Surgical advantages of gastric SMTs by laparoscopy and endoscopy cooperative surgery

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.

The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis

Background and Objectives

The objective was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery.

Methods

The randomised controlled trials (RCTs), which are about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours were searched from the PubMed (1998-1990-2018.6), Wanfang Data (1990-2018.6), China National Knowledge Infrastructure (1979-2018.6) and International Statistical Institute (1998-2018.6). The data were extracted from these trials, and the meta-analysis was made through from RevMan 5.3 software.

Results

Six RCTs involving 451 patients were included in the study (227 patients in the laparoscopy combined with gastroscopy positioning group and 224 patients in laparoscopic surgery group). Compared with laparoscopic surgery group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could shorten the post-operation hospital stay (P < 0.05) and reduce the intraoperative blood loss (P < 0.05). However, there was no significant difference in others between the two groups, such as operation time (P > 0.05), post-operative time of recovery of intestinal peristalsis (P > 0.05) and the total hospital stay (P > 0.05).

Conclusion

Compared with laparoscopic surgery group, the better total effect occurs in laparoscopy combined with gastroscopy positioning group for the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.

Comparison of laparoscopy combined with gastroscopy positioning and open resection for gastric stromal tumours: A meta-analysis

Background and Objectives

The aim of the study was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery.

Methods

I searched the randomized controlled trials (RCTs) about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours from the PubMed (1998~2018.06), Wanfang Data (1990~2018.06), China National Knowledge Infrastructure (1979~2018.06) and International Statistical Institute (1998~2018.06). I extracted the data from these trials, and I got the meta-analysis from RevMan 5.3 software.

Results

Twenty-six RCTs involving 1710 patients were included (870 patients in the laparoscopy combined with gastroscopy positioning group and 840 patients in openresection group). Compared with open resection group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could reduce the intraoperative blood (P < 0.05), shorten the post-operative time of recovery of intestinal peristalsis (P < 0.05), shorten the diet recovery time (P < 0.05), reduce the incidence of the incision infection, intestinal obstruction and pneumonia and also shorten the post-operation hospital stay (P < 0.05). However, there was no significant difference in the operation time (P > 0.05).

Conclusion

Compared with open resection group, the total effect of laparoscopy combined with gastroscopy positioning group in the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.

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

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.

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.

Laparoscopic and endoscopic cooperative surgery for intra-mucosal gastric carcinoma adjacent to the ulcer scars

Background

Laparoscopic and endoscopic cooperative surgery (LECS) was performed for the local resection of gastrointestinal stromal tumors (GIST). LECS enables less resection of the lesion area and preserves function. Furthermore, LECS can be safely performed and independent of tumor location. However, LECS is not usually used for cases involving gastric carcinoma because it may seed tumor cells into the peritoneal cavity when the gastric wall is perforated. Here, we report seven cases of LECS for intra-mucosal gastric carcinoma, which were difficult to carry out by endoscopic submucosal dissection (ESD) because of ulcer scars.

Methods

We performed LECS (classical LECS and inverted LECS) in seven cases of intra-mucosal gastric carcinoma. All cases had ulcer scars beside the tumor. LECS was chosen because ESD was thought to be difficult because of the ulcer scars. We only selected cases in which the patients did not prefer gastrectomy and endoscopic examination was indicative of intra-mucosal gastric carcinoma.

Results

In all cases, LECS was performed without severe complications including postoperative stenosis. Histopathology findings proved that the tumors were intra-mucosal carcinoma and had been resected completely. Furthermore, there were ulcer scars (Ul IIIs-IVs) beside the tumor. Currently, dissemination and recurrence have not been apparent.

Conclusions

LECS for intra-mucosal gastric carcinoma is an efficient procedure, but strict observation is necessary because of the possibility of peritoneal dissemination. Results suggest that LECS is likely to be effective for cases involving intra-mucosal gastric carcinoma that are difficult to treat by ESD due to ulcer scars.

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.

Nonexposure laparoscopic and endoscopic cooperative surgery (closed laparoscopic and endoscopic cooperative surgery) for gastric submucosal tumor

Laparoscopic and endoscopic cooperative surgery (LECS) is increasingly applied for gastric submucosal tumors (SMTs) such as gastrointestinal stromal tumors. However, the conventional LECS procedure has the potential risk that gastric contents and even tumor cells could spread into the abdominal cavity because the gastric wall has to be opened during the resection. To avoid this problem, we have developed a modified LECS procedure named "closed LECS." Ten patients underwent closed LECS for the resection of gastric SMTs. Closed LECS consists of the following steps: endoscopic submucosal layer dissection around the tumor, laparoscopic marking of a resection line on the serosal surface along submucosal dissection line, seromuscular suturing with the marked lesion inverted into the inside of the stomach, endoscopic circumferential seromuscular dissection, and peroral retrieval. In three of the initial five cases, the closed LECS procedure was not completed as planned because of the tumor size and endoscopic inappropriate seromuscular dissection. After modification of the procedure, the entire procedure was successful in all five cases. The mean resected tumor diameter was 24.1 ± 7.6 mm. The mean operation time was 253 ± 45 min. One patient experienced an intra-abdominal abscess potentially related to delayed perforation as a postoperative complication. The closed LECS procedure for gastric SMTs can theoretically be applied without contamination and tumor cell dissemination into the abdominal cavity.

Application of laparoscopy, endoscopy and laparoscopic and endoscopic cooperative surgery in gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) constitute the most common mesenchymal neoplasms of the gastrointestinal tract, among which 60%-70% are located in the stomach. All GISTs have malignant potential, varying from small lesions to aggressive sarcomas. Surgical resection with negative margins remains the best treatment for GISTs. Lymphadenectomy is not necessary because GISTs rarely metastasize to lymph nodes. Because of these biological behavior characteristics, the advantages of minimally invasive surgeries such as laparoscopic surgery and endoscopic surgery can be fully reflected in the surgical management of GISTs. The advent of laparoscopic and endoscopic cooperative surgery has broadened the scope and enhanced the safety of minimally invasive surgical treatment of GISTs. In this paper we will discuss the application of laparoscopy, endoscopy and laparoscopic and endoscopic cooperative surgery in the treatment of GISTs.

Hybrid NOTES: Combined Laparo-endoscopic Full-thickness Resection Techniques

Advances in laparoscopic surgery and therapeutic endoscopy have allowed these minimally destructive procedures to challenge conventional surgery. Because of its theoretic advantages and technical feasibility, laparoendoscopic full-thickness resection is considered to be the most appropriate option for subepithelial tumor removal. Furthermore, combination of laparoscopic and endoscopic approaches for treatment of neoplasia can be important maneuvers for gastric cancer resection without contamination of the peritoneal cavity if the sentinel lymph node concept is established. We are certain that the use of laparoendoscopic full-thickness resection will provide valuable experience that will allow operators to safely develop endoscopic full-thickness resection skills.

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

AIM: To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors.

METHODS: A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach.

RESULTS: The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described.

CONCLUSION: Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.

Cutting edge of endoscopic full-thickness resection for gastric tumor

Recently, several studies have reported local full-thickness resection techniques using flexible endoscopy for gastric tumors, such as gastrointestinal stromal tumors, gastric carcinoid tumors, and early gastric cancer (EGC). These techniques have the advantage of allowing precise resection lines to be determined using intraluminal endoscopy. Thus, it is possible to minimize the resection area and subsequent deformity. Some of these methods include: (1) classical laparoscopic and endoscopic cooperative surgery (LECS); (2) inverted LECS; (3) combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique; and (4) non-exposed endoscopic wall-inversion surgery. Furthermore, a recent prospective multicenter trial of the sentinel node navigation surgery (SNNS) for EGC has shown acceptable results in terms of sentinel node detection rate and the accuracy of nodal metastasis. Endoscopic full-thickness resection with SNNS is expected to become a treatment option that bridges the gap between endoscopic submucosal dissection and standard surgery for EGC. In the future, the indications for these procedures for gastric tumors could be expanded.

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.

Defining a Subgroup Treatable for Laparoscopic and Endoscopic Cooperative Surgery in Undifferentiated Early Gastric Cancer: the Role of Lymph Node Metastasis

BACKGROUND

Recently, the use of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either the preservation of the stomach or the minimization of the extent of partial resection. ESD has recently been practiced on a differentiated type of EGC. However, there is no clear evidence for endoscopic treatments of undifferentiated EGC. The purposes of this study are to investigate predictive factors of lymph node metastasis (LNM) in undifferentiated EGC and expand the possibility of using LECS for the treatment of undifferentiated EGC.

METHODS

Data from 116 patients with undifferentiated EGC and surgically treated were collected, and the association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (OR) with 95 % confidence interval (95 % CI) were calculated.

RESULTS

The tumor size (OR = 11.748, 95 % CI 2.034-62.213, P = 0.008), depth of invasion (OR = 13.928, 95 % CI 1.971-92.434, P = 0.016), and lymphatic vessel involvement (OR = 11.522, 95 % CI 2.645-59.172, P = 0.021) that were significantly associated with LNM by univariate analysis were found to be significant and independent risk factors for LNM by multivariate analysis. The LNM rate was 5.9 % (4/68) and 29.2 % (14/48) with intramucosal and submucosal undifferentiated EGC, respectively. LNM was observed in 66.7 % (2/3) of patients with both risk factors (tumor larger than or equal to 2.0 cm and the presence of lymphatic vessel involvement (LVI)), but in none of 36 patients without the two risk factors in intramucosal undifferentiated EGC. The 5-year survival rates were 88.9, 72.4, and 33.3 %, respectively, in cases with none, one, and two of the risk factors, respectively, in intramucosal undifferentiated EGC (P < 0.05).

CONCLUSIONS

ESD alone may be a sufficient treatment for intramucosal undifferentiated EGC if the tumor is less than 2.0 cm in size and when LVI is absent upon postoperative histological examination. LECS is feasible and safe for patients with undifferentiated EGC.

Gastric carcinoma originating from the heterotopic submucosal gastric gland treated by laparoscopy and endoscopy cooperative surgery

Gastric carcinoma is derived from epithelial cells in the gastric mucosa. We reported an extremely rare case of submucosal gastric carcinoma originating from the heterotopic submucosal gastric gland (HSG) that was safely diagnosed by laparoscopy and endoscopy cooperative surgery (LECS). A 66-year-old man underwent gastrointestinal endoscopy, which detected a submucosal tumor (SMT) of 1.5 cm in diameter on the lesser-anterior wall of the upper gastric body. The tumor could not be diagnosed histologically, even by endoscopic ultrasound-guided fine-needle aspiration biopsy. Local resection by LECS was performed to confirm a diagnosis. Pathologically, the tumor was an intra-submucosal well differentiated adenocarcinoma invading 5000 μm into the submucosal layer. The resected tumor had negative lateral and vertical margins. Based on the Japanese treatment guidelines, additional laparoscopic proximal gastrectomy was curatively performed. LECS is a less invasive and safer approach for the diagnosis of SMT, even in submucosal gastric carcinoma originating from the HSG.

Laparoscopic endoscopic cooperative surgery

Laparoscopic and endoscopic cooperative surgery (LECS) is a newly developed concept for tumor dissection of the gastrointestinal tract that was first investigated for local resection of gastric gastrointestinal stromal tumors (GIST). The first reported version of LECS for GIST has been named 'classical LECS' to distinguish it from other modified LECS procedures, such as inverted LECS, a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET), and non-exposed endoscopic wall-inversion surgery (NEWS). These modified LECS procedures were developed for dissection of malignant tumors which may seed tumor cells into the abdominal cavity. While these LECS-related procedures might prevent tumor seeding, their application is limited by several factors, such as tumor size, location and technical difficulty. Currently, classical LECS is a safe and useful procedure for gastric submucosal tumors without mucosal defects, independent of tumor location, such as proximity to the esophagogastric junction or pyloric ring. For future applications of LECS-related procedures for other malignant diseases with mucosal lesions such as GIST with mucosal defects and gastric cancer, some improvements in the techniques are needed.

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

Background

Laparoscopic and endoscopic cooperative surgery (LECS) is a minimally invasive surgical technique used to resect gastric submucosal tumors with intraluminal growth. Endoscopic submucosal dissection is used to determine the appropriate resection line from within the stomach lumen as it minimizes the stomach wall resection area and prevents postoperative stomach deformity. Although LECS is intended to preserve gastric function, few reports have evaluated postoperative residual gastric motility. Therefore, we conducted a retrospective analysis of patients who underwent LECS to determine the effects of LECS on residual gastric motility.

Methods

Twenty-two patients underwent endoscopy 3 to 12 months after LECS. Patients were evaluated for endoscopic evidence of gastric motility disorder, namely food residue and occurrence/exacerbation of reflux esophagitis. We considered patients with new onset of gastric symptoms and endoscopic evidence of gastric motility disorder to have clinically relevant gastric motility disorder. We described patient characteristics, tumor location, and surgical findings.

Results

Two of 22 patients developed clinically relevant gastric motility disorder after LECS. In one of these patients, the symptoms were not severe; only one had reduced dietary intake and had lost weight. We identified clinically relevant gastric motility disorder in two patients with gastrointestinal stromal tumors located in the lesser curvature of the stomach. The major axis of these two tumors was 34 mm and 38 mm.

Conclusions

Many patients did not have clinically relevant gastric motility disorder after LECS. Further investigation is required to identify predisposing factors for gastric motility disorder.

Single-port laparoscopic and endoscopic cooperative surgery for a gastric gastrointestinal stromal tumor: report of a case

We herein report a case of single-port laparoscopic and endoscopic cooperative surgery (LECS) for a gastric gastrointestinal stromal tumor (GIST). A 75-year-old female with an endoluminal GIST located near the esophagogastric junction underwent LECS. Both the mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. The endoluminal GIST was exteriorized to the abdominal cavity. The tumor and the edge of the incision line were closed using an endoscopic linear stapler. The LECS was successfully accomplished without the need for any skin incisions or additional ports. The length of the operation was 120 min and blood loss was 5 ml. Oral intake was resumed on the second day and the length of hospital stay was 5 days. No complications were noted and the patient had an excellent cosmetic result. In our experience, single-port LECS is feasible and safe for gastric GIST when performed by a surgeon experienced in laparoscopic and gastric surgery.

Non-exposed endoscopic wall-inversion surgery as a novel partial gastrectomy technique

In gastric full-thickness resection employing both endoscopy and laparoscopy, intraabdominal contamination or even possibly tumor seeding is unavoidable as a result of iatrogenic perforation and the resultant spread of gastric juice. To minimize contamination and resected tissue volume, we developed a new technique without perforation termed non-exposed endoscopic wall-inversion surgery (NEWS), and present here the preliminary results. In a clinical observation cohort study, NEWS was attempted in six patients with gastric SMT to investigate the procedure, mortality, and morbidity. NEWS consists of several steps: marking around a tumor on the mucosal as well as the serosal surface, submucosal injection of sodium hyaluronate with indigo carmine dye, circumferential seromuscular dissection with suture closure under laparoscopy, and circumferential mucosubmucosal incision under gastric endoscopy. The resected specimen is then retrieved perorally. Perforation occurred as a result of misidentification and technical inadequacy in the first three patients. After modification of the devices, the entire procedure was successfully achieved in the latter three. There were no complications in any of our six cases. NEWS allows en bloc full-thickness resection, theoretically avoiding contamination and tumor dissemination into the peritoneal cavity.