Novel intragastric trocar placed by PEG technique permits endolumenal use of rigid instruments to simplify complex endoscopic procedures

Use of an intragastric trocar to perform a novel stapling procedure for reflux disease

Background and study aims  A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure. Materials and methods  Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days. Results  The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm ² /mmHg, 2.7 ± 0.7 mm ² /mmHg post-procedurally, and 3.0 ± 0.8mm ² /mmHg on day 14. Average change in distensibility pre- and post-procedure was -2.3 ± 1.8 mm ² /mmHg (95 % confidence interval [CI] -0.5 to 5.1, P  = 0.08) while change in pre- and day 14 distensibility was -2.0 ± 1.4 mm ² /mmHg (95 % CI -0.1 to 4.2, P  = 0.06). Conclusions  An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days.

Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

Total-Laparoscopic Intragastric Surgery for Cardia Endogenous Gastric Submucosal Tumors: A Single-Center Short-Term Experience

BACKGROUND

Total-laparoscopic intragastric surgery (T-LIGS) has gradually been accepted for the treatment of endogenous gastric submucosal tumors. However, it is difficult to perform T-LIGS when the tumor is located at the esophagogastric junction (cardia endogenous gastric submucosal tumor [CEGSMT]) without special laparoscopic instruments that are not available in most developing countries. We have successfully treated 12 cases of CEGSMTs using conventional laparoscopic instruments and achieved acceptable outcomes. This study was conducted to evaluate the surgical techniques for CEGSMT management.

METHODS

A retrospective analysis was conducted involving all the CEGSMT patients who were treated with T-LIGS in the General Surgery Department of Guangdong General Hospital from August 2014 to June 2016.

RESULTS

There were 12 patients successfully treated with T-LIGS. The surgical time ranged from 56 to 108 minutes, and the blood loss was 5-70 mL. The distance to the tumor from the dentate line was 12-24 mm, and the tumor diameter was 17-28 mm. The tumor margins were 9-15 mm, and the eating time was 2-4 days. The drainage tube indwelling time was 2-4 days, and the discharge time was 4-6 days. The follow-up exams revealed no recurrences, dysphagia, acid reflux, or other digestive symptoms.

CONCLUSIONS

It is safe and feasible to perform T-LIGS using conventional laparoscopic instruments to treat CEGSMTs. We suggest that T-LIGS can be performed for endogenous mucosal tumors within 3 cm from the cardiac dentate line and less than 3 cm in size.

Gastric endoscopic submucosal dissection via gastrostoma before the second operation for esophageal perforation: A case report

A 69-year-old man with advanced esophageal cancer and 2 early gastric cancers received chemoradiotherapy and was scheduled to undergo subtotal esophagectomy after gastric endoscopic submucosal dissection (ESD). However, left lower esophageal perforation induced by vomiting suddenly occurred, and he urgently underwent esophago-proximal gastrectomy and gastrostomy without reconstruction. The resected specimen showed a complete response of pretreatment for the esophageal cancer and radical resection of one gastric cancer. Radical resection of the other gastric lesion was necessary before reconstruction. The fistula of gastrostoma was gradually dilated from 6.7 to 9.3 mm in order to pass the endoscope. At nine months after emergent operation, gastric ESD was performed via only the gastrostoma. A hemoclip with thread was attached to the specimen, and the thread was pulled out of the gastrostoma. The specimen was able to be removed en bloc, resulting in radical resection. Gastric tube reconstruction through the posterior sternal route was performed at six months after the ESD. He has not developed recurrence of the esophageal or gastric cancer in the two years since the emergent operation.