Laparoscopic Partial Gastrectomy Research Articles

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor with tumor diameter of >5 cm.

Laparoscopic and endoscopic cooperative surgery (LECS) is an effective treatment for gastric gastrointestinal stromal tumors (GISTs). The utility of LECS for gastric GISTs of > 5 cm remains controversial. This study was performed to investigate the feasibility of LECS for gastric GISTs with a tumor diameter of >5 cm. We analyzed 43 patients with gastric GISTs who underwent LECS or laparoscopic partial gastrectomy (Lap-Partial Gx). We compared the surgical outcomes of LECS versus Lap-Partial Gx and of LECS for a tumor diameter of > 5 versus ≤ 5 cm. In the comparison of LECS versus Lap-Partial Gx, there were no significant intergroup differences in the operative time or blood loss volume. The morbidity rate was similar between the groups. No postoperative mortality occurred in either group. In the comparison of LECS for a tumor diameter of > 5 versus ≤ 5 cm, there were no significant intergroup differences in operative time, or blood loss volume. The morbidity rate was similar between the > 5-cm and ≤ 5-cm groups (0.0% vs. 4.5%, respectively ; p = 0.56). Additionally, no recurrence or death occurred during follow-up in either group. LECS is a feasible option for gastric GISTs with a tumor diameter of > 5 cm. J. Med. Invest. 71 : 148-153, February, 2024.

Surgery for multiple gastric gastrointestinal stromal tumors and large esophageal diverticulum related to germline mutation of the KIT gene: a case report

BackgroundFamilial gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the digestive tract caused by germline gain-of-function mutations in the KIT gene or platelet-derived growth factor receptor alpha gene (PDGFRA). These mutations cause not only multiple GISTs but also diffuse hyperplasia of interstitial cells of Cajal (ICCs), which is related to esophageal motility disorder.Case presentationA 53-year-old man was referred to our hospital because of anemia and dysphagia. Fifteen years earlier, he had undergone a laparoscopic partial gastrectomy for multiple gastric GISTs with a germline mutation in exon 17 of the KIT gene. An upper gastrointestinal endoscopy revealed that the patient had multiple gastric GISTs and a large esophageal diverticulum directly above the esophagogastric junction. The largest gastric tumor was 7 cm, with a delle that might cause bleeding. Because the patient presented with dysphagia, we performed video-assisted thoracic esophagectomy and laparoscopic-assisted proximal gastrectomy simultaneously. The patient had survived without metastasis for 4 years after surgery and dysphagia had improved.ConclusionsThis is the first report of successful laparoscopic–thoracoscopic surgery for a patient with familial gastric GISTs accompanied with a large esophageal diverticulum.

Synchronous Multifocal Early Gastric Cancer: How Important is A Meticulous Endoscopic Examination? A Case Report and Literature Review

Introduction: The incidence rate of synchronous early gastric cancer is reported to be 5% to 15%, and several risk factors that increase its incidence have already been identified. Synchronous lesions are reported to be neglected in 32.4% of early gastric neoplasia cases. Method: Case report of a 75-year-old woman, with mucosa atrophy, intestinal metaplasia, with early gastric adenocarcinoma in antrum, CT staging without alterations, underwent surgical treatment using endoscopic submucosal dissection (ESD). Results: The anatomopathological result demonstrated a lesion of 2 cm, a well-differentiated non-ulcerated adenocarcinoma, without lymphatic-vascular invasion, with a positive deep submucosal margin, eCURE C-2. A D1+ complementary laparoscopic partial gastrectomy was performed. The analyzes of the surgical specimens showed an ESD area of ulcer scar without tumor and another early gastric cancer (T1a) at 2.2 cm distance with normal mucosa between them. Thirty six lymph nodes were free of disease. Conclusion: In this case, the patient had 3 risk factors for synchronic injury, but it was only discovered during the salvage gastrectomy. Thorough endoscopy should be performed in all patients and even more so in patients with risk factors. Failure to recognize these lesions can result in evolution to advanced cancer

Gastric schwannoma coexisting with tubular adenoma of the gallbladder: a rare combination.

We report a case of a man in his early 50 s who was admitted to our hospital for anorexia. An imaging examination led to a preoperative diagnosis of a gastrointestinal stromal tumor and gallbladder stones. He underwent treatment by laparoscopic cholecystectomy and distal partial gastrectomy with lymph node dissection. The final histopathological diagnosis was gastric schwannoma and tubular adenoma of the gallbladder. Gastric schwannoma accounts for only 0.2% of all gastric tumors, and tubular adenoma constitutes only 2.2% of gallbladder tumors. This report describes the diagnosis and treatment process for this combination of tumors, thus providing a reference for similar cases.

S3609 Gastric Schwannoma in a Patient With Early Satiety

Introduction: Schwannomas are an uncommon subtype of benign gastrointestinal mesenchymal tumor found most frequently in the stomach originating from the Auerbach myenteric nerve plexus. Gastric schwannoma is frequently mistreated as it shares many similarities with GIST. We present the case of a patient with early satiety and iron deficiency anemia who was found to have gastric schwannoma on upper endoscopy. Case Description/Methods: A 59-year-old female with endometriosis and iron deficiency anemia on oral iron supplementation presented to our clinic with complaints of fatigue, frequent post-prandial cough, early satiety, and dark stools. She reported chronic NSAID use and denied abdominal pain, dysphagia, nausea, and unexplained weight loss. Initial CBC demonstrated a hemoglobin of 9.2 g/dL with positive stool guaiac testing. Cessation of NSAIDs led to hemoglobin improvement within normal limits. EGD revealed a roughly 5 cm smooth submucosal mass in the distal gastric body along the greater curvature with firm consistency and a central depression (Figure A). Colonoscopy was unremarkable. Abdominal CT demonstrated an exophytic mass within the gastric wall with relatively homogenous attenuation and enhancement (Figure B). Endoscopic ultrasound with FNA of the mass revealed pathology suspicious for a stromal cell neoplasm and elective laparoscopic partial gastrectomy was performed with findings of a 4.7 x 3.7 x 3.6 cm submucosal mass consistent with schwannoma with Sox10/S100 positivity and DOG-1/c-KIT negativity. The patient resumed a normal diet 2 days after surgery without complications. Discussion: Gastric schwannoma is frequently misdiagnosed as GIST due to similar prevalence, clinical symptoms, and appearance. Some studies suggest a misdiagnosis rate of up to 96.7%. Key to the diagnosis is the presence of S-100 positivity in schwannoma as GIST is negative for this marker. Additionally, DOG-1 and c-KIT are markers positive in GIST but negative in schwannoma. Most gastrointestinal schwannomas are solitary with sizes ranging from < 1 cm to 28 cm. Endoscopic ultrasound with FNA biopsy is recommended to increase chances of preoperative diagnosis by approximately 10%. Treatment modalities vary based on tumor size, with endoscopic resection suggested for tumors < 3 cm in diameter and surgical excision for larger sized masses. Malignant transformation is extremely rare occurring in roughly 2% of cases with S-100 expression decreasing as dedifferentiated Schwann cells form.Figure 1.: A. Endoscopic appearance of schwannoma as a smooth exophytic submucosal mass with central depression seen along the greater curvature of distal gastric body. B. Abdominal CT demonstrating luminal compression of the gastric body by a schwannoma with relatively homogenous attenuation and enhancement.

TU1.8 Laparoscopic partial gastrectomy as day-case surgery: Our 12-month experience

Abstract Aim Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. We present our experience in same-day discharge after laparoscopic partial gastrectomy (LPG) in 19 consecutive patients during 2021. Our aim was to review our outcomes and assess the safety and efficacy of outpatient LPG over 12 months to determine if this procedure can be safely performed in the ambulatory setting. Methods Retrospective review of all consecutive patients who underwent ambulatory LPG from January 2021 to December 2021. Patient age, social circumstances, and other demographics were recorded as well as any comorbidities and ASA score. All patients were discharged home the same day after surgery without an overnight stay at the hospital. Incidence of complications and re-admission to the hospital after discharge were reviewed up to 30 days from surgery. Results From January 2021 to December 2021, 19 consecutive patients underwent LPG. The mean age was 47 years (range, 23–74 yr). 17 patients (89%) had gastric GIST tumor resected. Mean recovery room time was 131 minutes (30–385 min). No patients (0%) were readmitted within 30 days. There were no complications and no open conversions or deaths occurred in the series. Conclusion With stringent patient selection and utilization of enhanced recovery pathways, our study indicates that LPG may be suitable for the outpatient setting. Our low overall readmission and complication rate portends to the feasibility of laparoscopic PG as a safe outpatient procedure.

Surgical and Oncological Outcomes after Neoadjuvant Therapy for Non-Metastatic Gastric GISTs.

Surgical resection with negative margins of non-metastatic gastric GISTs is considered the main therapeutic option in GISTs treatment. Neoadjuvant therapy with imatinib is associated with higher response rates in advanced GISTs. We reported 34 patients with non-metastatic gastric GISTs who underwent partial gastrectomy at the Oncology Center, Mansoura University, Egypt, after receiving a daily dose of 400mg of imatinib as a neoadjuvant treatment in the period between October 2012 and January 2021. Twenty-two cases underwent open partial gastrectomy, and twelve cases had a laparoscopic partial gastrectomy. The median tumor size at diagnosis was 13.5cm (range 9-26cm) and the duration of neoadjuvant therapy was 10.91months (range 4-12months). Thirty-three patients had a partial response, while one patient showed progression of the disease on neoadjuvant treatment. Adjuvant therapy was conducted in 29 (85.3%) cases. Complications of neoadjuvant treatment were reported in seven cases in the form of gastritis, bleeding per rectum, fatigue, thrombocytopenia, neutropenia, and edema lower limbs. The disease-free survival (DFS) in this study was 34.53months, and the overall survival (OS) was 37months. Recurrence developed in two cases, gastric and peritoneal recurrence (25 and 48months from the initial diagnosis, respectively). We haveconcluded thatneoadjuvant treatment with imatinib for non-metastatic gastric GISTs is a safe and effective method for tumor downsizing and devitalization to allow minimally invasive and/or organ sparing surgery. Moreover, it decreases the risk of intraoperative tumor rupture and relapse, thus improving the oncological outcome of such tumors.

Single Surgical Approach for Gastric Gastrointestinal Stromal Tumor and Cholecystolitiasis by Laparoscopic Procedure

Introduction: Gastrointestinal stromal tumor (GIST) is a rare neoplasm representing 80% of gastrointestinal neoplasms. Laparoscopic resection is only recommended for GIST less than 2 cm and 5 cm for laparoscopic wedge resection. Thus, a large GIST is recommended to complete resection through laparotomy. A large GIST of the gastric fundus can be found in patients, which coincides with an upper right abdominal quadrant pain caused by cholecystolithiasis. A suggested laparotomy for tumor resection and cholecystectomy may result in poor recovery in the postoperative period. Therefore, one approach surgery with minimally invasive laparoscopic partial gastrectomy using Endoflex stapler and cholecystectomy was performed to achieve the optimal outcome.Case Presentation: A 43-year-old male had a major complaint of hematemesis and melena for one month and colicky pain in the right upper quadrant of the abdomen with increased intensity in the last two months. Contrast-enhanced abdominal MSCT revealed a solid 4.6 x 4 x 5.6 cm exophytic mass on the gastric fundus, added with 0.5 cm gall bladder stone. Laparoscopic partial gastrectomy and cholecystectomy were performed in a single minimal invasive surgical procedure. The post-operative period was uneventful. The patient experienced minimum pain, early mobilization, and better diet tolerance. He was discharged on day four after the surgery. Besides, the histopathologic result revealed a malignant mesenchymal tumor according to GIST with a tumor-free margin of resection.Conclusions: Single approach surgery with minimal laparoscopic partial gastrectomy and cholecystectomy has provided optimal outcomes for patients with large GIST and cholecystolithiasis.

THE FREQUENCY OF HYPOTHERMIA IN LAPAROSCOPIC PARTIAL GASTRECTOMY AT CHO RAY HOSPITAL, YEAR 2021

Introduction: Currently, the hypothermia in laparoscopic gastrectomy has not been given due attention, leading to a high rate of postoperative hypothermia. Therefore, the care, monitoring and intervention to reduce the rate of hypothermia during and after surgery is one of the issues that need attention.&#x0D; Objectives: The study was carried out with 2 objectives: (1) Determining the rate of hypothermia in patients during laparoscopic partial gastrectomy at Cho Ray Hospital; (2) Understanding risk factors for hypothermia in laparoscopic partial gastrectomy patients.&#x0D; Methods: Descriptive cross-sectional study on 65 laparoscopic partial gastrectomy patients under general endotracheal anesthesia, from February 2021 to July 2021. The temperature was continuously measured and noted every 30 minutes from induction to the end of surgery by esophageal probe.&#x0D; Results: In the study, all patients were under endotracheal anesthesia, The proportion of the age group 70 years and older is 35.38%, the rate of male 76.92%. The average anesthetic time was 166,77±44,05 minutes, the mean surgery time was 145,0±42,70 minutes. The average temperature of the operating room is 23,79°C. The rate of 87,69% of patients was warmed with just a sheet. Research results show that the rate of hypothermia in patients after surgery is 72,31%. Factors related to the rate of hypothermia include age group over 70, smoking, method of warming, BMI, operating room temperature.&#x0D; Conclusion: Need to monitor the body-temperature and use continously critacal warming methods the prevent the hypothermia during and after gastrectomy surgery patients.

Evaluation of Laparoscopy Combined with Intraoperative Gastroscopic Local Gastrectomy in the Treatment of Gastric Neuroendocrine Tumors

Objective: To analyze the clinical effect of laparoscopy combined with intraoperative gastroscopic local gastrectomy in the treatment of gastric neuroendocrine tumors. Methods: A total of 100 patients with gastric neuroendocrine tumors that were treated in the Affiliated Hospital of Chifeng University from January 2016 to March 2021 were selected as the research subjects. They were divided into two groups by the digital table method. The control group underwent laparoscopic partial gastrectomy while the research group underwent laparoscopy combined with intraoperative gastroscopic partial gastrectomy. The curative effects of the two groups were compared. Results: There was no significant difference in the number of surgical lymph node dissections between the two groups (p &gt; 0.05); the amount of bleeding in the research group was lower than that in the control group; the operation time, time taken to get out of bed, gastrointestinal function recovery time, time taken for first eating, and hospital stay were shorter than those in the control group (p &lt; 0.05); the incidence of complications and the recurrence rate in the research group were lower than those in the control group (p &lt; 0.05). Conclusion: Laparoscopy combined with intraoperative gastroscopic local gastrectomy in the treatment of gastric neuroendocrine tumors has significant clinical effect and high safety.

Laparoscopic Partial Gastrectomy for Large Gastric GISTs.

Gastrointestinal stromal tumors (GISTs) are considered the most common mesenchymal tumors in the gastrointestinal tract and the stomach is the most frequently site affected (50-60%). The safety and feasibility of laparoscopic surgery for gastric GISTs of sizes larger than 5cm remains unclear. It depends on the surgical skills, tumor location, and the learning curve of the surgeons. Between December 2013 and January 2021, 30 patients diagnosed with gastric GISTs underwent laparoscopic partial gastrectomy. This is a retrospective study done in Surgical Oncology unit, Oncology Center, Mansoura University, Egypt. The most common tumor location was in the greater curvature in (46.7%). The mean tumor size was 9.5cm (range 5-17cm). All of the patients underwent laparoscopic partial gastrectomy. Associatedsplenectomy was done for onlyone patient. The mean operative time was 152.67min and the estimated blood loss (EBL) was 139.33ml. The mean hospital stay was 3.53days. The mean follow-up period was 32.4months. Laparoscopic resection for gastric GISTs has become a feasible method. Patients with large tumors have the same favorable outcomes as small tumors. Large-sized GISTs may receive neoadjuvant therapy to downstage the disease and make it amenable for laparoscopic resection.

Endoscopic obturation with tissue adhesive for bleeding gastric stromal tumor: a case report

Primary endoscopic hemostasis for bleeding gastrointestinal stromal tumor (GIST) is rarely reported. Herein, we report the case of a patient with a bleeding GIST that was treated with endoscopic obturation with tissue adhesive. A 46-year-old man presented with hematemesis and tarry stool for 1 day. Upper GI endoscopy revealed a bleeding submucosal tumor at the stomach fundus and an exposed pulsatile vessel was seen at the defect. Endoscopic obturation with tissue adhesive was performed to treat the defect and the bleeding was successfully stopped. No recurrence of bleeding was observed through a gastric tube, and 6 days after endoscopic obturation, the patient underwent laparoscopic partial gastrectomy. Endoscopic obturation with tissue adhesive is a feasible and effective method to treat bleeding GIST.

Clinical Significance of Intra-operative Gastroscopy for Tumor Localization in Totally Laparoscopic Partial Gastrectomy

BackgroundTumor localization during totally laparoscopic gastrectomy is challenging owing to the invisibility of tumors on the serosal surface. We aimed to evaluate the clinical significance of intra-operative gastroscopy in totally laparoscopic partial gastrectomy. MethodsWe reviewed 1084 gastric cancer patients who underwent either intra- or extracorporeal partial gastrectomy between 2014 and 2018. The intracorporeal group with intra-operative gastroscopy (intra-operative gastroscopy group, n = 187), the intracorporeal group without intra-operative gastroscopy (non-intra-operative gastroscopy group, n = 267), and the extracorporeal group (n = 630) were evaluated for the adequacy of surgical resection margins. We assessed whether total gastrectomy could be avoided according to the performance of intra-operative gastroscopy if the tumor was located within 3–5 cm away from the gastroesophageal junction. ResultsThe proximal margin positivity was lesser in the intra-operative gastroscopy group than in the non-intra-operative gastroscopy group (0% versus 2.2%; P = 0.045) but similar to that in the extracorporeal group (0% versus 0.6%; P = 0.579). The number of cases with proximal resection margins < 1 cm was lower in the intra-operative gastroscopy group than in the non-intra-operative gastroscopy group (3.7% versus 9.4%; P = 0.025) but comparable with that in the extracorporeal group (3.7% versus 4.1%; P = 0.815). Among 94 patients with lesions located within 3–5 cm apart from the gastroesophageal junction, the intra-operative gastroscopy group (n = 47) had fewer patients who underwent total gastrectomy than the non-intra-operative gastroscopy group (n = 47) (12.8% versus 44.7%; P = 0.001). Intra-operative gastroscopy was the only independent factor that prevented total gastrectomy (P = 0.001). ConclusionIntra-operative gastroscopy can provide margin safety during intracorporeal partial gastrectomy, avoiding unnecessary total gastrectomy.

Laparoscopic resection of pediatric gastric schwannoma/perineuroma

Abstract Schwannomas and Perineuromas are rare findings in the GI tract, especially in pediatric patients. They typically present in the fifth to sixth decade of life with a female predominance. In this case, we describe a 13-year-old female who presented with multiple GI complaints including weight loss and anemia. She was found to have an umbilicated mass in the lesser curvature of the stomach suspicious of a gastrointestinal stromal tumor (GIST). The mass was resected via a laparoscopic partial gastrectomy. The pathology report confirmed the diagnosis of a gastric hybrid schwannoma and perineuroma staining for EMA and S-100 protein.

0884 The Effect of Bariatric Surgery on Sleep Disordered Breathing in Adolescents and Young Adults

Abstract Introduction Childhood obesity is the major risk factor sleep disordered breathing (SDB). Severely obese young people may require bariatric surgery for correction of obesity, if other methods of weight loss have failed. We aim to assess the effect of bariatric surgery on SDB, in adolescents and young adults. Methods We conducted a retrospective chart review study of patients who underwent bariatric surgery between January 1, 2006 and August 31, 2019 at Cincinnati Children’s Hospital. Only patients who had pre-operative and post-operative polysomnograms were included in the study. Results Twenty-seven children and young adults (female: 59.2%) met the criteria for entry into analysis. The mean age of subjects at the time of weight loss surgery was 17.9 years (range: 12.9 to 32.5). Majority of the patients underwent laparoscopic partial gastrectomy (85.2%) and the remaining underwent laparoscopic gastric bypass surgery (14.8%). The average duration of follow up for post study measurements after the surgery was 10.4 months (Range: 0.4 to 57.5). The median Body Mass Index (BMI) was significantly lower at post-surgery (49.9 kg/m2[IQR: 45.4-55.9][pre] vs 39.3 kg/m2[IQR: 33.9-46][post], P&amp;lt;0.001). The median obstructive AHI was significantly reduced at post-surgery (6.7/hr[IQR: 3.1-16.4][pre] vs 2.6/hr[IQR: 1.6-6][post], P= 0.03). Median heart rate (HR) during REM (79 bpm[IQR:67-90][pre] vs 67 bpm[IQR: 59.7-72][post], P&amp;lt;0.0001) and NREM (81 bpm[IQR:65-91][pre] vs 65 bpm[IQR: 58-73][post], P&amp;lt;0.0001) sleep were significantly lower at post-surgery. There was no statistically significant difference in sleep architecture (sleep latency, arousal index and percentage of REM, N1 and N3 sleep, P&amp;gt; 0.05) except N2 sleep (53.1% [IQR:47.7-57.3] [pre] vs 55.7% [IQR:51.4-63.7] [post], P= 0.03) which was significantly increased at post-surgery. Conclusion There was significant improvement in BMI and SDB after weight loss surgery in children and young adults. Interestingly, there was a decrease in heart rate during both REM and NREM sleep after surgery which may suggest a decrease in sympathetic activation due to improvement if SDB. The sleep architecture remained unchanged after surgery, except the percentage of N2 sleep. Support Cincinnati Children’s Hospital Research Foundation

Multiple heterochronic gastrointestinal stromal tumors in the stomach detected 6\u2009years after resection: a case report

BackgroundTo date, only a few cases of multiple GISTs with different clones in different organs have been published. However, a case of multiple GISTs with different clones occurring in a single organ has never been reported.Case presentationA 41-year-old patient underwent laparoscopic partial gastrectomy for gastric gastrointestinal stromal tumor (GIST) in 2012. The pathological findings showed high-risk characteristics for recurrence, so he received adjuvant therapy with imatinib for 3 years. In 2018, 3 years after completing the adjuvant therapy, tumor lesions at residual gastric cardia were incidentally identified by follow-up computed tomography (CT). The pathological findings of the tumor biopsy revealed gastric GIST. He underwent secondary laparoscopic partial gastrectomy and was diagnosed with high-risk GIST. Adjuvant therapy with imatinib was restarted immediately. The two gastric GISTs had the same exon 11 mutations in the c-kit gene, but they had different missense mutations. This molecular heterogeneity suggested that they were derived from different origins.ConclusionWe reported a multiple heterochronic GIST in the stomach detected 6 years after resection. There may be a possibility that another heterochronic GIST will occur in the remnant stomach in the future, so close follow-up will be needed.

Ulcerated gastrointestinal stromal tumor causing a gastrogastric intussusception.

When a gastrointestinal intussusception is found, an underlying lesion should be excluded.

Eosinophil granuloma due to parasite treated by laparoscopic and endoscopic cooperative surgery: a case report

BackgroundGastric eosinophilic granuloma caused by parasitic infection is rare. It is often suspected to be a malignant disease and it is difficult to diagnose. We successfully diagnosed and removed a gastric eosinophilic granuloma using laparoscopic and endoscopic cooperative surgery (LECS).Case presentationA 35-year-old woman visited our hospital because of epigastric pain. Upper gastrointestinal endoscopy revealed a 15 mm submucosal tumor (SMT) with changes in the folds, such as enlargement and convergence, located in the greater curvature of the lower gastric body. Computed tomography (CT) showed a dense, nonenhanced area of 15 mm at the same site. SMT was suspected, but undifferentiated cancer could not be excluded. We performed laparoscopic partial gastrectomy using LECS for resection biopsy.Histopathological examination showed an SMT 8 × 8 × 5 mm in size with an unclear boundary and necrosed insects at the core of the tumor. There was marked eosinophilic infiltration around the area. The diagnosis was gastric granuloma caused by parasitic infection.ConclusionsIt is difficult to differentiate gastric eosinophilic granuloma caused by parasitic infection from malignant disease. In this case, LECS is considered a minimally invasive and useful procedure.

Effects of different doses of magnesium sulfate on pneumoperitoneum-related hemodynamic changes in patients undergoing gastrointestinal laparoscopy: a randomized, double-blind, controlled trial

BackgroundThe infusion of magnesium sulfate is well known to reduce arterial pressure and attenuate hemodynamic response to pneumoperitoneum. This study aimed to investigate whether different doses of magnesium sulfate can effectively attenuate the pneumoperitoneum-related hemodynamic changes and the release of vasopressin in patients undergoing laparoscopic gastrointestinal surgery.MethodsSixty-nine patients undergoing laparoscopic partial gastrectomy were randomized into three groups: group L received magnesium sulfate 30 mg/kg loading dose and 15 mg/kg/h continuous maintenance infusion for 1 h; group H received magnesium sulfate 50 mg/kg followed by 30 mg/kg/h for 1 h; and group S (control group) received same volume 0.9% saline infusion, immediately before the induction of pneumoperitoneum. Systemic vascular resistance (SVR), cardiac output (CO), mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), serum vasopressin and magnesium concentrations were measured. The extubation time, visual analogue scale were also assessed. The primary outcome is the difference in SVR between different groups. The secondary outcome is the differences of other indicators between groups, such as CO, MAP, HR, CVP, vasopressin and postoperative pain score.ResultsPneumoperitoneum instantly resulted in a significant reduction of cardiac output and an increase in mean arterial pressure, systemic vascular resistance, central venous pressure and heart rate in the control group (P < 0.01). The mean arterial pressure (T2 – T4), systemic vascular resistance (T2 – T3), central venous pressure(T3-T5) and the level of serum vasopressin were significantly lower (P < 0.05) and the cardiac output (T2 – T3) was significantly higher (P < 0.05) in group H than those in the control group. The mean arterial pressure (T4), systemic vascular resistance (T2), and central venous pressure(T3-T4) were significantly lower in group H than those in group L (P < 0.05). Furthermore, the visual analog scales at 5 min and 20 min, the level of vasopressin, and the dose of remifentanil were significantly decreased in group H compared to the control group and group L (P < 0.01).ConclusionMagnesium sulfate could safely and effectively attenuate the pneumoperitoneum-related hemodynamic instability during gastrointestinal laparoscopy and improve postoperative pain at serum magnesium concentrations above 2 mmol/L.Trial registrationThe study was retrospectively registered at Chinese Clinical Trial Registry; the registration number is ChiCTR-IPD-17011145, principal investigator: D.Y. Q., date of registration: April 13, 2017.

Hybrid Laparoscopic and Endoscopic Partial Gastrectomy for Ulcerated GIST: Surgical Technique with Video.

Gastrointestinal stromal tumors of the gastric cardia pose several technical difficulties to their resection because they are difficult to access, and they must be removed respecting oncological principles, and due to their proximity to the gastroesophageal junction, excessive removal of gastric tissue may cause deformation with gastric dysfunction, or gastroesophageal reflux. Hybrid laparoscopic endoscopic partial gastrectomy is a technique that avoids these problems making use of three principles. First the tumor is pinpointed, marked, and resected under combined laparoscopic and endoscopic control to assure that it is completely resected without compromising the structure of the gastroesophageal junction. Second, a dissection of the abdominal esophagus is performed as during a Nissen fundoplication in order to increase the distance between the tumor and the gastroesophageal junction. Third the lesser curvature of the stomach is dissected, and the terminal branches of the left gastric vessels are controlled from the gastric incisura to the gastroesophageal junction exposing the lesser curvature and the posterior wall of the stomach. The tumor is resected under endoscopic control, tangentially with an endoscopic stapler applied parallel to the lesser curvature similarly to a sleeve partial gastrectomy. No abdominal drain is used, and a nasogastric tube is left in place for the first 24h after surgery. The patient receives fluid diet on the first postoperative day, is discharged on the second postoperative day, and is followed up in the outpatient department for a week. In this technical paper, the procedure is described in detail and demonstrated with video.