 2.85 ± 0.24 d, p < 0.01), earlier postoperative eating (1.96 ± 0.98 d vs. 3.50 ± 1.15 d, p < 0.01), shorter average postoperative hospital stay (3.44 ± 1.00 d vs. 7.85 ± 1.18 d, p < 0.01), smaller perforation rate (0 vs. 25%, p < 0.05), and fewer surgical supplies. No recurrence or metastasis cases were found between the two groups during the follow-up period, and there were no cases of death due to gastric GISTs.

Conclusion

LECD is a novel surgery for small gastric gastrointestinal stromal tumors that leads to satisfactory short-term outcomes and meets the idea of minimally invasive surgery and rapid recovery; compared with ESD, LECD surgery has some advantages in clinical practice. However, further follow-up is needed to confirm.

Safety and efficiency of endoscopic resection versus laparoscopic resection in gastric gastrointestinal stromal tumours: A systematic review and meta-analysis

The application of endoscopic resection (ER) in gastric gastrointestinal stromal tumours (GIST) is controversial. We carried out a meta-analysis to compare the safety and efficiency of ER with laparoscopic resection (LR) in patients with gastric GISTs. We searched PubMed to identify studies comparing ER with LR in GIST. The outcomes focused on two areas: safety, including operation time, blood loss, length of hospital stay, time to flatus, time to liquid, time to soft diet, and postoperative complications; and efficiency, including positive margin, recurrence, and long-term survival. A total of 1292 patients from 12 studies were included in the meta-analysis. Patients undergoing ER had a shorter operation time (standardised mean difference [SMD] -1.48, 95% confidence interval [CI] -2.18 to -0.78) and shorter time to soft diet (SMD -1.02, 95% CI -1.52 to -0.52) than those undergoing LR. No significant differences were observed between the groups in terms of blood loss, length of hospital stay, time to flatus, time to liquid, and postoperative complications. ER was also associated with greater positive margins compared with LR (relative risk 6.32, 95% CI 1.41-28.26). There were no significant differences between ER and LR for recurrence and 5-year disease-free survival. The limited evidence suggests that ER is a more effective strategy for improving postoperative recovery without increasing the risk of surgery and recurrence in gastric GIST. However, close attention should be paid to margin status after ER.

Lyophilizable and Multifaceted Toll-like Receptor 7/8 Agonist-Loaded Nanoemulsion for the Reprogramming of Tumor Microenvironments and Enhanced Cancer Immunotherapy

The low therapeutic efficacy of current cancer immunotherapy is related to nonimmunogenic and immunosuppressive tumor microenvironments (TMEs). To overcome these limitations, both the immune priming of antitumoral lymphocytes and the reprogramming of immunosuppressive factors in TMEs are essential. Here, we suggest a nanoemulsion (NE)-based immunotherapeutic platform that can not only modulate tumor-induced suppression but also induce an effective cell-mediated immune response for T cell proliferation. Multifunctional NEs can be fabricated by integrating the efficacy of NEs as delivery systems and the multifaceted immunomodulation characteristics (i.e., immunostimulation and reprogramming of immunosuppression) of small molecule-based Toll-like receptor 7/8 agonists. Local in situ vaccination of melanoma and cervical tumor models with tumor antigens (protein and peptide) adjuvanted with NE loaded with TLR7/8 agonists [NE (TLR7/8a)] induced the recruitment and activation of innate immune cells, infiltration of lymphocytes, and polarization of tumor-associated M2 macrophages, which resulted in inhibition of tumor growth and prolonged survival in both primary and rechallenged tumor models. Antibody-depletion experiments also suggested that macrophages, type I IFN (IFN-α and IFN-β), CD8⁺ T cells, and NK1.1⁺ cells contributed to the antitumor effect of NE (TLR7/8a). The combination of antitumoral lymphocytes and reprogramming of immunosuppressive TMEs induced by NE (TLR7/8a) treatment evoked a synergistic antitumor immune response with immune checkpoint blockade therapy (anti-PD-1 and anti-PD-L1).

Gastric calcifying fibrous tumor suspected to be complicated with immunoglobulin G4-related disease treated by laparoscopy and endoscopy cooperative surgery: a case report

Background

Calcifying fibrous tumor (CFT) is a rare benign soft tissue lesion.

Case presentation

A 30-year-old woman was admitted to our hospital with complaints of epigastralgia. A 15-mm submucosal tumor was identified in the greater curvature of the superior body of the stomach by upper gastrointestinal endoscopy. Endoscopic ultrasonography revealed a hypoechoic lesion with an acoustic shadow consistent with calcification. Computed tomography showed a gastric tumor with calcification. A gastrointestinal stromal tumor was diagnosed, and gastric wedge resection was performed by laparoscopy and endoscopy cooperative surgery. On pathological examination, the tumor was identified to be a CFT. Postoperative serum IgG4 levels were 26.0 mg/dl, which supported the diagnosis of probable immunoglobulin G (IgG) 4-related disease, according to the comprehensive diagnostic criteria of IgG4-related disease. The patient was discharged on postoperative day 7 and remains well with no evidence of tumor recurrence for 2 years after resection.

Conclusion

We herein reported a patient with a gastric CFT suspected to be complicated with immunoglobulin G4-related disease that was successfully treated by laparoscopy and endoscopy cooperative surgery.

Endoscopic Removal of Gastrointestinal Stromal Tumors in the Stomach: A Single-Center Experience

BACKGROUND AND AIMS

Endoscopic removal of GISTs (gastrointestinal stromal tumors) is recently recognized, but less is known about its efficacy and safety. This study is aimed at assessing the feasibility, clinical efficacy, and safety of the endoscopic removal of gastric GISTs.

PATIENTS AND METHODS

Endoscopic removal (ER) of GISTs was performed in 134 patients at our hospital between January 2015 and January 2019. The clinical features, surgical outcomes, complications, pathological diagnosis, and risk classification were evaluated retrospectively.

RESULTS

ER was successful in 131 cases (98%), including 58 by ESD (endoscopic submucosal dissection), 43 by ESE (endoscopic submucosal excavation), 25 by EFTR (endoscopic full-thickness resection), and 5 by STER (submucosal tunneling endoscopic resection). In addition, GISTs of two cases were resected using LECS (laparoscopic and luminal endoscopic cooperative surgery) for the extraluminal and intraluminal growth pattern. The average tumor size was 1.89 ± 1.25 cm (range: 0.5-6.0 cm). Of these patients, 26 cases had a large tumor size (range: 2.0-6.0 cm), and endoscopic removal was successful in all of them. During the procedure, endoclips were used to close the perforation in all cases, without conversion to open surgery. The average length of hospital stay was 5.50 ± 2.15 days (range: 3-10 days). In the risk classification, 106 (79.7%) were of a very low risk, 25 (18.8%) of a low risk, and 2 (1.5%) of a moderate risk. The moderate-risk cases were treated with imatinib mesylate after ER. No recurrence or metastasis was observed during the follow-up period of 23 ± 8 months (range: 3-48 months).

CONCLUSIONS

The endoscopic treatment is feasible, effective, and safe for gastric GISTs, and individualized choice of approaches is recommended for GISTs.

Clinical feasibility and safety of third space robotic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumors dissection : A new surgical technique for treating gastric GISTs

Background

Surgical management of gastric gastrointestinal stromal tumors (GISTs) has evolved towards minimal invasiveness. Laparoscopic wedge resection and laparoscopic and endoscopic cooperative surgery had been considered as standard surgical treatments for gastric GISTs > 2 cm. However, stomach deformation and the full-thickness gastric defect caused by these procedures may increase the risk of morbidity. To address these problems, we developed a novel technique, third space robotic and endoscopic cooperative surgery (TS-RECS), which could dissect the tumor entirely while preserving the intact mucosal layer. Here we performed a prospective evaluation of the feasibility and safety of TS-RECS.

Methods

Patients with gastric GISTs were recruited between April 2018 and April 2019. During the operation, the gastric GIST was located by endoscopic view firstly and the submucosal injection was performed. The tumor was then dissected through robotic surgery. Clinicopathological characteristics, operative data, adverse events, and follow-ups were prospectively collected and analyzed.

Results

A total of 20 patients with gastric GISTs received TS-RECS. The mean tumor size was 33.0 ± 7.3 mm. R0 resection was achieved in all patients with a median operation time of 115 min and a median blood loss of 20 ml. The integrity of mucosal layer was maintained in 95% (19/20) of the patients. All patients started oral diet on postoperative day 1 or 2, staying in the hospital for a median of 6 days after surgery. There were no major adverse events. Local or distant recurrences were not observed during a median follow-up period of 10 months.

Conclusions

Our study suggests that TS-RECS appears to be a feasible and safe technique which could be an alternative method for resecting gastric GISTs > 2 cm.

Clinical Trials

ClinicalTrials.gov NCT03804762.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-07223-w) contains supplementary material, which is available to authorized users.

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

Laparoscopic and endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMTs) has been developed under the concept of resecting gastric tumors with both complete curability and preserving organ functions. Precise resection is obtained by classical LECS, however, concerns regarding intraoperative bacterial infection and dissemination of the tumor cells into the abdominal cavity by LECS with exposure technique still remain. To prevent these concerns, several LECS-related procedures with non-exposure techniques, such as combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique (CLEAN-NET) and non-exposed endoscopic wall-inversion surgery (NEWS), have been reported to be safe and feasible. Classical LECS, CLEAN-NET, and NEWS have the same concept, however, each has its own different characteristic procedures; exposure or non-exposure technique, inversion of the tumor into or outer the lumen, retrieval of tumor per oral or through the abdominal cavity, and dominance in the role of the endoscopist or the laparoscopic surgeon. Familiarization with these procedure details is important to understand their indications, advantages and limitations, resulting in providing a tailored minimally invasive surgery for patients. The main scope of this review article is to introduce readers to the clinical application, procedure, and results of CLEAN-NET, both from previous literatures and from our experience, as well as to offer a closer look at its advantages and limitations while comparing with other LECS procedures from the viewpoint of introducing CLEAN-NET first.

Feasibility and Safety of a Novel Laparoscopic and Endoscopic Cooperative Surgery Technique for Superficial Duodenal Tumor Resection: How I Do It

BACKGROUND

Pancreatoduodenectomy is considered to be a very invasive treatment for early superficial duodenal tumors (SDTs), which have a lower risk of lymph node metastasis. Partial resection of the duodenum with endoscopic submucosal dissection for SDT resection is an attractive technique but it is associated with a high risk of complications. We describe our technique for SDT resection.

METHOD

It includes the following elements: freeing the transverse mesocolon, exposing and mobilizing the second part of the duodenum and the head of the pancreas (Kocher maneuver), confirming the location of the ulcer bed for endoscopic submucosal dissection, and laparoscopic suturing by hand in the seromuscular layer of the duodenum. We performed this technique in 10 patients between March 2015 and March 2017.

RESULTS

The median tumor diameter and resected tissue diameter were 36 (20-54) and 41 (25-60) mm, respectively. Curative resection (R0) with negative margins was achieved for all patients. There were no conversions to open surgery in this series. No postoperative complications were above grade 2 in the Clavien-Dindo classification system. No recurrences were observed during the medium-term follow-up period.

CONCLUSION

This technique is safe and feasible and can be an option for surgical SDT resection.

Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-third gastric cancer

BACKGROUND

Double-flap technique (DFT) has received increased attention as an anastomotic procedure preventing reflux esophagitis after laparoscopic proximal gastrectomy (LPG) for upper-third gastric cancer. However, incidence of anastomotic stricture still remains high. This study was a retrospective review aimed to demonstrate details of surgical outcomes and to assess risk factors for anastomotic complications using pre-operative CT image after LPG with DFT (LPG-DFT).

METHODS

Patient background data, surgical outcomes, post-operative courses, and complications for patients who underwent LPG-DFT from January 2013 to June 2017 were collected. In addition to the details of short-term outcomes, risk factors for anastomotic stricture and gastroesophageal reflux were analyzed.

RESULTS

The study sample was 147 patients, including 139 patients with upper-third gastric cancer and 8 patients with submucosal tumor of the upper-third stomach. The overall morbidity rate was 12.2% (18/147), and 97.3% (143/147) of the patients achieved R0 resection. Twelve (8.3%) patients required endoscopic balloon dilatation for anastomotic stenosis, and six (4.2%) suffered regurgitation grade ≥ B in the Los Angeles classification. Multivariate analysis revealed that diameter of the esophagus < 18 mm on pre-operative CT image and the presence of short-term complications were found to be independent risk factors for post-operative anastomotic stenosis. No specific risk for gastroesophageal reflux was identified.

CONCLUSIONS

The incidence rate of anastomotic complications after LPG-DFT was far lower than that reported after conventional esophagogastrostomy. Alternative anastomotic method may be considered for patients with diameter of the esophagus < 18 mm on pre-operative CT image. Prevention of short-term complications may lessen post-operative stricture.

Syringeable immunotherapeutic nanogel reshapes tumor microenvironment and prevents tumor metastasis and recurrence

The low response rate of current cancer immunotherapy suggests the presence of few antigen-specific T cells and a high number of immunosuppressive factors in tumor microenvironment (TME). Here, we develop a syringeable immunomodulatory multidomain nanogel (iGel) that overcomes the limitation by reprogramming of the pro-tumoral TME to antitumoral immune niches. Local and extended release of immunomodulatory drugs from iGel deplete immunosuppressive cells, while inducing immunogenic cell death and increased immunogenicity. When iGel is applied as a local postsurgical treatment, both systemic antitumor immunity and a memory T cell response are generated, and the recurrence and metastasis of tumors to lungs and other organs are significantly inhibited. Reshaping of the TME using iGel also reverts non-responding groups to checkpoint blockade therapies into responding groups. The iGel is expected as an immunotherapeutic platform that can reshape immunosuppressive TMEs and synergize cancer immunotherapy with checkpoint therapies, with minimized systemic toxicity.

The limited efficacy of current immunotherapy suggests low antigen-specific T cells and immunosuppressive factors in tumor microenvironment (TME). Here, the authors develop a syringeable immunomodulatory multi-domain nanogel that can reprogram the TME and induce enhanced cancer immunotherapy.

Gastric schwannoma with high accumulation on fluorodeoxyglucose-positron emission tomography resected by non-exposed endoscopic wall-inversion surgery

Gastric schwannoma is a relatively rare tumor arising from Auerbach plexus in the muscle layer of the gastric wall, and constitutes 0.1% to 0.2% of all gastric tumors and 5% of benign non-epithelium-related gastric tumors. We report the case of a 49-year-old woman in whom upper gastrointestinal endoscopy revealed an approximately 2-cm submucosal tumor on the anterior wall of the fornix of the stomach. Contrast-enhanced computed tomography revealed a homogeneously enhanced lesion (~ 17 mm) in the upper third of the stomach as well as a lesion (~ 25 mm) on the left kidney that was strongly enhanced in the early phase. An ¹⁸F-fluorodeoxyglucose positron emission tomography scan revealed high accumulation that is characteristic of gastric tumors. The possibility of malignancy was not completely excluded, and the gastric tumor was resected by non-exposed endoscopic wall-inversion surgery. The patient was discharged with a good prognosis 5 days after surgery. In conclusion, non-exposed endoscopic wall-inversion surgery is a minimally invasive and effective method for resecting small gastric submucosal tumors (diameters < 3 cm) for which preoperative diagnosis is difficult.

Tailored management of primary gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common human sarcoma and can form along the entire gastrointestinal tract. Over the last 20 years, considerable advances have been made in our understanding of the biology of GISTs. The advent of tyrosine kinase inhibitors has provided effective medical therapy for the first time. In fact, given that GIST typically is driven by either a KIT or PDGFRA gene mutation, it has become a paradigm of targeted molecular therapy. In addition, diagnostic and surgical techniques have been refined. Here, the critical aspects of primary GISTs and how they are now managed with an integrated approach are summarized. Treatment plans are developed based on specific pathologic and molecular features of the tumor. The authors outline the general principles of therapy and highlight some of the nuances. Particular focus is given to diagnosis, surgical considerations, and the use of preoperative and postoperative tyrosine kinase inhibitors.

Non-exposed endoscopic wall-inversion surgery for pediatric gastrointestinal stromal tumor: A case report

Gastrointestinal stromal tumors (GIST) in patients under 18 years of age are classified as pediatric GIST. Pediatric GIST are extremely rare, and there are no reports of laparoscopic-endoscopic cooperative surgery for these lesions. We report the use of non-exposed endoscopic wall-inversion surgery as a laparoscopic-endoscopic cooperative surgery-related procedure for the treatment of a pediatric GIST. The case involved a 17-year-old male patient who presented with anemia and was found to have a bleeding gastric tumor. The tumor was resected transorally using the non-exposed endoscopic wall-inversion surgery technique. No gene mutation of c-Kit or Platelet-Derived Growth Factor Receptor α (PDGFRα) was found, and the final pathological diagnosis was epithelial-type GIST due to a succinate dehydrogenase abnormality. Follow-up included a CT scan every 4 months. No recurrence has occurred to date.

The short-term outcomes of laparoscopic-endoscopic cooperative surgery for colorectal tumors (LECS-CR) in cases involving endoscopically unresectable colorectal tumors

PURPOSE

Laparoscopic and endoscopic cooperative colorectal surgery (LECS) is widely used for the removal of endoscopically unresectable colonic polyps. We evaluated the invasiveness of LECS in comparison to conventional laparoscopic surgery (CLS) for endoscopically unresectable colorectal tumors.

METHOD

We retrospectively analyzed the data of patients with colorectal adenoma or mucosal cancer and submucosal tumors who underwent either LECS or CLS at a single, high-volume center in Japan between 2004 and 2017. The short-term and oncological outcomes were compared between groups.

RESULTS

Of the 83 eligible patients, 15 underwent LECS and 68 underwent CLS. There was no conversion to open surgery in either group. En bloc resection was achieved in all cases in both groups. The median time to solid diet intake was the same in both groups (2 days, p = 0.39). The median duration of hospital stay after surgery was 6 days (range 4-12 days) in the LECS group and 10 days (range 5-68 days) in the CLS group (p = 0.01). Clavien-Dindo grade ≥ 3 postoperative complications only occurred in the CLS group (two cases, p = 0.37).

CONCLUSION

Our results indicated that LECS is a safe and feasible technique that results in high-quality colorectal polyp resection with quicker recovery and favorable 30-days postoperative outcomes.

Endoscopic full thickness resection versus submucosal tunneling endoscopic resection for removal of submucosal tumors: a review article

Submucosal tumors (SMT) are protuberant lesions with intact mucosa that have a wide differential. These lesions may be removed by standard polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgically. However, in lesions that arise from the muscularis propria, full thickness resection is recommended. This can be completed using either endoscopic full thickness resection (EFTR) or submucosal tunneling endoscopic resection (STER). EFTR can be accomplished by completing a full thickness resection followed by defect closure or by securing gastrointestinal wall patency before resection. STER is an option that first creates a mucosal dissection proximal to the lesion to allow a submucosal tunnel to be created. Using this tunnel, the lesion may be resected. When comparing STER to EFTR, there was no significant difference when evaluating tumor size, operation time, rate of complications, or en bloc resection rate. However, suture time, amount of clips used, and overall hospital stay were decreased in STER. With these differences, EFTR may be more efficacious in certain parts of the gastrointestinal tract where a submucosal tunnel is harder to accomplish.

Efficacy and safety of endoscopic submucosal dissection for non-ampullary duodenal polyps: A systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is commonly used to treat early-stage digestive cancer because it results in a higher frequency of en-bloc resection and a lower frequency of local recurrence. However, the efficacy and safety of duodenal ESD remain unclear. Therefore, present study is aimed at evaluating clinical outcomes of duodenal ESD.

METHODS

To evaluate the efficacy and safety of duodenal ESD, electronic databases (MEDLINE, CENTRAL and EMBASE) were searched by two independent reviewers. The authors were contacted for additional information. A meta-analysis was performed to evaluate the efficacy and safety of duodenal ESD.

RESULTS

A total of 7 studies (203 patients) were included in the quantitative synthesis analysis. The pooled proportions of the frequencies of en-bloc resection, need for surgical intervention, bleeding, intraoperative perforation and delayed perforation were 87%, 4%, 2%, 15% and 2%, respectively. The quality of evidence regarding on surgical intervention outcomes was rated as moderate, whereas that of en-bloc resection was rated as low because of its marked inconsistency.

CONCLUSIONS

Duodenal ESD produced acceptable outcomes in terms of the en-bloc R0 resection, but the incidence of procedure-related adverse events is high (PROSPERO register, CRD42017057110).

Laparoscopic-endoscopic Rendezvous Procedures for Upper Gastrointestinal Tumors Guided by Laser-supported Reverse Diaphanoscopy: A Modified Technique

INTRODUCTION

Precisely locating benign upper gastrointestinal tumors during laparoscopic-endoscopic surgery remains difficult and inaccurate. We describe reverse laser-supported diaphanoscopy (RLSD) for locating gastrointestinal tumors during laparoscopic surgery and present prospective evaluation results of the first cases.

MATERIALS AND METHODS

We studied 13 patients [women:men=7:6; mean age, 67 (range, 41 to 83) y] who underwent gastroscopic-laparoscopic rendezvous procedures during 2015 to 2018. Surgery duration, marking duration, and specimen resection size were recorded. The largest and smallest specimen resection margins were measured.

RESULTS

After locating tumors using RLSD, patients underwent successful resections. Histopathologic examination confirmed 5 cases of gastrointestinal stromal tumor; 3, neuroendocrine tumors; 2, heterotopic pancreatic tissue; 1, leiomyoma; 1, adenoma; 1, hyperplastic polyp. We employed 4 to 6 marks, depending on tumor location and size. The average marking duration was 14 minute (1 to 21 min); the average surgery duration, 73 minute (37 to 143 min). The smallest resection median margin was 2.0 mm (1.0 to 5.0 mm); the largest, 7.0 mm (2.0 to 12.0 mm).

CONCLUSIONS

RLSD precisely locates gastric benign tumors during laparoscopic-endoscopic rendezvous procedures.

Current Status of Endoscopic Resection of Gastric Subepithelial Tumors

Most gastrointestinal (GI) subepithelial tumors (SETs) are identified incidentally during endoscopic examination and are located in the stomach. Some SETs are malignant or have the potential to become malignant. Tumors originating from deeper layers, such as the muscularis propria or serosa, are not easy to diagnose and resect. Current guidelines recommend yearly endoscopic surveillance of SETs smaller than 2 cm. This recommendation may not be cost-effective in managing GI SETs. Endoscopic resection results not only in obtaining sufficient tissue for pathological diagnosis but also in resection and curing the tumor. Many different endoscopic methods for resection of GI SETs have been published in the literature. To avoid confusion, we have divided these methods into standard endoscopic submucosal dissection, modified endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and nonexposed and exposed endoscopic full-thickness resection. These procedures offer less invasive approaches than surgery for resection of GI SETs and may be the most cost-effective in taking care of patients with GI SETs.

Laparoscopic endoscopic cooperative surgery (LECS) for the gastrointestinal tract: Updated indications

Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure combining laparoscopic gastric resection with endoscopic submucosal dissection for local resection of gastric tumors with appropriate, minimal surgical resection margins. The LECS concept was initially developed from the classical LECS procedure for gastric submucosal tumor resection. Many researchers reported that classical LECS was a safe and feasible technique for resection of gastric submucosal tumors, regardless of tumor location, including the esophagogastric junction. Recently, LECS was approved for insurance coverage by Japan's National Health Insurance plan and widely applied for gastric submucosal tumor resection. However, the limitations of classical LECS are the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and tumor cell seeding in the peritoneum. The development of modified LECS procedures, such as inverted-LECS, non-exposed endoscopic wall-inversion surgery, a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique, and closed-LECS, has almost resolved these drawbacks. This has led to a recent increase in the indication of modified LECS to include patients with gastric epithelial neoplasms. The LECS concept is also beginning to be applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future. Sentinel lymph node mapping could also be combined with LECS, resulting in a portion of early gastric cancers being treated by LECS with sentinel node mapping.

CLEAN-NET: a modified laparoendoscopic wedge resection of the stomach to minimize the sacrifice of innocent gastric wall

BACKGROUND

To avoid excessive sacrifice of the tissue surrounding the submucosal tumor in gastric wedge resection with a stapling device, we perform a "combined laparoscopic and endoscopic approach for neoplasia with a nonexposure technique" (CLEAN-NET). Herein the operative technique of CLEAN-NET is described and its short-term outcomes in 50 patients are evaluated.

PATIENTS AND METHODS

Between December 2015 and July 2017 CLEAN-NET was performed in 50 patients with gastric submucosal tumors. During the operation, the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. When seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. The mucosa is then transected with a stapling device to execute full-thickness resection of the specimen. Finally, the seromuscular defect is repaired by hand-sewn suture. The hospital records of the 50 patients were reviewed to assess the outcomes. The margin width was compared with those measured in another group with 19 patients, who underwent conventional wedge resection with a stapling device.

RESULTS

The operation was completed as CLEAN-NET and the tumor was resected en-bloc without rupture in all patients. The average operation time ranged from 50 to 220 min with an average of 105.4 min. The post-operative course was uneventful. Microscopically the surgical margin was tumor-negative (R0 resection) in all cases. The margin width in the CLEAN-NET group was smaller than that in the wedge resection group (5.4 mm ± 2.5 vs. 33.1 mm ± 14.7).

CONCLUSIONS

CLEAN-NET can be performed safely with an acceptable operation time. CLEAN-NET can be a useful option in the laparoscopic surgical treatment of gastric submucosal tumors, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided.

An innovative laparoscopic and endoscopic technique in an animal model: combined gastric full-thickness tumor resection

Background and study aims  The combination of endoscopy with laparoscopy for full-thickness gastric resection has received much attention. The advantage in using it is removak of the target lesion without resection of excessive normal tissue. The technique could prevent deformed scars, particularly at the cardia and in the prepyloric area. The aim of this protocol was to evaluate a new combined operation for full-thickness resection of the gastric wall. Materials and methods  Gastric subepithelial lesions in multiple topographic locations of the stomach were simulated in seven live pigs. Full-thickness gastric resection was undertaken and after assessment of the outcome, the animals were euthanized. The primary endpoint was accomplishment of the procedure following all steps in the new technique, in various gastric locations. The secondary endpoints were duration of the procedure, quality of specimen margins, and complications. Results  Resections were successful, complete, and complication-free, ensuring a safe surgical margin of healthy tissue. The procedure was completed in 50 minutes. No mucosal perforation or gas escape occurred. Conclusions  The combined technique was safe, effective and minimally invasive. No expensive materials were used. Lesion exposure, gastric content leakage, incomplete resection, and excessive normal tissue elimination were avoided. Human trials of this technique may be warranted.

Potential for local resection with sentinel node basin dissection for early gastric cancer based on the distribution of primary sites

BACKGROUND

Based on the sentinel node (SN) concept, function-preserving surgery with SN basin dissection (SNBD) can be performed for SN-negative early gastric cancers. Particularly, a resection area can be minimized when the SN basin and primary site are closely localized. The aim of this study was to compare probabilities of being candidates for local resection with SNBD based on tumor location among patients with early gastric cancer.

METHODS

We retrospectively analyzed 358 patients who underwent surgery with SN mapping for gastric cancer in our institution from November 1999 to April 2014. The proportion of patients who had a localized single basin and the distributions of the SN basins and primary sites were investigated. Patients with single basin drainage excluding remote sentinel node basin were considered as candidates for local resection with SNBD.

RESULTS

Of the 358 patients, 191 (53%) patients were considered eligible for local resection with SNBD. Patients with tumors located in the upper third of the stomach were more likely candidates for local resection than those with tumors in other locations (upper third, 68%; middle third, 50%; and lower third, 51%), whereas patients with tumors located in the anterior wall were less likely candidates than those with tumors other locations (anterior wall, 31%; posterior wall, 58%; greater curvature, 55%; and lesser curvature, 57%).

CONCLUSION

We found that > 50% of the patients indicated for SN navigation surgery, particularly those with tumors in the upper third of the stomach, potentially could undergo partial resection with SNBD.

Laparoendoscopic Transgastric Resection of Prepyloric Gastrointestinal Stromal Tumor

This case report describes an 83-year-old woman with multiple comorbidities who presented with melena and coffee-ground emesis with diagnostic studies evident for a large prepyloric gastrointestinal stromal tumor. She underwent combined laparoendoscopic transgastric resection surgery for the tumor, performed by a team of gastroenterologist and thoracic surgeon with a successful outcome. The case and videos in this report provide a descriptive demonstration of the steps leading up to the surgical intervention followed by a step-by-step illustration of the combined surgical technique, thus highlighting the importance of multidisciplinary approach for optimal treatment of prepyloric gastrointestinal stromal tumor.

Possibility of limited gastrectomy for early gastric cancer located in the upper third of the stomach, based on the distribution of sentinel node basins

PURPOSE

Several recent studies have evaluated the feasibility of the sentinel node (SN) concept for gastric cancer. The aim of our study was to investigate limited gastrectomy with SN basin dissection in SN navigation surgery (SNNS) for patients with early-gastric cancer located in the upper-third of the stomach.

METHODS

147 patients received SNNS for early-gastric cancer at our institution. Of these, 26 patients diagnosed with early-gastric cancer < 4 cm in size and located in the upper-third of the stomach were retrospectively analyzed for the distribution of SN and SN basins.

RESULTS

In three of the 26 patients, lymph node metastasis was limited to the left gastric artery (LGA) basin. The breakdown of the basins were as follows: A single LGA basin, 19 cases; a non-single LGA basin, seven cases. A non-single LGA basin was significantly associated with the clinicopathological factors, such as tumor spread to the middle-third of the stomach, tumor location at the center of the greater curvature, and undifferentiated adenocarcinoma, compared to the single LGA basin group.

CONCLUSIONS

Our data revealed that the distribution of the SN basins in early-gastric cancer measuring less than 4 cm in size and located in the upper-third of the stomach was significantly correlated with tumor spread, tumor location, and the pathological findings.

Sealed endoscopic full-thickness resection for gastric cancer: a pilot study in an ex vivo and in vivo porcine model

Background and study aims  Endoscopic full-thickness resection (EFTR) is a useful procedure that allows minimal resection of the gastric wall because the tumor can be located endoscopically. However, the procedure carries a risk of peritoneal infection or dissemination. Thus, we devised a new EFTR technique in which the serosa is sealed using a silicone sheet to prevent the escape of gastric juice. Materials and methods  Three whole stomachs were harvested from pigs for an ex vivo experiment, and seven pigs were used for an in vivo experiment. In both experiments, silicone sheets and gauze were pasted to the serosa using a fibrinogen-thrombin solution. A seromuscular incision was then made endoscopically using a HookKnife. We then evaluated whether stomach collapse could be prevented using this technique. Furthermore, the method was compared with conventional laparoscopic-assisted EFTR (LA-EFTR) in terms of resection time and quality of endoscopic view. Results  In the ex vivo experiment, stomach collapse was suppressed and the seromuscular layer could be incised layer by layer. In the in vivo experiment, the time required for seromuscular incision with the new EFTR technique was significantly shorter than that with the conventional method. All layers of the stomach were smoothly resected under good endoscopic view. Conclusions  Sealed EFTR is a potentially useful technique for the minimally invasive resection of gastric tumor. All layers of the stomach could be incised while confirming the incision line from the inside of the stomach and avoiding exposure of the tumor to the abdominal cavity.

Laparoscopic and endoscopic cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors

Background and study aims  We developed a laparoscopy endoscopy cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors. The aim of this study was to evaluate the feasibility of LECS, which combines endoscopic submucosal dissection (ESD) and laparoscopic partial colectomy. Patients and methods  We performed LECS for 17 colorectal tumors in 17 patients (male:female 10:7; mean age, 66.5 years). The clinicopathological outcomes of these 17 cases and the feasibility of LECS were evaluated retrospectively. Indications for LECS were as follows: 1) intramucosal cancer and adenoma accompanied by wide and severe fibrosis; 2) intramucosal cancer and adenoma involving the diverticulum or appendix; and 3) submucosal tumors. Results  We successfully performed LECS procedures in 17 cases (intramucosal cancer [n = 6], adenoma [n = 9], schwannoma [n = 1], and gastro-intestinal stromal tumour [GIST] [n = 1]. Mean tumor diameter was 22.4 mm (range, 8 - 41 mm). LECS was successfully performed in all 17 cases without conversion to open surgery; the R0 rate was 100 %. LECS was applied to the following situations: involving the appendix (n = 6), tumor accompanied by severe fibrosis (n = 5), involving the diverticulum (n = 3), submucosal tumor (n = 2), and poor endoscopic operability (n = 1). We experienced no adverse events (e. g., leakage or anastomotic stricture) and the median hospital stay was 6.4 dayus (range, 4 to 12). All 17 patients who were followed for ≥ 3 months (median, 30.8 months; range, 3 - 72 months) showed no residual/local recurrence. Conclusion  LECS was a safe, feasible, minimally invasive procedure that achieved full-thickness resection of colorectal tumors and showed excellent clinical outcomes.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Laparoscopic Endoscopic Cooperative Surgery for Gastrointestinal Stromal Tumors

With the development of laparoscopy and digestive endoscopy, multiple laparoscopic and endoscopic cooperative surgeries (LECSs) for gastrointestinal stromal tumors have recently been developed. Classic LECS has been confirmed as a feasible and safe treatment procedure for gastrointestinal stromal tumors with regard to both short-term surgical and long-term oncological outcomes; however, classic LECS has the potential risk of gastric contents or tumor cells spilling into the abdominal cavity because the gastric wall has to be opened during the procedure. Various modified LECS techniques have aimed at further minimizing invasiveness, such as the full-thickness resection method using the nonexposure technique (combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique), nonexposed endoscopic wall-inversion surgery, and closed LECS. This review describes and summarizes the current LECS for gastrointestinal tumor.

Gastric washing by distilled water can reduce free gastric cancer cells exfoliated into the stomach lumen

PURPOSE

Intragastric free cancer cells in patients with gastric cancer have rarely been studied. The purpose of this study was to investigate the detection rate of intragastric free cancer cells in gastric washes using two types of solutions during endoscopic examination. We further clarified risk factors affecting the presence of exfoliated free cancer cells.

METHODS

A total of 175 patients with gastric cancer were enrolled. Lactated Ringer's solution (N = 89) or distilled water (DW; N = 86) via endoscopic working channel was sprayed onto the tumor surface, and the resultant fluid was collected for cytological examination. We compared the cancer-cell positivity rate between the two (Ringer and DW) groups. We also tested the correlation between cancer-cell positivity and clinicopathological factors in the Ringer group to identify risk factors for the presence of exfoliated cancer cells.

RESULTS

The cancer-cell positivity rate was significantly higher in the Ringer group than that in the DW group (58 vs 6%). Cytomorphology in the Ringer group was well maintained, but not in the DW group. The larger tumor size (≥ 20 mm) and positive lymphatic involvement were significant risk factors of exfoliated free cancer cells.

CONCLUSIONS

Cancer cells can be highly exfoliated from the tumor surface into the gastric lumen by endoscopic irrigation in large gastric cancer with lymphatic involvement. Gastric washing by DW can lead to cytoclasis of free cancer cells; therefore, it may minimize the possibility of cancer-cell seeding in procedures carrying potential risks of tumor-cell seeding upon transluminal communication, such as endoscopic full-thickness resection and laparoscopy-endoscopy cooperative surgery.

Clinical Overview of GIST and Its Latest Management by Endoscopic Resection in Upper GI: A Literature Review

AIMS

To review the clinical presentation, diagnosis, assessment of risk of malignancy, and recent advances in management (mainly focusing on the role of endoscopic resection) of gastrointestinal stromal tumors (GISTs) in upper GI.

METHOD

We searched Embase, Web of science, and PubMed databases from 1993 to 2018 by using the following keywords: "gastrointestinal stromal tumors," "GIST," "treatment," and "diagnosis." Additional papers were searched manually from references of the related articles.

FINDINGS

The improvement of endoscopic techniques in treating upper gastrointestinal subepithelial tumors especially gastrointestinal tumors has reduced the need for invasive surgery in patients unfit for surgery. Many studies have concluded that modified endoscopic treatments are effective and safe. These treatments permit minimal tissue resection, better dissection control, and high rates of en bloc resection with an acceptable rate of complications.