Non-exposed Endoscopic Wall-inversion Surgery Research Articles

Endoscopic Treatment for Gastric Subepithelial Tumor.

Most gastric subepithelial tumors (SETs) are asymptomatic and are often incidentally discovered during endoscopic procedures conducted for unrelated reasons. Although surveillance is sufficient for the majority of gastric SETs, certain cases necessitate proactive management. Laparoscopic wedge resection, although a viable treatment option, has its limitations, particularly in cases where SETs (especially those with intraluminal growth) are not visualized on the peritoneal side. Recent advances in endoscopic instruments and technology have paved the way for the feasibility of endoscopic resection of SETs. Several promising endoscopic techniques have emerged for gastric SET resection, including submucosal tunneling endoscopic resection, endoscopic full-thickness resection (EFTR), laparoscopic and endoscopic cooperative surgery (LECS), and non-exposure EFTR (non-exposed endoscopic wall-inversion surgery and non-exposure simple suturing EFTR). This study aimed to discuss the indications, methods, and outcomes of endoscopic therapy for gastric SETs. In addition, a simplified diagram of the category of SETs according to the therapeutic indications and an algorithm for the endoscopic management of SET is suggested.

Progress in the treatment of early gastric cancer with Laparoscopic and endoscopic cooperative surgery

With the introduction of minimally invasive methods into the field of surgery, the concept of early gastric cancer (EGC) treating has gradually changed from the pursuit of standardized traditional surgical methods to precise, individualized, interdisciplinary collaborative management. Both endoscopic therapy and laparoscopic surgery have their limitations for early gastric cancer treatment. Meanwhile, Laparoscopic and endoscopic cooperative surgery (LECS) combines the advantages of endoscopy and laparoscopy to perform local gastric resection and regional lymph node dissection, providing a more effective surgical approach for radical resection of early gastric cancer. The application of LECS in the treatment of early gastric cancer has been increasing, from the initial laparoscopy-assisted endoscopic full-thickness resection to the evolvement of a variety of improved procedures such as combined laparoscopic and endoscopic approach for neoplasia with a non-exposure technique, non-exposed endoscopic wall-inversion surgery, and the possibility of combined (sentinel lymph node drainage area) regional lymph node dissection or sentinel lymph node navigation surgery, which expands the indications for endoscopic surgery and maximizes the preservation of normal gastric tissue structure and function while ensuring radical treatment, and will certainly become an important development direction in the treatment of early gastric cancer in the future.

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

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. 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. 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. 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.

Laparoscopic and endoscopic cooperative surgery for full-thickness resection and sentinel node dissection for early gastric cancer.

The endoscopic submucosal dissection (ESD) technique has become the gold standard for submucosal tumors that have negligible risk of lymph node metastasis (LNM), due to its minimal invasiveness and ability to improve quality of life. However, this technique is limited in stage T1 cancers that have a low risk of LNM. Endoscopic full thickness resection can be achieved with laparoscopic endoscopic cooperative surgery (LECS), which combines laparoscopic gastric wall resection and ESD. In LECS, the surgical margins from the tumor are clearly achieved while performing organ-preserving surgery. To overcome the limitation of classical LECS, namely the opening of the gastric wall during the procedure, which increases the risk of peritoneal tumor seeding, non-exposed endoscopic wall-inversion surgery was developed. With this full-thickness resection technique, contact between the intra-abdominal space and the intragastric space was eliminated.

Successful non-exposed endoscopic wall-inversion surgery for gastric stromal tumor and gastric ESD for dysplastic lesion during a single procedure.

Successful non-exposed endoscopic wall-inversion surgery for gastric stromal tumor and gastric ESD for dysplastic lesion during a single procedure.

Combined laparoscopy-endoscopy local resection for early gastric cancer

The surgical treatment of early gastric cancer (EGC) is undergoing the development of minimally invasive, precise and individualized treatment. The concept is changing from simple emphasis on radical treatment to giving consideration to both radical treatment and functional preservation. Combined laparoscopy-endoscopy local resection can achieve accurate resection of the lesions of EGC and solve the problem of lymph node dissection which cannot be performed in endoscopic mucosal dissection (ESD). At present, there are several methods of combined laparoscopy-endoscopy local resection for EGC, such as laparoscopy-assisted endoscopic full-thickness resection (EFTR), endoscopy-assisted wedge resection (EAWR), combined laparoscopic and endoscopic approach for neoplasia with a non-exposure technique (CLEAN-NET), and non-exposed endoscopic wall-inversion surgery (NEWS). These methods of local resection have the advantages of minimal invasion, shorter operation time, and less blood loss compared to conventional gastrectomy. Concerning the issue of lymph node dissection in combined laparoscopy-endoscopy surgery, sentinel node navigation can be the solution, although cumbersome intraoperative lymph node tracing, operative failure and false negative still exist. As a developing treatment for EGC, combined laparoscopy-endoscopy local resection will have a good application prospect in the future.

Laparoscopy-assisted endoscopic full-thickness resection of upper gastrointestinal subepithelial tumors: A single-center early experience.

Recently, there have been important developments in minimally invasive full-thickness resection of subepithelial tumors (SETs) of the upper gastrointestinal tract. However, there remain challenges with techniques such as laparoscopy-endoscopy cooperative surgery (LECS) and non-exposed endoscopic wall-inversion surgery (NEWS). The aim of the present study was to further investigate the feasibility, efficacy and safety of laparoscopy-assisted endoscopic full-thickness resection (ETFR) of SETs and to evaluate the clinical outcomes. This retrospective study included 16 patients with upper gastrointestinal SETs who underwent laparoscopy-assisted EFTR between July 2016 and December 2017. The patient characteristics, surgical outcomes, postoperative course, results of the histopathological examination and short-term outcomes were reviewed and analyzed. A total of 10 patients in the LECS group and 6 patients in the NEWS group presented with SETs in the stomach (15 cases) or duodenum (1 case). The mean tumor size in the LECS group (5.6 cm) was larger compared with that in the NEWS group (2.1 cm). R0 resection was achieved in all patients, without adverse events or tumor recurrence. The NEWS group exhibited a lower white blood cell count and C-reactive protein level on the first postoperative day, reflecting the less prominent inflammatory response, less bleeding and shorter hospitalization. Therefore, laparoscopy-assisted EFTR by LECS and NEWS is a feasible and safe minimally invasive treatment option for upper gastrointestinal SETs in selected patients.

Novel treatment for submucosal tumor of the duodenum: Non-exposed endoscopic wall-inversion surgery

Novel treatment for submucosal tumor of the duodenum: Non-exposed endoscopic wall-inversion surgery

History and future perspectives in Japanese guidelines for endoscopic resection of early gastric cancer.

Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the therapeutic approach among institutions, and so on. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk-scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C-2 in the latest guidelines, additional gastrectomy with lymphadenectomy may be excessive for many patients, even those at high risk for LNM. Less-invasive function-preserving surgery, such as non-exposed endoscopic wall-inversion surgery with laparoscopic sentinel node sampling, may overcome this problem. In addition, further less-invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy.

Combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique (CLEAN-NET) for gastric submucosal tumors: updated advantages and limitations.

Laparoscopic and endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMTs) has been developed under the concept of resecting gastric tumors with both complete curability and preserving organ functions. Precise resection is obtained by classical LECS, however, concerns regarding intraoperative bacterial infection and dissemination of the tumor cells into the abdominal cavity by LECS with exposure technique still remain. To prevent these concerns, several LECS-related procedures with non-exposure techniques, such as combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique (CLEAN-NET) and non-exposed endoscopic wall-inversion surgery (NEWS), have been reported to be safe and feasible. Classical LECS, CLEAN-NET, and NEWS have the same concept, however, each has its own different characteristic procedures; exposure or non-exposure technique, inversion of the tumor into or outer the lumen, retrieval of tumor per oral or through the abdominal cavity, and dominance in the role of the endoscopist or the laparoscopic surgeon. Familiarization with these procedure details is important to understand their indications, advantages and limitations, resulting in providing a tailored minimally invasive surgery for patients. The main scope of this review article is to introduce readers to the clinical application, procedure, and results of CLEAN-NET, both from previous literatures and from our experience, as well as to offer a closer look at its advantages and limitations while comparing with other LECS procedures from the viewpoint of introducing CLEAN-NET first.

Clinical outcomes of non-exposed endoscopic wall-inversion surgery for gastric submucosal tumors: long-term follow-up and functional results.

To avoid the risk of iatrogenic dissemination during procedures, we have developed a combined laparoscopic and endoscopic surgery with a nonexposure technique for resection of gastric tumors. The study aim was to evaluate the feasibility and safety of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric submucosal tumors (SMTs). Between August 2013 and February 2018, NEWS was performed for 42 patients with gastric SMTs ≤ 3cm in diameter at our institution. We retrospectively investigated the patients' backgrounds, operative and perioperative outcomes, tumor pathological characteristics, and follow-up data. All tumors were resected with negative margins by NEWS. The median operation time was 198min, and the median estimated blood loss was 5.0mL. Adverse events occurred in one patient with pneumonia. All patients were alive without recurrence within the median follow-up period of 29.2months. The average body weight loss rate was 0.3 ± 4.0%. No food residue was observed at endoscopic follow-up. On the basis of slight body weight loss and the absence of food residue observed in the postoperative endoscopy, NEWS appeared to be safe and feasible for gastric SMTs and to preserve function of the remnant stomach.

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.

The first case of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric GIST in Germany

The first case of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric GIST in Germany

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.

Su1294 FEASIBILITY AND EFFICACY OF NON-EXPOSED ENDOSCOPIC WALL-INVERSION SURGERY (NEWS): A RETROSPECTIVE ANALYSIS IN 50 GASTRIC LESIONS

In endoscopic full-thickness resection with or without laparoscopic assistance, intentional perforation of the gastric wall which is unavoidable during the procedure may cause bacterial contamination as well as tumor-cell seeding particularly in ulcerated submucosal tumors (SMTs) or cancers. To avoid these risks, we have developed a non-exposure technique of laparoscopy-assisted endoscopic full-thickness resection, called non-exposed endoscopic wall-inversion surgery (NEWS). In this study, we retrospectively investigated the feasibility and efficacy of NEWS for gastric SMTs. Indication of NEWS included intraluminal or intramural growth-type gastric SMTs that were clinically diagnosed as gastrointestinal stromal tumors ≤3 cm in size, regardless of the existence of ulcerative findings; or cT1N0 single early gastric cancers (EGCs) ≤4 cm in size, except for an absolute indication for endoscopic resection (cT1aN0 intestinal-type, ≤2 cm). NEWS was performed as follows: laparoscopic sero-muscular incision after endoscopic submucosal injection, laparoscopic sero-muscular suturing with the lesion inverted, endoscopic muco-submucosal incision, and transoral retrieval. In EGCs, sentinel node navigation surgery was combined by using RI and indocyanine green injection. If stained sentinel nodes (SNs) had no metastasis by intraoperative histological assessment, NEWS with sentinel node basin dissection was conducted. The feasibility and efficacy of this technique was investigated by assessing short and middle term outcomes. NEWS was performed in 50 cases, including 41 SMTs and 9 EGCs between August 2013 and November 2017. The mean tumor size was 23.6 mm. In all cases, the procedure was completed in a mean procedural time of 202.6 min in SMT cases and 304.0 min in EGC cases, respectively, with 1 intraoperative perforation (2.0%). Final histological diagnoses were gastrointestinal stromal tumor (23), gastric cancer (8), leiomyoma (5), ectopic pancreas (5), neurinoma (3), no residual cancer after endoscopic resection (1), and others (5). R0 resection rate in 39 tumors was 97.4%. The mean discharge duration was 7.6 days following treatment. During the mean observational period of 24.5 months, overall and disease-free survival rates were 98% and 100%, respectively. In 1 EGC case who underwent NEWS with left gastric artery basin dissection, severe stasis because of adhesion to the peritoneum occurred, which required distal gastrectomy on the postoperative day 77. NEWS for gastric SMTs and EGCs appeared to be both feasible and safe. This non-exposed full-thickness resection technique by collaborative use of endoscopy and laparoscopy may be a useful option for minimally invasive local resection even for ulcerated SMTs or cancers without risk of tumor cell seeding due to the intentional perforation of the gastric wall.

Non-exposed endoscopic wall-inversion surgery for gastrointestinal stromal tumor.

Laparoscopic and endoscopic cooperative surgery (LECS) is an accepted method of laparoscopic wedge resection, which is minimally invasive, for gastrointestinal stromal tumors (GISTs). We established a type of LECS achieving a full-thickness resection, non-exposed endoscopic wall-inversion surgery (NEWS), in an effort to prevent exposure of the peritoneal cavity to gastric intraluminal contents. We employed this surgical technique in 28 gastric GIST patients. We failed to complete NEWS in the initial two patients and in one patient with a large tumor (40 mm × 35 mm), but otherwise carried out the procedure successfully. Although a learning effect is speculated to occur, based on a decreasing trend in the operation time, the median operation time was 184 minutes showing that NEWS is still a time-consuming method. No significant differences were recognized in tumor size or location, except near the esophagogastric junction (EGJ), nor in the cross-sectional circumference. NEWS is feasible and appears to be a good option, especially for small GISTs with mucosal ulceration rendering full-thickness enucleation by opening of the gastric wall unfeasible.

Laparoscopy and endoscopy cooperative surgery for gastric tumor.

168 Background: Laparoscopic wedge resection is widely performed for managing gastric submucosal tumors (SMTs) that measure ≤5 cm in diameter. Laparoscopy and endoscopy cooperative surgery (LECS) is performed to ensure a sufficient margin while avoiding deformation or stenosis. Methods: We conducted a retrospective review of the data of 76 patients who underwent LECS for SMTs or early gastric cancers at our institution between April 2012 and July 2017. While Non-exposed Endoscopic Wall-inversion Surgery (NEWS) was performed for tumors with a major axis diameter of ≤5 cm and minor axis diameter of ≤3 cm, for other tumors, we adopted classical LECS or used the combination of laparoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET). Results: The tumor was located in the upper-/middle-/lower-third of the stomach in 49/20/7 cases. The mean operation time was 201.7 ± 66.2 min, and the mean blood loss was 4.7 ± 12.8 ml. The mean tumor size was 28.6 ± 11.6 mm. The histological tumor types included GIST (n = 38), leiomyoma (n = 14), schwannoma (n = 6), early gastric cancer (n = 8) and others (n = 10). The surgical procedure consisted of classical LECS/CLEAN-NET/NEWS in 17/15/44 cases; all early gastric cancers were treated by NEWS. The mean length of postoperative hospital stay was 8.7 ± 3.9 days. The mean serum levels of C-reactive protein on POD1 and POD3 were 3.2 ± 1.9 and 4.4 ± 3.4 mg/dl, respectively. The postoperative complications were anastomotic stenosis (n = 1), delayed gastric emptying (n = 3), pneumonia (>Grade II by the Clavien-Dindo classification) (n = 1) and exacerbation of GERD (>Grade II by the Clavien-Dindo classification) (n = 3). In the patient group that developed complications, the postoperative resumption of water intake was later, and the postoperative hospital stay was longer as compared to the group without complications (p = 0.04, 0.028). No relationship was observed between the likelihood of development of complications and the tumor location. Conclusions: Use of minimally invasive surgical procedures such as LECS could minimize the extent of gastric resection without deformation, stenosis. We consider that for surgical complications the LECS approach can be employed, regardless of the tumor location.

Non-exposed endoscopic wall-inversion surgery for a gastrointestinal stromal tumor of the stomach: A case report.

Complete surgical resections are crucial for permanently curing patients with gastrointestinal stromal tumors (GISTs). Laparoscopic wedge resection is a widely accepted surgical treatment, but identifying the tumor margin from a serosal laparoscopic view is challenging when using this technique. Non-exposed endoscopic wall-inversion surgery (NEWS) for patients with gastric GISTs is a novel, minimally invasive surgical technique that may aid in complete resection of the tumor margin by endoscopy and laparoscopy methods, removing the whole layer of the gastric wall and the entire tumor, with decreased risk of peritoneal contamination or tumor spread to the peritoneum. To the best of our knowledge, the present study reports the first use of NEWS for a patient with small gastric GIST in Thailand. A 61-year old female presented with jaundice and was diagnosed with acute viral hepatitis A. At 4 months, the severity of the symptoms had decreased but the serum transaminase in the liver function tests remained elevated. The computed tomography scans incidentally demonstrated a gastric mass that protruded into the lumen. Endoscopic examination revealed a 2.5×2.0-cm sub-epithelial tumor located in the posterior wall of the upper gastric body. The patient was informed and consented to undergo NEWS. No intraoperative or immediate postoperative complications were detected. The patient was discharged 5 days following the surgery. In a follow-up visit 4 weeks subsequent to the surgery, the patient was healthy and without complications.

Optimal minimally invasive surgical procedure for gastric submucosal tumors

Laparoscopic wedge resection (LWR) is widely performed for managing gastric submucosal tumors (SMTs). Despite the development of novel procedures such as laparoscopy-endoscopy cooperative surgery (LECS) and nonexposed endoscopic wall-inversion surgery (NEWS), the most appropriate surgical intervention for gastric SMTs remains unclear. We retrospectively reviewed patient characteristics, surgical outcomes, postoperative courses, results of histopathological examinations, and surgical costs of 71 consecutive patients who underwent LWR, LECS, or NEWS for gastric SMTs from January 2010 to June 2016 in our institute. LWR, LECS, and NEWS were performed in 31, 14, and 26 cases, respectively. Patient backgrounds were comparable between groups. LWR was not performed for esophagogastric (E-G) junction tumors to avoid postoperative stricture, and LECS was not performed for ulcerated tumors to prevent tumor dissemination. NEWS was considered for tumors smaller than 3cm for transoral extraction. Resected specimen area of the LWR group was significantly larger than that of the other groups. Further, the LWR group had a significantly higher complication rate. Compared to the LECS group, postoperative serum C-reactive protein level was significantly lower and postoperative hospitalization was significantly shorter in the NEWS group. Also, operation costs were significantly lower in the NEWS group. The surgical procedure for gastric SMTs must be carefully chosen according to tumor size, location, and presence or absence of ulceration. For selected patients, NEWS is suggested to be an appropriate option for the treatment of gastric SMTs.

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.