Treatment Of Gastric Submucosal Tumors Research Articles

Comparative Assessment of Laparoscopic and Endoscopic Cooperative Surgery with Laparoscopic Wedge Resection for the Treatment of Gastric Submucosal Tumors

Abstract Background The most commonly performed surgical resection technique for gastric submucosal tumors (gSMTs) is laparoscopic wedge resection (LWR). Notably, laparoscopic and endoscopic cooperative surgery (LECS) is a surgical procedure that combines laparoscopic gastric resection with an endoscopic submucosal dissection for the local resection of gastric tumors, which provides appropriate and minimal surgical resection margins. Methods Seventy-nine gSMT patients who underwent surgical resection at our department between January 2004 and January 2023 were retrospectively assessed. LWR and LECS were performed in 61 and 18 patients, respectively. Clinicopathological features and short-term surgical outcomes were assessed between the two groups. A 2:1 propensity score matching was performed to mitigate the effects of selection biases. Regardless of the surgical procedure, all the patients underwent curative resection with negative margins. Results The LWR and LECS groups included 24 and 12 patients, respectively. The mean operative duration was significantly shorter in the LWR group than in the LECS group (LWR, 131.1 min; LECS, 195.2 min; p < 0.05). The mean ratio of tumor diameter to resected specimen diameter was significantly higher in the LECS group than in the LWR group (LWR, 60.3%; LECS, 78.9%; p < 0.05). The mean ratio of tumor area to resected specimen area was significantly higher in the LECS group than in the LWR group (LWR, 44.7%; LECS, 66.3%; p < 0.05). Conclusion LECS was performed safely with a minimal and optimal safety margin compared with LWR. The findings suggest that LECS can be a feasible option for the treatment of gSMTs.

The Feasibility and Safety of the Clip-and-Snare Method with a Prelooping Technique for Gastric Submucosal Tumors Removal: A Single-Center Experience (with Video).

Aim This study compared the efficacy and safety of endoscopic submucosal dissection (ESD) combined with clip-and-snare method and a prelooping technique (CSM-PLT) with ESD alone for the treatment of gastric submucosal tumors (gSMTs). Methods We retrospectively enrolled a matched group of 86 patients who received ESD combined with CSM-PLT or ESD alone from July 2010 to July 2020. The primary outcomes included complete resection, en bloc resection, and R0 resection. Results Eighty-six patients with gSMTs were enrolled in ESD combined with CSM-PLT group and ESD group, respectively. There were no significant differences in gender, age, tumor size, tumor location, and tumor origin between the two groups. The complete resection, en bloc resection, and R0 resection rates were comparable between two groups (P=1, P=0.31, and P=0.25, respectively). There were no significant differences in terms of hospital stays, hospitalization cost, postoperative complications, and residual rate (P=0.42, P=0.74, P=0.65, and P=1, respectively) between the two groups. However, the ESD combined with CSM-PLT was associated with a shorter procedure duration and fewer intraoperative complications (P < 0.001 and P=0.024, respectively). In addition, the incidence of intraoperative bleeding in ESD combined with CSM-PLT group was significantly lower than that in ESD group (P=0.04). Conclusion Both ESD combined with CSM-PLT and ESD were effective and safe modalities for the treatment of gSMTs. However, ESD combined with CSM-PLT was associated with a shorter procedure duration and fewer intraoperative complications.

Application of dental floss traction assisted endoscopic submucosal excision in treatment of gastric submucosal tumors

Application of dental floss traction assisted endoscopic submucosal excision in treatment of gastric submucosal tumors

Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients\u2019 tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection

Background and aimsEndoscopic full-thickness resection (EFTR) has been increasingly applied in the treatment of gastric submucosal tumors (G-SMTs) with explorative intention. This study aimed to compare the efficacy, tolerability, and clinical outcomes of EFTR and surgical intervention for the management of muscularis propria (MP)-derived G-SMTs.MethodsBetween September 2011 and May 2019, the clinical records of patients with MP-derived G-SMTs undergoing EFTR at our endoscopic unit were collected. A cohort of people with primary MP-derived G-SMTs treated by surgery was matched in a 1:1 ratio to EFTR group with regard to patients’ baseline characteristics, clinicopathologic features of the tumor and the procedure date. The perioperative outcomes and follow-up data were analyzed.ResultsIn total, 62 and 62 patients were enrolled into the surgery and EFTR group, respectively, with median follow-up of 786 days. The size of G-SMTs (with ulceration) ranged from 10 to 90 mm. For patients with tumor smaller than 30 mm, surgery and EFTR group presented comparable procedural success rate (both were 100%), en bloc resection rate (100% vs. 94.7%), tumor capsule rupture rate (0% vs. 5.3%), and pathological R0 resection rate (both were 100%). EFTR had a statistically significant advantage over surgery for estimated blood loss (3.12 ± 5.20 vs. 46.97 ± 60.73 ml, p ≤ 0.001), discrepancy between the pre- and postprocedural hemoglobin level (5.18 ± 5.43 vs. 9.84 ± 8.25 g/L, p = 0.005), bowel function restoration [1 (0–5) vs. 3 (1–5) days, p ≤ 0.001], and hospital cost (28,617.09 ± 6720.78 vs. 33,963.10 ± 13,454.52 Yuan, p = 0.033). The patients with tumor larger than 30 mm showed roughly the same outcomes after comparison analysis of the two groups. However, the clinical data revealed lower en bloc resection rate (75.0% vs. 100%, p = 0.022) and higher tumor capsule rupture rate (25.0% vs. 0%, p = 0.022) for EFTR when compared to surgery. The procedure time, duration of postprocedural fasting and antibiotics usage, and hospital stay of the two groups were equivalent. The occurrence rate of adverse events within postoperative day 7 were 74.2% and 72.6% after EFTR and surgery, respectively (p = 1.000). No complications occurred during the follow-up.ConclusionFor treatment of MP-derived G-SMTs (with or without ulceration), our study showed the feasibility and safety of EFTR, which also provided better results in terms of procedural blood loss, the postoperative bowel function restoration and cost-effectiveness when compared to surgery, whereas the surgery was superior in en bloc resection rate for G-SMTs larger than 30 mm. The postprocedural clinical outcomes seemed to be equivalent in these two resection methods.

Factors that predict the technical difficulty during endoscopic full-thickness resection of a gastric submucosal tumor

Background and aim: endoscopic full-thickness resection (EFTR) is widely accepted for the treatment of gastric submucosal tumors (SMTs). However, technical difficulties sometimes occur. The aim of the present study was to assess the safety and efficacy of EFTR for gastric SMTs and to explore risk factors for technical difficulty. Methods: the clinical data of patients who received EFTR for gastric SMTs was retrospectively collected from April 2011 to September 2019. Efficacy was defined as an en bloc resection. Difficult EFTR was defined as a procedure time ≥ 120 minutes and/or the occurrence of major adverse events, such as major bleeding, abdominal pain or peritonitis. Finally, risk factors for technical difficulty of EFTR such as gender, age, tumor location, size, symptomatic, regular, outgrowth, operator experience and pathology were analyzed in a univariate and multivariate analysis. Results: one hundred SMTs were removed by EFTR. The average surgery time was 75.73 ± 45.9 (range: 20-250) minutes and the average tumor size was 16.23 ± 7.73 (range: 6-40) mm. With regard to efficacy, en bloc resection was achieved in 98 cases (98 %). A total of ten patients (9.9 %) had complications, namely two intra-operative bleeding, one delayed bleeding and seven patients had abdominal pain (overt peritonitis). EFTR was ceased in one patient due to massive intra-operative bleeding and conversion to laparoscopic surgery was necessary. One patient required laparoscopic surgery due to delayed bleeding, and other complications were resolved with a conservative treatment. A total of 18 cases (17.8 %) encountered a difficult EFTR: tumor size ≥ 3 cm (p = 0.008) and location at the gastric corpus (p = 0.007) were risk factors for a difficult EFTR according to the logistic analysis. Conclusion: EFTR is safe and effective for the treatment of gastric SMTs. Tumor size of ≥ 3 cm and location at the gastric corpus are risk factors for a difficult EFTR.

CLEAN-NET: a modified laparoendoscopic wedge resection of the stomach to minimize the sacrifice of innocent gastric wall.

To avoid excessive sacrifice of the tissue surrounding the submucosal tumor in gastric wedge resection with a stapling device, we perform a "combined laparoscopic and endoscopic approach for neoplasia with a nonexposure technique" (CLEAN-NET). Herein the operative technique of CLEAN-NET is described and its short-term outcomes in 50 patients are evaluated. Between December 2015 and July 2017 CLEAN-NET was performed in 50 patients with gastric submucosal tumors. During the operation, the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. When seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. The mucosa is then transected with a stapling device to execute full-thickness resection of the specimen. Finally, the seromuscular defect is repaired by hand-sewn suture. The hospital records of the 50 patients were reviewed to assess the outcomes. The margin width was compared with those measured in another group with 19 patients, who underwent conventional wedge resection with a stapling device. The operation was completed as CLEAN-NET and the tumor was resected en-bloc without rupture in all patients. The average operation time ranged from 50 to 220min with an average of 105.4min. The post-operative course was uneventful. Microscopically the surgical margin was tumor-negative (R0 resection) in all cases. The margin width in the CLEAN-NET group was smaller than that in the wedge resection group (5.4mm ± 2.5 vs. 33.1mm ± 14.7). CLEAN-NET can be performed safely with an acceptable operation time. CLEAN-NET can be a useful option in the laparoscopic surgical treatment of gastric submucosal tumors, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided.

Clinical efficacy of modified totally laparoscopic intra-gastric surgery for submucosal tumors adjacent to the gastric cardia or pylorus

Objective To explore the clinical efficacy of modified totally laparoscopic intra-gastric surgery for the treatment of submucosal tumors adjacent to the cardia or pylorus. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 48 patients with gastric submucosal tumors adjacent to the cardia or pylorus between September 2014 and March 2018 were collected. There were 22 males and 26 females, aged from 38 to 78 years, with an average age of 58 years. Patients were performed multi-port or single-port modified laparoscopic intra-gastric surgery. Observation indicators: (1) surgical treatments; (2) postoperative recovery; (3) results of postoperative pathological examination; (4) follow-up. Patients were followed up by outpatient examination and telephone interview to detect the postoperative complications and tumor metastasis and recurrence up to June 2018. Measurement data with normal distribution were expressed as Mean±SD and measurement data with skewed distribution were described as M (range). Count data were represented as absolute number or percentage. Results (1) Surgical treatments: 48 patients underwent modified totally laparoscopic intra-gastric surgery successfully, including one patient combined with proximal gastrectomy, without conversion to open surgery. Of the 48 patients, 43 underwent multi-port modified laparoscopic intra-gastric surgery and 5 underwent single-port modified laparoscopic intra-gastric surgery. The operation time and volume of intraoperative blood loss were 68 minutes (range, 45-110 minutes) and 20 mL (range, 5-100 mL). The oncologic evaluation of 48 patients: 48 patients had complete resection of tumors, without tumor rupture. The tumor diameter and distance from margin to tumor were 32 mm (range, 20-40 mm) and 6 mm (range, 5-10 mm). (2) Postoperative recovery: the time for initial oral intake and duration of postoperative stay were 2.8 days (rang, 1.0-5.0 days) and 5.3 days(range, 3.0-11.0 days). There were 4, 3, 1 and 1 patients complicated with surgical infection, delayed gastric emptying, sub-phrenic hydrops and digestive leakage respectively in the 48 patients. (3) Results of postoperative pathological examination: the distance from tumor margin to gastric cardia or pylorus, tumor diameter, circumferential resection margin were 15 mm (range, 0-30 mm), 24 mm (range, 10-65 mm), 6 mm (range, 5-10 mm), respectively. Growth patterns of cancer in the 48 patents included 27 of intraluminal type, 12 of intermural type, 9 of mixed type. Pathological types of 48 patients: there were 26 patients with leiomyoma, 9 with gastrointestinal stromal tumor, 4 with other rare tumors, 2 with carcinoid, 2 with mucosa-associated lymphoma, 2 with inflammatory fibrous polyps, 2 with gastritis cystica profunda, 1 with ectopic pancreas. (4) Follow-up: 41 of the 48 patients were followed up for 3-48 months, with a median follow-up time of 22 months. No tumor recurrence was detected in 37 of 41 patients by 3 times of gastroscopy and no stenosis or dysfunction of cardia or pylorus was detected in 39 patients by 2 times of upper gastrointestinal imaging (one patient undergoing two examinations) . During the follow-up, there was no surgery-related complication or tumor-specific death. Conclusion Modified totally laparoscopic intra-gastric surgery is safe and feasible for the treatment of gastric submucosal tumors adjacent to the cardia or pylorus. Key words: Submucosal tumors; Intra-gastric surgery; Cardia; Pylorus; Laparoscopy

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.

Endoscopic mucosa-sparing lateral dissection for treatment of gastric submucosal tumors: a prospective cohort study.

In our previous work, we developed a modified method for the removal of gastric submucosal tumors (SMTs), called endoscopic mucosa-sparing lateral dissection (EMSLD). This prospective study aimed to evaluate the efficacy and postoperative outcomes of EMSLD. We prospectively enrolled 25 consecutive patients with gastric SMTs, who received EMSLD treatment. Clinicopathological characteristics and operation-related outcomes were analyzed. The mean age of patients was 49.3 ± 9.7 years, and the mean tumor size was 14.6 ± 6.1 mm. En bloc resection was achieved in all cases. The mean procedure time was 47.3 ± 25.9 minutes, and the estimated blood loss was 4.8 ± 3.5 mL. Endoscopic full-thickness resection was performed in six patients (24 %) because the tumors originated from the deep muscularis propria layer. All perforations and resection defects were successfully closed by the retained mucosa and endoclips. No serious complications related to EMSLD were encountered during or after the procedure. EMSLD was reliable and effective for the removal of gastric SMTs. However, large-scale randomized controlled trials are needed.

Hyperechoic demarcation line between a tumor and the muscularis propria layer as a marker for deciding the endoscopic treatment of gastric submucosal tumor.

Minimally invasive endoscopic resection has been rapidly adopted as a new technique for treating patients with gastric submucosal tumors (SMTs) originating in the muscularis propria (MP) layer. This study was conducted to evaluate the information obtained from endoscopic ultrasonography (EUS) to determine the appropriate endoscopic dissection method for treating SMTs originating in the MP layer. Between February 2014 and May 2016, a total of 50 patients with gastric SMTs originating in the MP layer were enrolled in this study. The clinical features of the patients and their endoscopic, EUS, and histopathologic findings, as well as their postoperative follow-up data, were analyzed in this retrospective study. The mean age of the patients was (55.0±10.2) years, and the male/female ratio was 17:33. Endoscopic submucosal dissection (ESD) was performed on 43 patients and an endoscopic full-thickness resection (EFR) was performed on seven patients. The most frequent location for an SMT was in the upper body region of the stomach (n=16), and the most common pathological diagnosis was a gastrointestinal stromal tumor (GIST) (n=32). The overall rates for complete resection were 95.3% (41/43) and 100.0% (7/7) when the SMTs were treated by ESD and EFR, respectively. The presence of a complete tumor capsule was significantly associated with a complete resection (P=0.001). Of the cases treated by ESD, nine patients developed perforation, one of whom required laparoscopic surgery. The remaining patients were closed with clips or purse-string sutures. The presence of an MP2-type tumor (P=0.018) and a wide connection with the MP layer (P=0.044) were significantly associated with perforation. A preoperative evaluation of the integrity and the location of a tumor capsule and the length of the tumor connection with the MP layer by EUS can improve the complete resection rate and reduce the occurrence of intraoperative complications. Tumors with a complete capsule originating from the superficial MP layer or with a narrow connection with the MP layer are appropriate candidates for treatment by ESD.

Totally laparoscopic intragastric surgery for gastric submucosal tumors located near the esophagogastric junction

Background: Laparoscopic partial gastrectomy (LAP) is a standard treatment for gastric submucosal tumors (SMTs). However, for SMTs located in the special parts such as the esophagogastric junction (EGJ) or the lesser curvature, LAP is difficult to approach with considerable risk of causing deformity or stenosis, tumor must be exposed via gastrotomy or handled by laparoscopic intragastric surgery (LIGS). We designed the totally laparoscopic intragastric surgery (T-LIGS), and describe this procedure and its clinical outcomes for gastric SMTs. Methods: Fourteen consecutive patients with gastric intraluminal SMTs located near the EGJ underwent T-LIGS at our center from January 2012 to December 2014. The clinicopathological results of these 14 cases were analyzed. Results: T-LIGS was successfully performed on all the patients. The mean operation time was 71.1±22.2 min (range, 45–110 min) and the mean blood loss was 9.3±7.0 mL (range, 5–30 mL). There was no death or intraoperative complications in our series. One patient experienced a postoperative complication of gastroparesis, one patient experienced surgical site infection, both recovered after conservative treatment. The mean postoperative length of hospital stay was 6.6±1.7 days (range, 5–11 days). All patients received complete resection with a negative margin. Histopathologic diagnoses were gastrointestinal stromal tumor (GIST) in nine cases, neurofibroma in two, neuroendocrine tumor (NET) in two, and mucosa associated lymphoid tissue lymphoma in one. There was one case of stenosis of the EGJ, and no case of tumor recurrence, during a mean follow-up of 13.9±7.4 months (range, 6–30 months). Conclusions: T-LIGS is a safe, feasible, and effective procedure, its suitable for treatment of gastric SMTs located near the EGJ.

Mo2008 Per Oral Endoscopic Tunneling Resection (POET) for treatment of gastric submucosal tumors

Mo2008 Per Oral Endoscopic Tunneling Resection (POET) for treatment of gastric submucosal tumors

Duodenal tubular resection using laparoscopic-endoscopic cooperative surgery: A new technique for the treatment of duodenal lesions.

Laparoscopic-endoscopic cooperative surgery (LECS) is a minimally invasive surgical technique that combines the advantages of laparoscopic surgery and endoscopic treatment. LECS has been developed for treatment of gastric submucosal tumors and can be applied to superficial non-ampullary duodenal tumors. Here we describe the use of LECS for duodenal mucosal cancer. After the placement of five ports, an endoscopic procedure was performed to confirm the tumor location and to place marks around the tumor. The jejunum was then resected 10 cm from the ligament of Treitz, and the connective tissue between the pancreas and duodenum was dissected to close to Vater's papilla. Duodenal resection was performed with a stapling device 2 cm to the oral side of the tumor, with endoscopic confirmation of the duodenal papilla, and duodenal tubular resection was then accomplished. Duodeno-jejunostomy was carried out using the same stapling device. There were no postoperative complications. This case shows that duodenal tubular resection using LECS enables curability through a minimally invasive procedure that offers the advantages of laparoscopic surgery and endoscopic treatment. This technique is applicable to duodenal lesions such as those due to duodenal mucosal cancers.

Tu1729 Comparison of Once and Twice Daily Intravenous PPI Injections for Prevention of Bleeding After Endoscopic Resections

invasion (ORZ22.83, 95% CI 4.80-108.46, p!0.001) were the independent factors to predict complete healing of ulceration. Conclusions: Administration of PPI for differentiated EGC with ulcer which meet the expanded criteria is effective to reduce the procedure time and heal the ulcer lesion. In differenciated EGC meeting the expanded criteria for ESD, complete healing of ulcer after PPI administration suggests mucosal cancer. Tu1729 Comparison of Once and Twice Daily Intravenous PPI Injections for Prevention of Bleeding After Endoscopic Resections Sung Woo Jung*, Joo Hee Park, Seung Young Kim, Jong Jin Hyun, Ja Seol Koo, Jong-Jae Park, Hoon Jai Chun, Sang Woo Lee Korea University College of Medicine, Seoul, Korea (the Republic of) Background and Aims: Endoscopic resection(ER) is commonly used to remove gastric neoplasms. However, effective treatment dosing or scheduling of proton pump inhibitors (PPI) for the prevention of delayed bleeding after an ER remains unclear. Patients and Methods: One hundred seventy-six patients with gastric adenoma or early gastric cancer were enrolled. After an endoscopic procedure, each subject was randomly assigned to 40 mg q 24 hourrs (once daily group) or 40 mg q 12 hourrs (twice daily group) of IV pantoprazole for 2 days, and subsequently had 40 mg of oral pantoprazole daily. The second-look endoscopy was performed 2 days after an ER to compare the signs of re-bleeding and ulcer status between two groups. Results: Eighty-five patients were treated with 40 mg q 24 hourrs of IV pantoprazole and 91 patients were treated with 40 mg q 12 hourrs of IV pantoprazole. There were no significant differences in the stigmata of early bleeding at the second-look endoscopy (12.1% in once daily group versus 12.0% in twice daily group, pZ0.414) or in the rate of endoscopic hemostatic procedures for the stigmata (30.8% in once daily group versus 32.7% in twice daily group, pZ0.852). Conclusion: Intravenous injections of 40 mg pantoprazole once or twice daily for 2 days after an ER were evenly effective for the prevention of early bleeding. Tu1730 Clinical Impact of Submucosal Tunneling Endoscopic Resection for the Treatment of Gastric Submucosal Tumors Originating From the Muscularis Propria Layer Quan-Lin Li, Jian-Wei Hu, Chen Zhang, Mei-Dong Xu*, Li-Qing Yao, Ping-Hong Zhou Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background: Submucosal tunneling endoscopic resection (STER) can be adequately adopted as an effective treatment for subumucosal tumors (SMTs) originating from the muscularis propria (MP) layer at the esophagus and cardia. However, it has been seldom used for gastric SMTs. Our purpose was to evaluate the clinical impact of STER for gastric SMTs arising from the MP layer. Methods: Thirty-two patients with gastric SMTs from the MP layer were retrospectively identified from a prospectively maintained database including a total of 403 consecutive patients with STER. The main outcome measurements were complete resection rate, adverse events, local recurrence and distant metastases during follow-up. Results: Of the 32 lesions, 12 were located in the gastric corpus close to the cardia, 3 in the gastric fundus close to the cardia, 6 in the lesser curvature of the gastric corpus, and 11 in the greater curvature of the gastric antrum. STER was successfully performed in all patients with en bloc resection of tumors. The mean tumor size was 2.3 cm (range 1.0-5.0 cm). The complete resection rate was 100%. The operation time ranged from 25 to 125 min (mean, 51.8 min). All complications related to STER were successfully managed with conservative treatments. Local recurrence or distant metastasis did not occur during a follow-up period of 6-32 months. Conclusion: STER is a safe and effective therapeutic strategy for eligible gastric SMTs originating from the MP layer. Submucosal tunneling in the stomach may be more challenging than that in the esophagus, but does not increase procedure-related adverse events or prevent successful STER for eligible gastric SMTs. Clinical characteristics AB574 GASTROINTESTINAL ENDOSCOPY Volume 81, Sex (female/male), no. 14/18 Mean patient age (range), y 48.1 (31-73) Tumor location, no. Gastric fundus close to the cardia 3 Gastric corpus close to the cardia 12 Lesser curvature of the gastric corpus 6 Greater curvature of the gastric antrum 11 Procedure-related parameters Mean diameter of lesion (range), cm 2.3 (1-5) Mean procedure time (range), min 51.8 (25-125) No. 5S : 2015 Clinical characteristics www.gie En bloc resection rate, % 100%

Clinical impact of submucosal tunneling endoscopic resection for the treatment of gastric submucosal tumors originating from the muscularis propria layer (with video).

Submucosal tunneling endoscopic resection (STER) can be adequately adopted as an effective treatment for submucosal tumors (SMTs) originating from the muscularis propria (MP) layer at the esophagus and cardia. However, it has been seldom used for gastric SMTs. Our purpose was to evaluate the clinical impact of STER for gastric SMTs arising from the MP layer. Thirty-two patients with gastric SMTs from the MP layer were retrospectively included. The main outcome measurements were complete resection rate, adverse events, local recurrence, and distant metastases during follow-up. Of the 32 lesions, 12 were located in the gastric corpus close to the cardia, 3 in the gastric fundus close to the cardia, 6 in the lesser curvature of the gastric corpus, and 11 in the greater curvature of the gastric antrum. STER was successfully performed in all patients with en bloc resection of tumors. The mean tumor size was 2.3 cm (range 1.0-5.0 cm). The complete resection rate was 100%. The operation time ranged from 25 to 125 min (mean 51.8 min). All complications related to STER were successfully managed with conservative treatments. Local recurrence or distant metastasis did not occur during a follow-up period of 6-32 months. STER is a safe and effective therapeutic strategy for eligible gastric SMTs originating from the MP layer. Submucosal tunneling in the stomach may be more challenging than that in the esophagus, but does not increase procedure-related adverse events or prevent successful STER for eligible gastric SMTs.

Endoscopic Submucosal Tunnel Technique for the Treatment of Gastric Submucosal Tumors

Endoscopic Submucosal Tunnel Technique for the Treatment of Gastric Submucosal Tumors

Sa1570 Submucosal Tunneling Endoscopic Resection for Treatment of Gastric Submucosal Tumors

Sa1570 Submucosal Tunneling Endoscopic Resection for Treatment of Gastric Submucosal Tumors

Endoscopically assisted laparoscopic local resection of gastric tumor

BackgroundMinimally invasive procedures have been applied in treatment of gastric submucosal tumors. Currently, combined laparoscopic - endoscopic rendezvous resection (CLERR) emerges as a new technique which further reduces operative invasiveness.Case presentationA-57-year-old female patient presented with epigastric pain. She was submitted to gastroscopy, which revealed a tumor located at the angle of His. Biopsy specimens demonstrated a leiomyoma. The patient underwent endoscopically assisted laparoscopic resection of the tumor. The operative time was 45 minutes. Diagnosis of leiomyoma was confirmed by the final histopathological examination. The patient had an uneventful postoperative recovery and was discharged on the 2nd postoperative day.ConclusionCombined laparoscopic and endoscopic rendezvous resection appears as a promising alternative minimally invasive technique. It offers easy recognition of the tumor, regardless of location, safe dissection, and full thickness resection with adequate margins as well as less operative time.

Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by overstitch: a preclinical study

Gastric submucosal tumors are often treated by laparoscopic wedge resection. This study aimed to examine the feasibility of gastric full-thickness resection through a totally endoscopic approach using the master and slave transluminal endoscopic robot (MASTER), and closure of the luminal defect with an endoscopic suturing device. The operation was performed in two live porcine models under general anesthesia. First, the anterior wall of the stomach was slung to the abdominal wall using a percutaneous suturing device. An imaginary 5-cm lesion was marked using a needle knife. After the initial mucosal incision was made using an IT knife, the MASTER was introduced through a long overtube. A circumferential mucosal incision was completed with the MASTER to expose the muscularis propria which was grasped and incised to the serosal layer by electrocautery applied through the hook of the MASTER. The full-thickness resection of the gastric wall was completed with retraction using the grasper and dissection using the hook. While the defect was being created, the luminal space was maintained with traction of the percutaneous sutures. The defect was closed with suture plication using an Apollo Overstitch device. Two full-thickness gastric resections were performed in two nonsurvival porcine models (body weight = 30 and 35 kg, respectively) using the MASTER. The total procedure time was 56 min for the first model and 70 min for the second model. The luminal view was maintained during the whole procedure, and there was no damage to surrounding organs throughout the whole procedure. The gastric defects were closed successfully using Overstitch, with satisfactory gastric distension and no gas leakage afterward. The current experiment demonstrated the feasibility and safety of a totally endoscopic approach for the treatment of gastric submucosal tumors: full-thickness resection with the MASTER and successful closure of the defect using Overstitch.

Laparoscopic Transgastric Resection of Gastric Submucosal Tumors Located Near the Esophagogastric Junction

BackgroundLaparoscopic wedge resection is widely accepted as a choice of treatment for gastric submucosal tumors (SMTs). But it cannot easily be applied to tumors located near the esophagogastric junction (EGJ) due to the high risk of causing deformity or stenosis in the gastric inlet. We evaluated our laparoscopic transgastric surgical technique for gastric SMTs located near the EGJ and clinical outcomes. MethodsTwelve consecutive patients with gastric intraluminal SMTs located 3 cm or less from the EGJ underwent laparoscopic transgastric resection at our institution from June 2010 to November 2012. The clinicopathological results of these 12 cases were analyzed. ResultsLaparoscopic transgastric resection was successfully performed on all the patients. The mean operation time was 125 ± 25 min (range, 85–160 min) and the mean blood loss was 53 ± 32 mL (range, 10–120 mL). There was no death in our series. One patient experienced a postoperative complication of upper gastrointestinal tract bleeding due to the errhysis along the staple line treated with an endoscopic hemostatic clip. The mean postoperative length of hospital stay was 5.1±1.2 days (range, 3–7 days). All patients received complete resection with a negative margin. Histopathologic diagnoses were gastrointestinal stromal tumor in seven cases, leiomyoma in four, and heterotopic pancreas in one. There was no tumor recurrence or evidence of stenosis of the EGJ during a mean follow-up of 15.3±9.6 months (range, 1–30 months). ConclusionsLaparoscopic transgastric resection is simple, safe, and effective for gastric intraluminal SMTs located near the EGJ.