468 Human Hybrid Endoscopic and Laparoscopic Management of Mass Lesions of the Foregut

Abstract

To date, most reports of NOTES procedures in humans have recapitulated laparoscopic procedures such as cholecystectomy which have an excellent safety profile and little long term implications for quality of life. We sought to determine if a subset of mass lesions of the foregut would be amenable to a hybrid laparoscopic and endoscopic approach with decreased operative morbidity and long term quality of life implications. Six patients with mass lesions of the foregut were were offered hybrid laparoscopic and endoscopic management. Two patients had mass lesions involving the gastroesophageal (GE) junction, two patients had gastrointestinal stromal tumors (GIST) involving the proximal stomach, one patient had an antral mass, and one patient had a duodenal duplication cyst. The lesions were deemed unresectable by the referring gastroenterologist as well as the tertiary care gastroenterologist and were referred for surgical management. Pre-operative EGD, EUS with or without FNA, and cross sectional imaging were obtained for all patients. All procedures were performed in the operating room under general anesthesia. All six patients underwent a laparoscopic and endoscopic hybrid procedure (Table 1). Both lesions involving the GE junction were successfully resected using a combined approach and these patients were spared a total or subtotal gastrectomy. The two patients with GIST tumors were not successfully resected via the hybrid approach and they proceeded to laparoscopic resection. In one case the tumor was too large to be completely ensnared with a 5.5cm snare despite laparoscopic assistance. In the second case, there was involvement of the serosal surface and a full thickness laparoscopic wedge resection was performed. The antral mass was resected using a hybrid approach and this patient was spared an antrectomy. The final patient with a duodenal duplication cyst was successfully managed with a hybrid approach and this patient was spared a laparotomy, duodenotomy, cystectomy, and sphincteroplasty. There were no immediate complications. All six patients have remained asymptomatic without evidence of recurrence over 80 months of cumulative follow-up.TablePatient characteristics and resultsSerial numberAge/genderLesion sizePreliminary pathologyResection; outcomeFinal pathology162/F2.6cm X 2.3cm X 1.4cmAdenoma with high-grade dysplasiaHybrid; spared total gastrectomyIntramucosal carcinoma262/F3.3cm x 1.9cm x 1.6cmNon-diagnosticHybrid; spared total gastrectomyHyperplastic polyp363/M4.8cm x 4.2cm x 2.4cmGISTSurgical; partial gastrectomyGIST432/M4.8cm x 2.5cm x 1.4cmDuodenal duplication cystHybrid; spared laparotomy, duodenotomy, sphincteroplastyNA558/M1.9cm x 1.8cm x 1.8cmNAHybrid; spared Billroth gastrectomyLipoma646/F2.5cm x 2.0cm x 2.0cmGISTSurgical; wedge resectionGIST Open table in a new tab This is the first report of successful hybrid laparoscopic and endoscopic management for a malignant tumor of the GE junction. The hybrid technique was safe and feasible in six human patients with foregut mass lesions which were not amenable to endoscopic management. Out of six cases, the technique was successful in sparing four patients a major surgical resection with long term quality of life implications. In highly selected cases, a hybrid approach may be superior to either standard surgical or endoscopic management. This report demonstrates the promise of NOTES not in recapitulating, but in improving on the current standard approach.