1686 Laparoscopic-Assisted Endoscopic Submucosal Dissection of Early Gastric Adenocarcinoma

Abstract

INTRODUCTION: A 69-year-old man underwent esophagogastroduodenoscopy (EGD) a year ago which showed intestinal metaplasia without dysplasia in the gastric antrum and incisura. A repeat EGD showed a single plague in the distal esophagus and erosive gastritis. Biopsies revealed high grade dysplasia (HGD) in the gastric cardia and extensive intestinal metaplasia in the rest of the stomach. A subsequent endoscopic ultrasound and CT imaging of chest, abdomen and pelvis revealed no evidence of extraluminal extension or distant metastasis. Given the tumor location surgical resection would require a total gastrectomy. After consultation with surgical oncology, a decision was made to attempt endoscopic submucosal dissection (ESD) with laparoscopic assistance. CASE DESCRIPTION/METHODS: In this video report, an initial EGD was performed which confirmed a superficial gastric ulcer in the cardia. A laparoscopic gastrotomy with placement of the 15mm laparoscopic port was performed. The endoscope with a cap was introduced through the port directly into the stomach. The lesion in the gastric cardia was visualized in a retrograde direction. ESD was performed using a Dual-J Knife. A 15mm area was resected. The ESD site was examined for any perforation, bleeding or defects and none were noted. Following the endoscopic portion of the procedure, the abdomen was re-insufflated and inspected for signs of perforation and none were found. The gastrotomy was then closed. On gross pathologic examination the gastric cardia specimen measured 1.9 × 1.7 × 0.3 cm. Microscopic examination revealed well differentiated (G1) focal intramucosal adenocarcinoma arising in a background of intestinal metaplasia with HGD. Tumor invaded lamina propria but no invasion of muscularis mucosa was identified. All margins were uninvolved by carcinoma and dysplasia. The final pathologic stage of the resected specimen was pT1a. Given the findings, lymph node disease was determined to be extremely low and less invasive ESD was expected to be curative 1, 2. A follow up EGD 2-months post-procedure showed no evidence of recurrence. DISCUSSION: In conclusion, tumors of the gastric cardia are among the most technically difficult lesions to be removed by ESD with curative rates around 66% 3. This decreases further with tumors located in the anterior hemisphere or have deep submucosal invasion. Laparoscopic assistance provides a head on view for a full thickness ESD. Our case demonstrates this technique is safe and effective. Watch the video: http://bit.ly/2LuEe7N.