Does laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors preserve residual gastric motility? Results of a retrospective single-center study

Outcomes of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors: A retrospective multicenter study at 21 Japanese institutions

AIM

We conducted a multicenter study on classical laparoscopic and endoscopic cooperative surgery (LECS) and LECS-related procedures to retrospectively clarify the safety, problems, and mid-term outcomes of these methods after their coverage by the national health insurance.

METHODS

A total of 201 patients who underwent classical LECS/LECS-related procedures for gastric submucosal tumors (G-SMTs) in 21 institutions affiliated with the Laparoscopy Endoscopy Cooperative Surgery Study Group from April 2014 to March 2016 were included. Data was retrospectively obtained from the patients' charts.

RESULTS

The most common surgical procedure was classical LECS (155 patients, 77.1%), non-exposed endoscopic wall inversion surgery (22 patients, 11.4%), a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (16 patients, 8%), and closed LECS (two patients, 1%). Only six (3%) patients underwent LECS with gastrostomy. The mean operative time and blood loss were 188.4 (70-462) minutes and 23.3 (0-793) g, respectively. Ten (5%) patients developed postoperative complications (Clavien-Dindo classification grade II or higher). Two patients needed reoperation due to postoperative bleeding or anastomotic leakage. All tumors were resected with negative margins. A total of 127 (63.2%) patients underwent follow-up observations for over 36 months, one of whom had a recurrence of peritoneal dissemination and one had poor oral intake.

CONCLUSION

Classical LECS and LECS-related procedures for G-SMTs have favorable short/mid-term outcomes.

Current Status of Endoscopic Full-Thickness Resection for Gastric Subepithelial Tumors: A Literature Review Over Two Decades

BACKGROUND

With the development of endoscopic technology and devices, endoscopic full-thickness resection (EFTR) has been challengingly introduced for gastric subepithelial tumors (SETs). The resection and closure strategies are under investigation. This systematic review was performed to assess the current status and limitations of EFTR for gastric SETs.

SUMMARY

MEDLINE was searched using the keywords "endoscopic full-thickness resection" or "gastric endoscopic full-thickness closure" AND "gastric" or "stomach" from January 2001 to July 2022. The outcome variables were the complete resection rate, major adverse event (AE) rate including delayed bleeding and delayed perforation, and closure-associated outcomes. Among 288 studies, 27 eligible studies involving 1,234 patients were included in this review. The complete resection rate was 99.7% (1,231/1,234). The major AE rate was 1.13% (14/1,234), with delayed bleeding in two (0.16%) patients, delayed perforation in one (0.08%), panperitonitis or abdominal abscess in three (0.24%), and other AEs in eight (0.64%). Surgical interventions were required intraoperatively or postoperatively in 7 patients (0.56%). Three patients underwent intraoperative conversion to surgery, due to intraoperative massive bleeding, technical difficulty of closure, and retrieval of falling tumor in the peritoneal cavity. Postoperative surgical rescues for AEs were required in four (0.32%). Subgroup analysis of AE outcomes showed no significant differences among closure techniques consisting of endoclips, purse-string suturing, and over-the-scope clips.

KEY MESSAGES

This systematic review demonstrated acceptable outcomes of EFTR and closure for gastric SETs, indicating that EFTR is a promising forthcoming procedure.

Lap-Endo cooperative surgery (LECS) in gastric GIST: updates and future advances

BACKGROUND

With advancements in the field of laparoscopic and endoscopic techniques leading to improved patient outcomes, open resection has become increasingly outdated for the treatment of gastric gastrointestinal stromal tumours (GIST). This is further superseded with the advent of laparoscopic and endoscopic cooperative surgery (LECS), an amalgamation of the two techniques to further improve results garnered while overcoming prior limitations each had individually.

METHODS

The electronic databases MEDLINE, Embase and PubMed were reviewed up to August 2021, using terms relating to LECS and gastric GIST. Relevant in-article references not returned in the searches were also considered.

RESULTS

Advancements in the field of laparoscopic and endoscopic techniques has led to improved patient outcomes, making open resection a thing of the past for gastric GIST. This has become even more apparent with the advent of LECS, coupling two cutting edge techniques to further improve results garnered while overcoming prior limitations each had individually. LECS has gained much favour by reducing surgical margins due to endoscopic visualisation without being limited to smaller tumours, allowing for better anatomical and functional preservation of prior anatomy. Furthermore, hybrid approaches have improved perioperative outcomes, with reduction in procedure time, post-procedure hospital stay and lesser complications. Additionally, subtypes of LECS such as inverted LECS, closed LECS, non-exposed endoscopic wall-inversion surgery (NEWS) and laparoscopy-assisted endoscopic full-thickness resection (LAEFR) have been developed that allows the abdominal cavity to not be exposed to tumour cells and gastric contents by extracting the lesion transorally.

CONCLUSIONS

LECS and its subtypes being a combination of two advanced techniques shows a synergistic effect that is promising. However, despite all these advantages of enhanced safety and certainty, there remains areas that require further improvement.

Comparison of purse-string suture versus over-the-scope clip for gastric endoscopic full-thickness closure: traction and leak pressure testing in ex vivo porcine model

BACKGROUND

The recently developed endoscopic full-thickness resection technique requires reliable closure. The main closure methods are the purse-string suture (PSS) technique and over-the-scope clip (OTSC) technique; however, basic data on the closure strength of each technique are lacking. This study was performed to compare the closure strengths of these two methods in an ex vivo porcine model.

METHODS

In the traction test, a virtual 5-cm full-thickness closure line was closed by the following six methods three times each: conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture. The primary endpoint was the tension at the starting point of dehiscence, measured in Newtons (N) by an automatic traction machine. In the leak test, a 15-mm gastric full-thickness defect was closed by PSS or OTSC six times each, and the closed stomach was then pressurized in a water container. The primary endpoint was the leak pressure when air bubbles appeared. The secondary endpoints were the procedure time and presence of complete inverted closure.

RESULTS

The mean tension was 2.16, 3.68, 5.15, 18.30, 19.30, and 62.40 N for conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture, respectively. Complete inverted closure was observed for seromuscular PSS, seromuscular OTSC, and surgical suture. The mean leak pressure was 13.7 and 24.8 mmHg in the PSS and OTSC group, respectively (P < 0.01). The mean procedure time was 541 and 169 s in the PSS and OTSC group, respectively (P < 0.01). Complete inverted closure was observed in OTSC alone.

CONCLUSION

The OTSC, which allows complete inverted closure, showed greater closure strength than PSS. Considering the size limitation suitable for single OTSC, a therapeutic strategy for closing the larger size is further warranted.

Efficacy and Safety of Laparoscopic Endoscopic Cooperative Surgery in Upper Gastrointestinal Lesions: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Laparoscopic and endoscopic cooperative surgery (LECS) combines advantages of endoscopy and laparoscopy in order to resect upper gastrointestinal lesions. Our aim was to evaluate the efficacy and safety of LECS in patients with EGJ (esophagogastric junction), gastric and duodenal lesions, as well as to compare LECS with pure endoscopic and pure laparoscopic procedures.

METHODS

PubMed, Scopus, and ISI Web of Knowledge were searched. Efficacy (R0, recurrence) and safety (conversion rate, procedure and hospitalization time, adverse events, mortality) outcomes were extracted and pooled (odds ratio or mean difference) using a random-effects model. Study quality was assessed with Newcastle-Ottawa Scale and heterogeneity by Cochran's Q test and I2 . Subgroup analysis according to location was performed.

RESULTS

This meta-analysis included 24 studies/1,336 patients (all retrospective cohorts). No significant differences were found between LECS and preexisting techniques (endoscopic submucosal dissection (ESD)/laparoscopy) regarding any outcomes. However, there was a trend to shorter hospitalization time, longer procedure duration, and fewer adverse events in LECS versus Laparoscopy and ESD. R0 tended to be higher in the LECS group. Hospitalization time was significantly shorter in gastric versus EGJ lesions (mean 7.3 vs. 13.7 days, 95% CI: 6.6-7.9 vs. 8.9-19.3). There were no significant differences in conversion rate, adverse events, or mean procedural time according to location. There was a trend to higher conversion rate and longer procedure durations in EGJ and higher rate of adverse events in duodenal lesions.

CONCLUSION

LECS is a valid, safe, and effective treatment option in patients with EGJ, gastric, and duodenal lesions, although existing studies are retrospective and prone to selection bias. Prospective studies are needed to assess if LECS is superior to established techniques.

KEY MESSAGES

LECS is safe and effective in the treatment of upper gastrointestinal lesions, but there is no evidence of superiority over established techniques.

Clinical outcomes of laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor

BACKGROUND

Laparoscopic and endoscopic cooperative surgery (LECS) is a well-recognized surgical procedure for gastric gastrointestinal stromal tumor (GIST). In this report, we describe the clinical outcomes of LECS procedures for gastric GIST in our institution.

METHODS

We performed LECS procedures, including classical LECS, inverted LECS, closed LECS, and combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET), in 40 gastric intraluminal and intramural type GIST patients, whose tumors were ≤ 50 mm in diameter, between September 2012 and December 2020. The patient background, surgical outcomes, postoperative morbidity and mortality, as well as the tumors' clinicopathological characteristics were analyzed retrospectively.

RESULTS

Pathological findings showed that most patients had a low or very low risk of tumor recurrence, while one patient had a high risk according to the modified-Fletcher's classification. The median length of postoperative hospital stay was 7 days. Only one patient had severe postoperative grade III complications according to the Clavien-Dindo (C-D) classification, after closed LECS, but was treated successfully with endoscopic hemostasis for postoperative hemorrhage. The remaining patients treated with LECS did not have severe complications. During the follow-up period (median, 31 months), all patients were disease-free, with no tumor recurrence or metastases.

CONCLUSION

LECS is a safe surgical procedure for gastric intraluminal and intramural type GIST ≤ 50 mm in diameter, with good clinical outcomes.

Clinical outcomes and functional analysis of third space robotic and endoscopic cooperative surgery versus laparoscopic wedge resection for gastric submucosal tumours: a propensity score-matched study

Third space robotic and endoscopic cooperative surgery (TS-RECS) is a novel minimally invasive surgery for resecting gastric submucosal tumours (GSMTs), which could accomplish the completely oncological curability and maximal functional preservation. This study investigated the clinical outcomes and gastrointestinal function after TS-RECS versus laparoscopic wedge resection (LWR) for GSMTs. This was a single-centre retrospective study that included 130 patients with GSMTs who underwent LWR or TS-RECS from 2013 to 2019. To overcome selection biases, we performed propensity score matching (1:1) using seven covariates that could impact the group assignment and outcomes. Then, the clinical outcomes and gastrointestinal function in the LWR and TS-RECS groups were compared in a matched cohort. Among the 130 enrolled patients, 96 patients underwent LWR, and 34 underwent TS-RECS and were matched into 30 patients for each group. There was no significant difference in the operation time between the two groups (P = 0.543). However, the TS-RECS group had significantly less blood loss (20,5–100 vs 95,10–310 ml, P < 0.0001) and better postoperative recovery in terms of time to oral intake (2,2–4 vs 3,2–6 days, P < 0.0001) and postoperative hospital stay (5,4–10 vs 8.5,5–16 days, P < 0.0001) than the LWR group. The severity and frequency scores of postoperative gastrointestinal symptoms in the TS-RECS group were significantly lower than those in the LWR group. The median follow-up period was 24 months (10–60 months) in the LWR group and 18 months (10–27 months) in the TS-RECS group, and there was in total a single recurrence in the LWR group. TS-RECS appears to be a technically safe and effective surgery with preservation of gastrointestinal function for resection of GSMT resection.

Comparison of endoscopic versus laparoscopic resection for gastric gastrointestinal stromal tumors: A preliminary meta-analysis

BACKGROUND AND AIM

For localized disease, complete surgical resection is regarded as the "gold standard" therapeutic modality. With the rapid development of endoscopic techniques, endoscopic resection (ESR) has been confirmed as an efficient and safe alternative for the treatment of gastrointestinal stromal tumors (GISTs) in the stomach. Nevertheless, the management of gastric GISTs remains poorly defined. The purpose of this study is to evaluate the security and effectiveness of ESR with laparoscopic resection (LAR) for gastric GISTs.

METHODS

A literature search of online databases was conducted to identify relevant comparative studies of ESR and LAR procedures for gastric GISTs published before April 10, 2020. The cumulative data analysis was also performed utilizing the software STATA.

RESULTS

In total, 10 studies involving 1165 patients met the inclusion criteria for analysis (651 for ESR and 514 for LAR). From the results of meta-analysis, patients who underwent ESR experienced decreased operative time (P = 0.000), less intraoperative blood loss (P = 0.002), earlier time to diet (P = 0.000), shorter hospital stay (P = 0.000), and lower total charges (P = 0.000) compared with LAR. Moreover, there were no significant differences between these two approaches concerning tumor rupture, conversion rate to other procedure, complete resection rate, postoperative complication rate, recurrence rate, and disease-free survival.

CONCLUSIONS

Endoscopic resection, as an effective alternative treatment strategy with satisfactory outcomes, is acceptable for selective patients with gastric GISTs compared with LAR. Further well-designed randomized controlled trials with large samples are warranted to corroborate our observations.

Closed laparoscopic and endoscopic cooperative surgery for early gastric cancer with difficulty in endoscopic submucosal dissection: a report of three cases

Background

Endoscopic submucosal dissection (ESD) is increasingly applied for early gastric cancer. ESD is a less invasive procedure and could be a radical treatment. However, in some cases, ESD cannot be completed owing to patient or technical factors. In such cases, which could have the potential for curative resection with ESD, standard gastrectomy is excessively invasive. Through closed laparoscopic and endoscopic cooperative surgery (LECS), gastric tumor can be precisely resected without exposing tumor cells to the abdominal cavity. Compared with standard gastrectomy, closed LECS is less invasive for the treatment of early gastric cancer.

Case presentation

We performed closed LECS for three cases of early gastric cancer after failed ESD. In all three cases, ESD was interrupted owing to technical and patient factors, including perforation, respiratory failure, and carbon dioxide narcosis. All three cases successfully underwent closed LECS with complete tumor resection and showed an uneventful postoperative course. All three patients remain alive and have experienced no complications or recurrence, with a median follow up of 30 (14–30) months.

Conclusions

Closed LECS is less invasive and useful procedure for the treatment of early gastric cancer, particularly in cases with difficulty in ESD.

Comparison of Nonexposed Endoscopic Wall-Inversion Surgery with Endoscopic-Navigated Laparoscopic Wedge Resection for Gastric Submucosal Tumours: Results of a Two-Centre Study

Introduction

The aim of this study was to compare the indications, operative details, and clinical outcomes of nonexposed endoscopic wall-inversion surgery with endoscopic-navigated laparoscopic wedge resection of gastric submucosal tumours.

Methods

Medical records were reviewed for patients who underwent nonexposed endoscopic wall-inversion surgery (NEWS) at the Faculty Hospital Kralovske Vinohrady and endoscopic-navigated laparoscopic wedge resection (LWR) at the Kepler University Hospital. Demographic, tumour, surgical, perioperative, and follow-up data were collected and compared.

Results

Eleven patients underwent NEWS and twelve patients underwent LWR. NEWS was associated with a longer operating time and more frequent suture line bleeding (3 cases in the NEWS group versus 1 case in the LWR group). Negative resection margins were achieved in all NEWS procedures and in 11 of the LWRs. The difference in size between the tumour and the resected specimen was smaller in the NEWS group. Length of hospitalisation was similar between the two groups (NEWS = 6.8 days, LWR = 6.5 days). Follow-up gastroscopies at 12 months postoperatively revealed no signs of recurrence in any of the patients.

Conclusion

Nonexposed endoscopic wall-inversion surgery is a new technique for the treatment of gastric tumours. It allows for more precise resections with more frequent achievement of negative resection margins than LWRs. Additionally, it may allow for better preservation of gastric function and limit communication between the gastric lumen and peritoneal cavity. The longer operating time and more frequent complications associated with the NEWS reflects the limited experience with these new techniques.

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.

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.

Endoscopic submucosal dissection for early gastric cancer on the lesser curvature in upper third of the stomach is a risk factor for postoperative delayed gastric emptying

BACKGROUND

Advances in Endoscopic submucosal dissection (ESD) technology have established ESD for early gastric cancer as a safe and stable technique. However, ESD may induce delayed gastric emptying and the cause of food residue retention in the stomach after ESD is not clear. This study aimed to clarify risk factors for delayed gastric emptying with food retention after gastric ESD.

METHODS

We retrospectively examined for food residue in the stomach 1 week after ESD was performed for early gastric carcinoma at Osaka Saiseikai Nakatsu Hospital from February 2008 to November 2016.

RESULTS

Food residue was observed in 68 (6.1%) of 1114 patients who underwent gastric ESD. The percentage of lesions located on the lesser curvature of the upper third of the stomach was 45.6% (31/68) in the food residue group and 3.5% (37/1046) in the non-food residue group, which was significantly different (P < 0.01). Multivariate logistic regression analysis revealed that lesions on the lesser curvature of the upper third of the stomach (Odds ratio [OR] 23.31, 95% confidence interval [CI] 12.60-43.61, P < 0.01), post-ESD bleeding (OR 4.25, 95%CI 1.67-9.80, P < 0.01), submucosal invasion (OR 2.80, 95%CI 1.34-5.63, P < 0.01), and age over 80 years (OR 2.34, 95%CI 1.28-4.22, P < 0.01) were independent risk factors for food retention after gastric ESD. Of the 68 patients, 3 had food residue in the stomach on endoscopic examination for follow-up observation after the ESD ulcer had healed.

CONCLUSIONS

Delayed gastric emptying with food retention after gastric ESD was associated with lesions located in the lesser curvature of the upper stomach, submucosal invasion of the lesion, age older than 80 years, and post-ESD bleeding, though it was temporary in most cases.

Preliminary analysis of hybrid laparoscopic procedure for resection of gastric submucosal tumors

OBJECTIVE

to evaluate the feasibility, safety and benefits of minimally invasive surgery for resection of gastric submucosal tumor (GSMT).

METHODS

we conducted a retrospective study of medical records of patients undergoing endoscopy-assisted laparoscopic resection of gastric submucosal tumors (prospectively collected) from 2011 to 2014. We evaluated clinical data, surgical approach, clinicopathological characteristics of the GSMT (size, location, histopathological and immunohistochemical exams), outcome and patients follow-up.

RESULTS

we evaluated six patients, 50% male, mean age 52±18 years and common symptoms of heartburn and gastric fullness. All patients underwent hybrid procedure without anatomical impairment of the organ. The average length of stay was 3.5 days and the average size of the tumors was 2.0±0.8cm, five of them (83%) in the proximal third of the stomach. The surgical specimens pathological and immunohistochemistry examination revealed one case of ectopic pancreas (17%), one grade 2 neuroendocrine tumor (17%), one lipoma (17%), one GIST (17%) and two leiomyomas (32%). There were no episodes of tumor rupture or intraoperative complications and no conversion to open surgery. During the postoperative follow-up period, none of the patients had recurrence, metastasis, fistula or stenosis.

CONCLUSION

the results showed that endoscopy-assisted laparoscopic resection is feasible and safe for patients with GSMT. Endoscopy proved to be essential in the location of lesions and as intraoperative support, especially when attempting to preserve the pylorus and cardia during surgery.

OBJETIVO

avaliar a viabilidade, segurança e vantagens da cirurgia minimamente invasiva para ressecção de tumores submucosos gástricos (TUSG).

MÉTODOS

estudo retrospectivo dos prontuários de pacientes submetidos à ressecção videolaparoscópica assistida por endoscopia digestiva alta para tumores submucosos gástricos (coletados prospectivamente) de 2011 a 2014. Os fatores avaliados foram dados clínicos, abordagem cirúrgica, características clinicopatológicas dos TUSG (tamanho, localização, exame anatomopatológico e imuno-histoquímico), resultados e acompanhamento dos pacientes.

RESULTADOS

foram avaliados seis pacientes, 50% do sexo masculino, com média de idade 52±18 anos e sintomas comuns de pirose e plenitude gástrica. Todos os pacientes foram submetidos ao procedimento híbrido e sem comprometimento anatômico do órgão. O tempo médio de internação foi 3,5 dias e o tamanho médio dos tumores foi 2,0±0,8cm, cinco deles (83%) no terço proximal do estômago. Os exames anatomopatológicos e imuno-histoquímicos das peças cirúrgicas demonstraram um caso de pâncreas ectópico (17%), um tumor neuroendócrino grau 2 (17%), um lipoma (17%), um GIST (17%) e dois leiomiomas (32%). Não houve episódios de ruptura do tumor nem complicações intraoperatórias e nenhuma conversão para cirurgia aberta. Durante o período de acompanhamento pós-operatório nenhum dos pacientes apresentou recidiva, metástase, fístula ou estenose.

CONCLUSÃO

os resultados obtidos mostraram que a ressecção laparoscópica assistida por endoscopia é viável e segura para pacientes com TUSG. A endoscopia mostrou-se fundamental na localização das lesões e suporte intraoperatório, principalmente na tentativa de preservar a cárdia e o piloro durante a cirurgia.

Novel approach of laparoscopic and endoscopic cooperative surgery (LECS) for cholecystectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) techniques, such as generating an artificial space between digestive tract layers for safer dissection, were thought to be safer for the resection of organs in cholecystectomy. We investigated whether combinations of endoscopic techniques and laparoscopic techniques could be performed more safely and rapidly.

MATERIAL AND METHODS

Laparoscopic and endoscopic cooperative-cholecystectomy (LEC-chole) and conventional laparoscopic cholecystectomy (Lapa-chole) were performed in six dogs. Operation time was defined as the time from the creation of the first port to the retrieval of the resected gallbladder (GB); and GB bed dissection time was the time from local injection of natural saline to the clipping of the cystic duct. The main roles of the endoscope in LEC-chole were to obtain a sufficient cutting space via local injection of natural saline to the GB bed and to monitor the operative view without laparoscopic camera, thus omitting the umbilical port.

RESULTS

The operation times were 60 ± 18.3 minutes for LEC-chole and 95 ± 7.0 for Lapa-chole (p = .036). The GB bed dissection times were 31 ± 8.54 minutes in LEC-chole and 50.6 ± 7.37 minutes in Lapa-chole (p = 0.048). There were significant differences in liver damage and bleeding (p = 0.116), but there were no significant differences in one-month survival.

CONCLUSIONS

The application of LEC-chole may be expanded to cholecystectomy.

Laparoscopic endoscopic cooperative surgery (LECS) for the upper gastrointestinal tract

We developed the laparoscopic and endoscopic cooperative surgery (LECS) technique, which combines endoscopic submucosal dissection (ESD) and laparoscopic gastric resection to resect gastric submucosal tumors (SMTs). Many researchers have reported LECS to be a feasible technique for gastric submucosal tumor resection regardless of tumor location, including the esophagogastric junction (EGJ). Recently, the Japanese National Health Insurance system approved LECS for insurance coverage, and it is now widely applied for gastric submucosal tumor resection. Initially, we applied LECS to gastric SMTs without ulcerative lesions due to concern about the possibility of tumor cells seeding into the peritoneal cavity, in a procedure termed "classical LECS". To expand the indication of LECS for gastric epithelial neoplasms, modified LECS procedures such as inverted LECS, non-exposed endoscopic wall-inversion surgery (NEWS), combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET), and closed laparoscopic and endoscopic cooperative surgery (closed-LECS) have been developed and applied to patients with gastric epithelial neoplasms. As a future perspective of LECS, we plan to combine the modified LECS procedure and sentinel node (SN) navigation surgery (SNNS) for clinical (c)Stage IA gastric cancer resection. This strategy could be a minimally invasive surgical technique for cStage IA early gastric cancer.

Current Status of Exposed Endoscopic Full-Thickness Resection and Further Development of Non-Exposed Endoscopic Full-Thickness Resection

Endoscopic full-thickness resection (EFTR) is a procedure that makes it possible to access the lesions that are on the wall of the digestive tract via the shortest distance through the mouth. Because of the ultra-minimal invasive nature of the treatment, pure EFTR is a highly promising surgical procedure that allows the radical excision of full-thickness layers of digestive tract tumors using only a flexible endoscope. There are 2 types of EFTR methods: exposed and non-exposed. Considering the risks of contracting infection and intraperitoneal dissemination of tumor cells, non-exposed EFTR is an ideal method. However, a number of issues remain unresolved, including the method for performing a full-thickness suture under endoscopic view and the challenge of securing the operating field in the case of gastrointestinal tract collapse. Moreover, advances in the development of equipment such as full-thickness suturing devices would be helpful to make this therapeutic procedure the most minimally invasive endoscopic surgery ever.

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

BACKGROUND AND AIMS

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, determining an appropriate resection line using only the laparoscopic approach is difficult. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique by combining laparoscopic gastric resection with endoscopic submucosal dissection, and we have used this procedure to resect gastric SMTs. In this study, the procedure is presented and its safety and feasibility for resecting gastric SMTs are evaluated.

METHODS

This retrospective study included 100 patients who underwent LECS for SMTs at the Department of Gastroenterological Surgery, Cancer Institute, between June 2006 and November 2014. The demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed.

RESULTS

Complete resection with negative surgical margins was achieved in all patients, and LECS was performed regardless of tumor location. The mean operation time was 174.3 minutes, with an estimated blood loss of 16.3 mL. In addition, the mean time until the initiation of oral intake was 1.4 days, and the mean postoperative hospital stay was 8.4 days. Moreover, no local or distant tumor recurrence was observed. The only severe adverse event was leakage, which was observed in 1 patient.

CONCLUSIONS

LECS was performed with a reasonable operation time, low blood loss, and minimal adverse events. Therefore LECS is safe and feasible for resecting gastric SMTs.

Comparison of endoscopic submucosal dissection and surgery for the treatment of gastric submucosal tumors originating from the muscularis propria layer: a single-center study (with video)

INTRODUCTION

Endoscopic submucosal dissection (ESD) has been used for the treatment of gastric submucosal tumors (SMTs). This study aims to compare clinical outcomes of ESD versus laparoscopic wedge resection (LWR) for gastric SMTs.

METHODS

This is a retrospective cohort study. Patients with SMTs who underwent ESD or LWR were enrolled in this study at a university-affiliated hospital from January 2010 to October 2015. Preoperative endoscopic ultrasound and computed tomography were performed to determine origin of layer and growth pattern. Clinical outcomes including baseline demographics, tumor size, operation time, blood loss, hospital stay, cost, pathology and postoperative complications were compared.

RESULTS

From January 2010 to October 2015, 68 patients with SMTs received ESD and 47 patients with SMTs received LWR. There was no difference in age, gender, body mass index, origin of layer and proportion with symptoms between ESD group and LWR group. However, tumor size was significantly larger in the LWR group (37.1 mm) than in the ESD group (25.8 mm, P = 0.041). For patients with tumors smaller than 20 mm, ESD was associated with shorter mean operation time (89.7 ± 23.5 vs 117.6 ± 23.7 min, P = 0.043), less blood loss (4.9 ± 1.7 vs 72.3 ± 23.3 ml, P < 0.001), shorter length of hospital stay (3.6 ± 1.9 vs 6.9 ± 3.7 days, P = 0.024) and lower cost (2471 ± 573 vs 4498 ± 1257 dollars, P = 0.031) when compared with LWR. For patients with tumors between 20 mm and 50 mm, ESD was associated with shorter mean operation time (99.3 ± 27.8 vs 125.2 ± 31.5 min, P = 0.039), less blood loss (10.1 ± 5.3 vs 87.6 ± 31.3 ml, P < 0.001), shorter length of hospital stay (4.0 ± 1.7 vs 7.3 ± 4.5 days, P = 0.027) and lower cost (2783 ± 601 vs 4798 ± 1343 dollars, P = 0.033) when compared with LWR. There were no significant differences in terms of rates of en bloc resection, complete resection and complication and histological diagnosis regardless of tumor size.

CONCLUSIONS

ESD can achieve similar oncological outcomes when compared with surgery for treatment of gastric SMT smaller than 50 mm.

Laparoscopic endoscopic cooperative surgery as a minimally invasive treatment for gastric submucosal tumor

Laparoscopic wedge resection is a useful procedure for treating patients with submucosal tumor (SMT) including gastrointestinal stromal tumor (GIST) of the stomach. However, resection of intragastric-type SMTs can be problematic due to the difficulty in accurately judging the location of endoluminal tumor growth, and often excessive amounts of healthy mucosa are removed; thus, full-thickness local excision using laparoscopic and endoscopic cooperative surgery (LECS) is a promising procedure for these cases. Our experience with LECS has confirmed this procedure to be a safe, feasible, and minimally invasive treatment method for gastric GISTs less than 5 cm in diameter, with outcomes similar to conventional laparoscopic wedge resection. The important advantage of LECS is the reduction in the resected area of the gastric wall compared to that in conventional laparoscopic wedge resection using a linear stapler. Early gastric cancer fits the criteria for endoscopic resection; however, if performing endoscopic submucosal dissection is difficult, the LECS procedure might be a good alternative. In the future, LECS is also likely to be indicated for duodenal tumors, as well as gastric tumors. Furthermore, developments in endoscopic and laparoscopic technology have generated various modified LECS techniques, leading to even less invasive surgery.

A case of primary adenocarcinoma of the third portion of the duodenum resected by laparoscopic and endoscopic cooperating surgery

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Laparoscopic and endoscopic cooperating surgery (LECS) enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing for duodenal neoplasms.

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Thorough mobilization of the mesocolon and pancreas head is essential for this procedure because it facilitates correct resection and suturing.

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LECS is a feasible treatment option for duodenal neoplasms.

Introduction

We report a case of primary adenocarcinoma in the third portion of the duodenum (D3) curatively resected by laparoscopic and endoscopic cooperating surgery (LECS).

Presentation of case

A 65-year-old woman had a routine visit to our hospital for a follow-up of rectal cancer resected curatively 2 years ago. A routine screening gastroduodenal endoscopy revealed an elevated lesion of 20 mm in diameter in the D3. The preoperative diagnosis was adenoma with high-grade dysplasia; however, suspicion about potential adenocarcinoma was undeniable. Curative resection was performed by LECS. Pathological examination revealed intramucosal adenocarcinoma arising from normal duodenal mucosa. The tumor was stage I (T1/N0/M0) in terms of the tumor, nodes, metastasis (TNM) classification. LECS for duodenal tumor has seldom been reported previously, and this is the first report of LECS for primary adenocarcinoma in the D3. The transverse mesocolon was removed from the head of pancreas to expose the duodenum, and the accessory right colic vein was cut; this was followed by the Kocher maneuver for mobilization of the lesion site.

Discussion

LECS enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing. Thorough mobilization of the mesocolon and pancreas head is essential for this procedure because it facilitates correct resection and suturing.

Conclusion

LECS is a feasible treatment option for duodenal neoplasms, including intramucosal adenocarcinoma, even though it exists in the D3.