Laparoscopic resection of benign tumors of the posterior gastric wall

Laparoscopic techniques and strategies for gastrointestinal GISTs

The laparoscopic approach is widely accepted surgical treatment for gastrointestinal submucosal tumors (SMTs). In this chapter, we will introduce laparoscopic techniques and strategy for gastrointestinal SMTs, in accordance with those for gastrointestinal stromal tumors (GISTs). The indication for a laparoscopic approach has been related to tumor size. The upper limit of tumor size has increased, according to recent trends, and there is no established guideline for a lower limit. All patients undergoing laparoscopic surgery receive preoperative examinations including gastrofiberscopy, upper gastrointestinal radiography, computed tomography (CT), and endoscopic ultrasonography (EUS). Gastric tumors <20 mm in diameter measured by EUS or CT are preoperatively localized by gastrofiberscopic clipping of the mucosa covering the SMT. While maintaining the principle of local resection with a negative resection margin, different surgical techniques are required depending on the location and configuration of the tumor. A single dose of a second-generation cephalosporin is administered to patients as a prophylactic antibiotic before or immediately after operation. If a patient undergoes wedge resection, a semi-bland diet will be provided within 48-72 hours. However, in cases of proximal or distal gastrectomy, the diet will be restricted for several days. A "no-touch" technique, by which the risk of tumor dissemination can be minimized, includes grasping the surrounding tissues, holding the threads sutured at the normal serosa around the tumor, and using a laparoscopic stapler or bag during laparoscopic resection.

Techniques of intragastric laparoscopic surgery

Benign or pre-cancerous lesions and foreign bodies of the stomach not amendable to endoscopic removal often require extensive surgery to address a process that does not necessitate lymph node sampling or formal gastrectomy. These lesions are particularly difficult to address endoscopically when located at the esophagogastric junction as a retroflexed view is needed. From its first description in 1995, intragastric laparoscopic surgery has evolved with respect to both technological advancements and tactical innovations. Here we report the development of four distinct techniques of laparoscopic intragastric surgery which we have developed over time and applied in 11 patients. These techniques consist of a (1) combined gastroscopic/laparoscopic approach when minimal manipulation of the lesion is needed, (2) multiport resection which provides optimal triangulation and allows for resection of more complex lesions, (3) stapled removal of broad-based lesions, and (4) single access technique with the device placed directly through the abdominal wall into the stomach. The techniques expand the surgeon's armamentarium to address more complex intragastric processes safely, while the typical postoperative benefits of minimal access surgery such as fast recovery time and less pain are preserved. As we gain greater experience with intragastric laparoscopic surgery, this technique holds the promise of becoming a standard surgical technique for benign lesions for which it is oncologically safe to perform a limited resection.

Intragastric endoscopic assisted single incision surgery for gastric leiomyoma of the esophagogastric junction

Single port laparoscopic surgery is becoming an alternative to conventional laparoscopic surgery as a new approach where all the conventional ports are gathered in just one multichannel port through only one incision. Appling this technical development, we have developed a new technique based on an intragastric approach using a single port device assisted by endoscopy (I-EASI: intragastric endoscopic assisted single incision surgery) in order to remove benign gastric lesions and GIST tumors placed in the posterior wall of the stomach or close to the esophagogastric junction or the gastroduodenal junction. We present a patient with a submucosal gastric tumor placed near the esophagogastric junction removed with this new approach.

Laparoscopic transgastric resection of gastric submucosal tumors located near the esophagogastric junction

BACKGROUND

Laparoscopic wedge resection is widely accepted as a choice of treatment for gastric submucosal tumors (SMTs). But it cannot easily be applied to tumors located near the esophagogastric junction (EGJ) due to the high risk of causing deformity or stenosis in the gastric inlet. We evaluated our laparoscopic transgastric surgical technique for gastric SMTs located near the EGJ and clinical outcomes.

METHODS

Twelve consecutive patients with gastric intraluminal SMTs located 3 cm or less from the EGJ underwent laparoscopic transgastric resection at our institution from June 2010 to November 2012. The clinicopathological results of these 12 cases were analyzed.

RESULTS

Laparoscopic transgastric resection was successfully performed on all the patients. The mean operation time was 125 ± 25 min (range, 85-160 min) and the mean blood loss was 53 ± 32 mL (range, 10-120 mL). There was no death in our series. One patient experienced a postoperative complication of upper gastrointestinal tract bleeding due to the errhysis along the staple line treated with an endoscopic hemostatic clip. The mean postoperative length of hospital stay was 5.1 ± 1.2 days (range, 3-7 days). All patients received complete resection with a negative margin. Histopathologic diagnoses were gastrointestinal stromal tumor in seven cases, leiomyoma in four, and heterotopic pancreas in one. There was no tumor recurrence or evidence of stenosis of the EGJ during a mean follow-up of 15.3 ± 9.6 months (range, 1-30 months).

CONCLUSIONS

Laparoscopic transgastric resection is simple, safe, and effective for gastric intraluminal SMTs located near the EGJ.

Hemoperitoneum caused by a ruptured GIST located in the posterior gastric wall managed by endoscopic diagnosis and laparoscopic treatment: case report and literature review

A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with <1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall.

A Band Lifting Assisted Method for Laparoscopic Resection of Gastrointestinal Stromal Tumors on the Posterior Wall of the Stomach

Laparoscopic surgical techniques are beneficial for the wedge resection of gastrointestinal stromal tumors (GISTs). We have developed a new technique of laparoscopic transgastric resection for GISTs of the posterior wall of the stomach, a band lifting wedge resection method that has been confirmed to ensure sufficient surgical margins around the resected specimen in 21 cases. GISTs located at the posterior wall of the stomach were collected for this study. Laparoscopic anterior gastrotomy was performed and a 9-Fr rubber band was looped around the base of the tumor, allowing it to be lifted up through the anterior gastrotomy. The lesion was transected using a laparoscopic linear cutter and the gastrotomy was then closed by sequential application of the linear cutter. Surgical specimens were examined immunohistochemically All GISTs were successfully and completely resected using the laparoscopic technique. The resected tumors were ellipse-shaped or round. Macroscopic examination of the resected specimens showed complete tumor excision with negative surgical margins in all patients. A band lifting method for transection of GISTs on the posterior wall of the stomach easily allows for sufficient surgical margins of GISTs. The technique is reliable and feasible for laparoscopic treatment of GISTs in the stomach.

Laparoscopic upper gut surgery

Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.

Laparoscopic intraluminal surgery for gastrointestinal malignancies

INTRODUCTION

Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery.

MATERIALS AND METHODS

The data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing.

RESULTS

From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal.

CONCLUSION

Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.

Laparoscopic surgery for submucosal tumors located at the esophagogastric junction and the prepylorus

BACKGROUND

Laparoscopic partial gastric resection is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, SMTs of either end of the stomach are generally managed by subtotal gastrectomies or total gastrectomies. This study was conducted to evaluate surgical techniques for management of SMTs located at the ends of the stomach.

METHODS

Among 63 patients who were diagnosed and underwent laparoscopic surgery for gastric SMTs at Seoul National University Bundang Hospital from May 2003 to May 2007, 11 SMTs located at the ends of the stomach were identified. The clinicopathologic results of these 11 SMTs were analyzed.

RESULTS

Laparoscopic partial wedge resections or tumor excisions were successfully performed on all patients except for those who had prepyloric tumors. Six men and five women had SMTs at the ends of the stomach. The patients ranged in age from 21-63 years (mean 43.4 +/- 13.5 years). Of six esophagogastric junctional tumors that showed low, homogeneous contrast enhancement on computed tomography (CT) scans, five were treated by laparoscopic transgastric enucleation and one by tumor-everting resection. One esophagogastric junctional tumor that leaned toward the fundus and showed a 6-cm-diameter endophytic mass with heterogeneous enhancement on CT scan was resected by laparoscopic wedge resection. The mean operation time was 100 min (range 60-210 min). Three laparoscopy-assisted distal gastrectomies and one laparoscopic wedge resection were performed on SMTs located near the prepyloric antrum. There were no intra- or postoperative complications. Duration of postoperative hospital stay ranged from 4-7 days.

CONCLUSION

Laparoscopic local resection is an effective treatment for SMTs located at the esophagogastric junction and can be used instead of a total or proximal gastrectomy. However, gastrectomies should be considered for SMTs located near the pylorus because of the small volume of the lower third of the stomach.

Application of laparoscopic techniques for resection of individual gastric submucosal tumors

Large gastric submucosal tumors should be excised to prevent ischemic mucosal ulceration of the overlying surface and central necrosis of the neoplasm, which may in turn lead to massive hemorrhage. Large tumors near the esophagocardiac junction or on the posterior wall are usually resected by an open procedure. We describe 2 cases of upper gastrointestinal tract bleeding owing to huge submucosal tumors in the posterior gastric high body treated by laparoscopic resection of the gastric tumors. These 2 patients recovered smoothly without major or minor complications. We emphasize that design of specific strategies for individual tumors is essential for the successful laparoscopic resection of tumors adjacent to the esophagocardiac junction and large tumors on the posterior wall.

Laparoscopic resection of gastric gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are neoplasms with low malignant potential. They occur most commonly in the stomach, where they are amenable to laparoscopic resection.

METHODS

A case note review of all patients undergoing laparoscopic resection of a presumed gastric GIST at the Norfolk and Norwich University Hospital, United Kingdom, was conducted.

RESULTS

Since September 1995, 30 patients have undergone this procedure. The patients had a mean age of 64.2 years (range, 31-87 years) and a mean weight of 74.1 kg (range, 44-104 kg). A presumptive diagnosis of GIST was made in all the cases based on the endoscopic and radiologic appearance of the lesion. Laparoscopic resection was completed successfully in 23 patients with a mean operating time of 73.8 min (range, 26-160 min). Seven procedures were converted to open surgery: three because the tumor was deemed too large for laparoscopic resection, two because the tumor could not be identified, one because of dense peritoneal adhesions, and one because of bleeding. The mean estimated blood loss was 196 ml (range, 0-1,000 ml), and the mean hospital stay was 5 days (ranges, 1-11 days). Pathologic analysis of the resected specimens showed 22 GISTs, 3 inflammatory fibroids, 2 submucosal lipomas, 1 submucosal varix, and 1 nest of heterotopic pancreatic tissue. D: uring a median follow-up period of 18 months (range, 2-101 months) there have been two cases of recurrence. In both cases, the tumor was catagorized as high risk for aggressive behavior after primary resection.

CONCLUSION

Stapled laparoscopic resection is a safe and effective treatment option for nonmetastatic primary gastric GIST.

Endoscopic band ligation without electrosurgery: a new technique for excision of small upper-GI leiomyoma

BACKGROUND

Leiomyoma is a relatively common submucosal tumor in the upper-GI tract. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated.

METHODS

The study included 59 patients with 64 small upper-GI leiomyomas arising in the muscularis propria as determined by endoscopy, EUS, and EUS-guided FNA. The distribution of the 64 leiomyomas was the following: esophageal, 50; gastric, 12; duodenal, 2. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning 2 weeks after banding, the lesions were observed endoscopically once per week until healing was complete.

RESULTS

The 50 esophageal leiomyomas sloughed completely. The mean time required for complete healing after band ligation was 3.6 weeks. Nine of the 12 gastric leiomyomas sloughed completely; the resulting ulcer defect was healed at a mean of 4.5 weeks. The other 3 lesions did not slough because they were not completely ligated. The two duodenal lesions sloughed completely after banding, and the mean time until healing of the defect was 4.5 weeks. No perforation occurred. Follow-up ranged from 16 to 31 months, during which time no recurrence was observed.

CONCLUSIONS

Endoscopic band ligation is an effective and safe treatment for small upper-GI leiomyoma.

Laparoscopy in the management of gastric submucosal tumors

BACKGROUND

Gastric tumors, including early gastric cancers, can be safely removed laparoscopically. They do not require an open laparotomy.

METHODS

From March 1995 to December 1998, we used laparoscopy to resect gastric submucosal lesions in 32 patients. There were 22 men and 10 women. The patients ranged in age from 23 to 67 years (median, 51.4 yr). The lesions were located in the upper third in one patient, in the middle third in 20 patients, and in the lower third in 11 patients. The tumors ranged in size from 2 to 6 cm in diameter. The operative procedures were wedge resection in 19 patients, wedge resection with gastrotomy in two patients, intragastric surgery in nine patients, intragastric surgery with gastrotomy in one patient, and proximal gastrectomy in one patient, using a four- or five-port technique. The exophytic mass was resected with an Endo-GIA, and the tumors on the mucosal surface were exposed via a gastrotomy and excised. The gastrotomy was closed with an intracorporeal suture. In all cases, the operation was finished after the confirmation of tumor-free margins on frozen-section biopsy specimens.

RESULTS

The duration of the operation ranged from 80 to 180 mins. The final pathologic findings were leiomyoma in 24 patients, adenomyoma in three patients, hyperplastic polyp in two patients, lipoma in one patient, hamartoma in one patient, and leiomyosarcoma in one patient. One case (3.1%) was converted to a mini-laparotomy due to technical difficulty; in one other case, more margin was resected laparoscopically due to the tumor-positive margin; and in one further patient, leakage was repaired by laparoscopic suturing on the 1st postoperative day. There were no other major complications and no deaths. The hospital stay ranged from 6 to 7 days. The maximum follow-up to date in these patients, including a case of leiomyosarcoma, was 42 months. There has been no evidence of tumor recurrence.

CONCLUSION

The application of laparoscopy to submucosal tumors of the stomach is technically feasible, safe, and useful. It should be considered a viable alternative to open surgery and gastroscopic management because of its low invasiveness and good postoperative results.

Laparoscopic gastric resection

This article focuses on laparoscopic gastric resections for neoplastic disease, gastric cancer, and gastric mesenchymal tumors. Established oncologic principles governing resections for neoplastic disease must not be overlooked in the laparoscopic approach to surgical management. Evidence-based information on surgical management of gastric cancer and stromal stomach tumors is presented, and the laparoscopic procedures that can be undertaken without compromising the clinical outcome are surveyed.

Surgical management of gastrointestinal bleeding

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

Laparoscopic ultrasound guidance for laparoscopic resection of benign gastric tumors

Laparoscopic excision of gastric leiomyoma is technically feasible and safe, but it may fail to localize the exact placement of the lesion because of the lack of tactile sensitivity. The authors present two cases of small gastric leiomyomas that were resected by a totally laparoscopic approach, assisted with intraoperative laparoscopic ultrasonography because the lesions could not be palpated. A gastric wedge resection with tumor-free margins was performed with an endostapler device. Use of a harmonic scalpel to divide the gastroepiploic vessels facilitated the laparoscopic procedure.

Laparoscopic resection of submucosal gastric tumors

In order to elucidate the efficacy in gastric surgery, we evaluated seven resected cases of a submucosal gastric tumor in which laparoscopic techniques were used. The patients consisted of 1 man and 6 women. The tumors were located in the upper, middle, and lower third of the stomach in 4, 1, and 2 cases, respectively. Three tumors were located mainly on the anterior gastric wall, 2 were on the posterior wall, and 2 were on the lesser curvature. The resected tumor size averaged 3.2 x 2.6 cm. The tumors were classified as intraluminal type (4 cases) and the extraluminal type (3 cases) according to the classification of growth type. A histopathological examination identified 4 leiomyomas, 1 leiomyosarcoma, and 4 smooth muscle tumors of indeterminate malignant potential. After a tumor resection, no recurrence of the lesions occurred during the postoperative follow-up. An extraluminal growing tumor was easily resected by the laparoscopic method without any additional procedures, and this therefore seemed to be a good indication for the laparoscopic method. In contrast, an intraluminal tumor was found to be more difficult to resect using the laparoscopic method without a companion method, e.g., intraoperative endoscopy, because of the difficulties in the detection and resection of the tumor from the serosal side. A more efficient technique must therefore be developed for this type of tumor.

Laparoscopic resection of heterotopic gastric pancreatic tissue

This report describes a laparoscopic approach for the treatment of a benign gastric mass. A 15-year-old female presented with recurrent epigastric pain. Preoperative endoscopic and x-ray evaluation demonstrated a submucosal tumor of the greater curvature. The patient underwent a laparoscopic resection of a heterotopic pancreatic tumor in the stomach. A description of our technique and a review of the pathophysiologic features of this disease is included.

Laparoscopic resection of solitary gastric schwannoma

We report a case of successful laparoscopic resection of a solitary schwannoma of the gastric fundus performed on emergency. The patient was a 52-year-old man who presented with an upper gastrointestinal hemorrhage. At admission, the endoscopy and hydro-CT scan showed a submucosal tumor, 2.5 cm in maximum diameter, with an area of central ulceration arising from the anterior wall of the gastric fundus. A wedge laparoscopic resection of the gastric wall was performed under endoscopic guidance. The defect in the anterior wall was repaired in part by linear stapler and in part using a continuous suture. The postoperative recovery was uneventful and the patient was discharged on the 4th postoperative day. Laparoscopic approach represents a safe and efficient approach for the treatment of benign tumors of the stomach, also on emergency basis.