Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

Understanding Gastric GIST: From Pathophysiology to Personalized Treatment

Background: Gastric gastrointestinal stromal tumors (GISTs) represent a subset of gastrointestinal tumors predominantly found in the stomach. Despite their rarity, these tumors carry significant implications for patient health and management. GISTs are potentially malignant tumors with unpredictable progression. They originate from the interstitial cells of Cajal, which are positioned between the intramural neurons and the smooth muscle cells of the digestive tract. These tumors are characterized primarily by mutations in the c-Kit gene, as well as other mutations such as those in the platelet-derived growth factor receptor alpha (PDGFRA) gene. Methods: Our comprehensive search across five databases initially yielded 2976 articles. After eliminating 197 duplicates, we screened the titles and abstracts of 2779 articles, excluding 2692 for not meeting the inclusion criteria. During the full-text screening, 16 more articles were excluded. Ultimately, 71 papers met the inclusion criteria and were included in our analysis. Results: Due to differences in study designs, inclusion criteria for patients, and reported outcomes, a meta-analysis was not conducted. The accurate diagnosis of GIST is established through histopathological examination and immunohistochemistry. Histopathologically, GISTs are classified into three main types: spindle cell, epithelioid, and mixed. The therapeutic management of GIST involves surgery, endoscopic treatment, and chemotherapy. Conclusions: The prognosis for GIST patients depends on various factors, including risk category, disease stage, applied treatments, and recurrence post-treatment. A significant recent advancement comes from artificial intelligence, which can be increasingly involved in both the diagnosis and treatment of this tumor.

Clinical course of small gastric subepithelial lesion less than 20 mm diagnosed by endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND AND AIM

Gastrointestinal stromal tumors (GISTs) are treated as malignant gastric subepithelial lesions (SELs), and resection is recommended. However, small gastric SELs < 20 mm with no malignant features are monitored without histopathological examination, and the frequency of malignancy is unknown. This study aimed to clarify the clinicopathological findings and clinical course of gastric SELs < 20 mm measured by endoscopic ultrasound (EUS).

METHODS

This retrospective cohort study included consecutive patients with small gastric SELs < 20 mm diagnosed using EUS at a tertiary referral center between 2009 and 2021. The clinical course after diagnosis using EUS-guided fine-needle aspiration (EUS-FNA) was reviewed.

RESULTS

Among 333 patients with small gastric SELs, 104 patients with 105 lesions underwent EUS-FNA. The pathological diagnosis was confirmed in 87 patients. GISTs were the most common pathology (47%). Among the 87 patients, 43 underwent therapeutic interventions, including tumor resection and chemotherapy. In groups of tumor resection, the pathological tumor size on the resected specimen was significantly larger than the size measured by EUS (19.5 mm vs 15.0 mm, P < 0.001), and 37% of resected SELs were 20 mm or over. No recurrence was observed after tumor resection during a mean follow-up period of 40 months.

CONCLUSIONS

Approximately 40% of small gastric SELs were malignant tumors, such as GIST, with most of them requiring treatment. Additionally, considering that the EUS measurement is 5 mm smaller than the pathological tumor diameter, further examinations, such as systematic EUS-FNA, may be required for SEL, including those smaller than 20 mm.

Innovations in Hybrid Laparoscopic Surgery: Integrating Advanced Technologies for Multidisciplinary Cases

Combining conventional laparoscopic techniques with cutting-edge technologies, such as robotics, improved imaging, and flexible equipment, hybrid laparoscopic techniques represent a revolutionary advancement in minimally invasive surgery. These methods have several benefits, such as increased accuracy, quicker healing periods, and fewer complications, which makes them especially useful in complicated multidisciplinary situations. The historical evolution, uses, benefits, and drawbacks of hybrid laparoscopic procedures are examined in this narrative review, which also covers urological, gastrointestinal, cardiothoracic, and gynecological surgery. The review focuses on how these methods promote interdisciplinary cooperation and creativity by enabling more accurate and successful surgical operations. It also discusses the equipment needs, integration difficulties, and technical difficulties that need to be resolved to reach the full potential of hybrid laparoscopic surgery. For hybrid laparoscopic procedures to become more widely used and effective in the future, there is a need for specialized training programs, interdisciplinary research collaborations, and ongoing technological advancements.

A rare presentation of gastric phytobezoar: Simultaneous bleeding and perforation. combined laparoscopic and endoscopic approach. Report of a case

INTRODUCTION

Bezoars are intraluminal conglomerates of indigestible foreign materials that accumulate in the gastrointestinal tract. We describe our experience with a patient with gastric perforation and concomitant gastric haemorrhage with severe anaemia, in whom we successfully extracted a giant gastric phytobezoar by cooperative laparoscopic and endoscopic surgery.

CASE PRESENTATION

A 68-year-old man was admitted with melena and septic shock. CT scan revealed a gastric perforation. We performed a combined laparoscopic and endoscopic approach with gastrotomy, removal of the phytobezoar and laparoscopic gastric suture. The suture was examined for leakage with the endoscopic hydropneumatic test to obtain direct vision of the suture and no evidence of leakage by insufflation of the area.

DISCUSSION

Gastric bezoars can be managed conservatively, endoscopically or surgically. Endoscopic removal, if effective, would be an attractive alternative for bezoar treatment. Usually endoscopic attempts are unsuccessful because of the large size of the bezoar and the difficulty in fragmentation. The laparoscopic approach for bezoar seems to have better postoperative outcomes. The main criticisms of the technique are abdominal spillage with risk of contamination as well as longer operative times.

CONCLUSION

In our case we simultaneously performed laparoscopic surgery and endoscopic operative procedure in accordance with the principles of laparoscopic and endoscopic cooperative surgery to treat the gastric bezoar in order to overcome the limits of a single technique.

Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

BACKGROUND

Minimally invasive surgery had been tailored to individual cases of gastric subepithelial tumors (SETs) after comparing the clinical outcomes of endoscopic resection (ER), laparoscopic resection (LR), and hybrid methods.

AIM

To study the use of Goldilocks principle to determine the best form of minimally invasive surgery for gastric SETs.

METHODS

In this retrospective study, 194 patients of gastric SETs with high probability of surgical intervention were included. All patients underwent tumor resection in the operating theater between January 2013 and December 2021. The patients were divided into two groups, ER or LR, according to the tumor characteristics and the initial intent of intervention. Few patients in the ER group required further backup laparoscopic surgery after an incomplete ER. The patients who had converted open surgery were excluded. A logistic regression model was used to assess the associations between patient characteristics and the likelihood of a treatment strategy. The area under the curve was used to assess the discriminative ability of tumor size and Youden's index to determine the optimal cut-off tumor size.

RESULTS

One-hundred ninety-four patients (100 in the ER group and 94 in the LR group) underwent tumor resection in the operating theater. In the ER group, 27 patients required backup laparoscopic surgery after an incomplete ER. The patients in the ER group had small tumor sizes and shorter procedure durations while the patients in the LR group had large tumor sizes, exophytic growth, malignancy, and tumors that were more often located in the middle or lower third of the stomach. Both groups had similar durations of hospital stays and a similar rate of major postoperative complications. The patients in the ER group who underwent backup surgery required longer procedures (56.4 min) and prolonged stays (2 d) compared to the patients in the LR group without the increased rate of major postoperative complications. The optimal cut-off point for the tumor size for laparoscopic surgery was 2.15 cm.

CONCLUSION

Multidisciplinary teamwork leads to the adoption of different strategies to yield efficient clinical outcomes according to the tumor characteristics.

Is single incision laparoscopic surgery (SILS) for gastric gastrointestinal stromal tumor (GIST) dependent on the location of the tumor?

BACKGROUND

We compared the surgical outcomes of single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for gastric gastrointestinal stromal tumor (GIST).

METHODS

We performed single-incision gastric wedge resection on prospectively-enrolled 15 consecutive patients with gastric GIST between November 2020 and April 2022 in a single tertiary center. The early perioperative outcomes of these patients were compared to those of patients who underwent CLS. The indications did not differ from those for conventional laparoscopic procedures for gastric GIST.

RESULTS

In total, 30 patients were assigned to the SILS (n = 15) and CLS (n = 15) groups. There were no significant differences in the estimated blood loss and intraoperative blood transfusion between the SILS and CLS groups. There were no intraoperative complications or conversions to multiple-port or open surgery in the SILS group. Proximally located tumors were more commonly treated with CLS than with SILS (P = 0.045). GISTs located in the greater curvature were more commonly treated with SILS than with CLS, although the difference was not statistically significant (P = 0.08). The mean incision length in the SILS group was 4.1 cm shorter than that in the CLS group (3.2 ± 0.7 and 7.3 ± 5.2 cm, respectively, P = 0.01). The postoperative analgesic dose was significantly lower in the SILS than in the CLS group (0.4 ± 1.4 and 2.1 ± 2.3, respectively P = 0.01). Also, the duration of postoperative use of analgesic was shorter in SILS than in CLS (0.4 ± 0.7 and 2.0 ± 1.8, respectively, P = 0.01). There were no significant differences in the early postoperative complications between the groups.

CONCLUSIONS

SILS is as safe, feasible, and effective for the treatment of gastric GIST as CLS with comparable postoperative complications, pain, and cosmesis. Moreover, SILS can be considered without being affected by the type or location of the tumor.

Non-exposed endoscopic wall-inversion surgery with one-step nucleic acid amplification for early gastrointestinal tumors: Personal experience and literature review

BACKGROUND

Laparoscopic and endoscopic cooperative surgery is a safe, organ-sparing surgery that achieves full-thickness resection with adequate margins. Recent studies have demonstrated the safety and efficacy of these procedures. However, these techniques are limited by the exposure of the tumor and mucosa to the peritoneal cavity, which could lead to viable cancer cell seeding and the spillage of gastric juice or enteric liquids into the peritoneal cavity. Non-exposed endoscopic wall-inversion surgery (NEWS) is highly accurate in determining the resection margins to prevent intraperitoneal contamination because the tumor is inverted into the visceral lumen instead of the peritoneal cavity. Accurate intraoperative assessment of the nodal status could allow stratification of the extent of resection. One-step nucleic acid amplification (OSNA) can provide a rapid method of evaluating nodal tissue, whilst near-infrared laparoscopy together with indocyanine green can identify relevant nodal tissue intraoperatively.

AIM

To determine the safety and feasibility of NEWS in early gastric and colon cancers and of adding rapid intraoperative lymph node (LN) assessment with OSNA.

METHODS

The patient-based experiential portion of our investigations was conducted at the General and Oncological Surgery Unit of the St. Giuseppe Moscati Hospital (Avellino, Italy). Patients with early-stage gastric or colon cancer (diagnosed via endoscopy, endoscopic ultrasound, and computed tomography) were included. All lesions were treated by NEWS procedure with intraoperative OSNA assay between January 2022 and October 2022. LNs were examined intraoperatively with OSNA and postoperatively with conventional histology. We analyzed patient demographics, lesion features, histopathological diagnoses, R0 resection (negative margins) status, adverse events, and follow-up results. Data were collected prospectively and analyzed retrospectively.

RESULTS

A total of 10 patients (5 males and 5 females) with an average age of 70.4 ± 4.5 years (range: 62-78 years) were enrolled in this study. Five patients were diagnosed with gastric cancer. The remaining 5 patients were diagnosed with early-stage colon cancer. The mean tumor diameter was 23.8 ± 11.6 mm (range: 15-36 mm). The NEWS procedure was successful in all cases. The mean procedure time was 111.5 ± 10.7 min (range: 80-145 min). The OSNA assay revealed no LN metastases in any patients. Histologically complete resection (R0) was achieved in 9 patients (90.0%). There was no recurrence during the follow-up period.

CONCLUSION

NEWS combined with sentinel LN biopsy and OSNA assay is an effective and safe technique for the removal of selected early gastric and colon cancers in which it is not possible to adopt conventional endoscopic resection techniques. This procedure allows clinicians to acquire additional information on the LN status intraoperatively.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

Optimal extent of lymph node dissection in gastric cancer

Gastric cancer still remains a major cause of cancer-related deaths globally. Stage-adapted, individualized treatment is crucial to achieving optimal oncological outcomes. Postoperative morbidity and accurate nodal staging are heavily influenced by the extent of lymph node dissection. On one hand, insufficient lymphadenectomy may result in understaging and undertreatment of a patient, on the other hand, unnecessary lymph node dissection may result in a higher rate of postoperative complications. Approximately one-third of patients with gastric cancer undergoes an avoidable lymph node dissection. Many of the recent treatment updates in the management of gastric cancer have a major influence on both surgical and oncological approaches. Currently, a wide range of endoscopic, minimally invasive, and hybrid surgical techniques are available. The concept of sentinel node biopsy and utilization of the Maruyama Computer Program are significant components of stage-adapted gastric cancer surgery. Likewise, centralization and application of national guidelines, widespread use of neoadjuvant therapy, and the stage migration phenomenon are serious concerns to be discussed. Our goal is to review the available surgical strategies for gastric cancer, with a primary focus on lymphadenectomy.

Early gastric cancer: A challenge in Western countries

Early gastric cancer (EGC) is an invasive carcinoma involving only the stomach mucosa or submucosa, independently of lymph node status. EGC represents over 50% of cases in Japan and in South Korea, whereas it accounts only for approximately 20% of all newly diagnosed gastric cancers in Western countries. The main classification systems of EGC are the Vienna histopathologic classification and the Paris endoscopic classification of polypoid and non-polypoid lesions. A careful endoscopic assessment is fundamental to establish the best treatment of EGC. Generally, EGCs are curable if the lesion is completely removed by endoscopic resection or surgery. Some types of EGC can be resected endoscopically; for others the most appropriate treatment is surgical resection and D2 lymphadenectomy, especially in Western countries. The favorable oncological prognosis, the extended lymphadenectomy and the reconstruction of the intestinal continuity that excludes the duodenum make the prophylactic cholecystectomy mandatory to avoid the onset of biliary complications.

The learning experience for endoscopic submucosal dissection in a non-academic western hospital: a single operator's untutored, prevalence-based approach

Background

Studies of learning experience in endoscopic submucosal dissection (ESD) commonly originate from the East. Little is known about the performance of ESD in low-volume western centers. Furthermore, it is unclear whether ESD can be self-taught without a tutored approach.

Methods

We performed a retrospective analysis of consecutive ESDs, performed in an untutored prevalence-based fashion by a single operator at a private Greek hospital from 2016-2020. Out of 60 lesions, standard ESD was applied for 54 and enucleation for 6; 41 were mucosal and 19 submucosal; 3 esophageal, 24 gastric, one duodenal, 12 colonic, and 20 rectal.

Results

Pathology revealed carcinoma (n=14), neuroendocrine tumor (n=7), precancerous lesion (n=27), or other submucosal tumors (n=12). The rates of en bloc and R0 resection were 98% and 91%, respectively. The median resection speed was <3 cm²/h for the first 20 cases, but improved progressively to ≥9 cm²/h after 40 cases. Two patients underwent laparoscopic surgery for colonic perforation, and one received a blood transfusion because of delayed bleeding (serious adverse event rate: 5%). No deaths occurred. The median hospital stay was 1.3 days. Variables associated with improvement in ESD speed during the second period of the study were the application of countertraction and the experience acquired through other endosurgical techniques.

Conclusions

ESD was safe and effective in a low-volume center, with an acceptable adverse events rate. At least 40 mixed cases were needed to achieve a high resection speed. Additive experience gained through other endosurgical procedures probably contributed to the improvement in performance.

Current surgical management of duodenal gastrointestinal stromal tumors

Duodenal gastrointestinal stromal tumors (D-GISTs) are uncommon mesenchymal tumors and are managed differently to common duodenal epithelial tumors. They may pose surgical challenges due to their unique but complex pancreaticoduodenal location of the gastrointestinal tract near the ampulla of Vater, pancreas, mesenteric blood vessels, biliary and pancreatic ducts. The surgical management of D-GISTs can be performed safely with good oncological outcomes provided an adequate resection margin can be achieved. The current surgical options of resectable primary D-GISTs varies with increasing complexity depending on the location, size and involvement of surrounding structures such as wedge resection with primary closure, segmental resection with small bowel anastomosis or radical pancreaticoduodenectomy. Laparoscopic approaches have been shown to be feasible and safe with good oncological outcomes in experienced hands. The minimally invasive techniques including robotic-assisted approach will likely increase in the future. D-GISTs have a prognosis comparable to gastric and other small bowel GISTs. However, the heterogeneity of different studies and the limited use of systemic tyrosine kinase inhibitor in the neoadjuvant and adjuvant settings may influence the overall survival of resected D-GISTs. The use of limited resection when condition allows is recommended due to lower surgical morbidity, less postoperative complications and better oncologic outcomes.

Endoscopic Resection for Gastric Subepithelial Tumor with Backup Laparoscopic Surgery: Description of a Single-Center Experience

The aim of this study was to analyze patients who underwent endoscopic resection (ER) for gastric subepithelial tumors (SETs) with a high probability of surgical intervention. Between January 2013 and January 2021, 83 patients underwent ER at the operation theater and 27 patients (32.5%) required backup surgery mainly due to incidental perforation or uncontrolled bleeding despite endoscopic repairing. The tumor was predominantly located in the upper-third stomach (81%) with a size ≤ 2 cm (69.9%) and deep to the muscularis propria (MP) layer (92.8%) but there were no significant differences between two groups except tumor exophytic growth as a risk factor in the surgery group (37% vs. 0%, p < 0.0001). Patients in the ER-only group had shorter durations of procedure times (60 min vs. 185 min, p < 0.0001) and lengths of stay (5 days vs. 7 days, p < 0.0001) but with a higher percentage of overall morbidity graded III (0% vs. 7.1%, p = 0.1571). After ER, five patients (6%) had delayed perforation and two (2.4%) required emergent laparoscopic surgery. Neither recurrence nor gastric stenosis was reported during long-term surveillance. Here, we provide a minimally invasive strategy of endoscopic resection with backup laparoscopic surgery for gastric SETs.

A modified endoscopic full thickness resection for gastric subepithelial tumors from muscularis propria layer: Novel method

BACKGROUND AND AIM

The removal of subepithelial tumors (SETs) is challenging, particularly in tumors originating from the muscularis propria (MP) in the upper gastrointestinal (GI) tract, owing to the high risk of perforation. We developed mechanical spray lumpectomy (MSL), which is a novel method to safely and easily remove the tumor. This study aimed to evaluate the feasibility and safety of MSL as a novel endoscopic treatment for gastric subepithelial lesions.

METHODS

We performed MSL in a total of 13 patients with upper GI SETs originating from the MP layer. First, mucosectomy was performed using a conventional snare. Repeated injections were performed towards the subserosal layer. After injection, the lesion was mechanically pushed to separate the MP layer using an endoscopic cap. Finally, the mucosa, submucosa, and MP layer with SETs were completely dissected using the spray coagulation mode, and the remaining defect was closed with clipping.

RESULTS

All tumors were completely resected. The mean procedure time was 84.38 ± 41.73 min. There were four leiomyomas, six GI stromal tumors, one mucosa-associated lymphoid tissue lymphoma, and two ectopic pancreases. Although small perforation occurred in only one case, the defect was successfully closed using hemostatic clipping. Moreover, no serious complications related to MSL were encountered during or after the procedure. No residual lesion or recurrence was observed during the follow-up period.

CONCLUSIONS

Mechanical spray lumpectomy can be a novel method that provides a safe and minimally invasive endoscopic treatment for upper GI SETs originating from the MP layer.

Choice of LECS Procedure for Benign and Malignant Gastric Tumors

Laparoscopic endoscopic cooperative surgery (LECS) refers to the endoscopic dissection of the mucosal or submucosal layers with laparoscopic seromuscular resection. We recommend a treatment algorithm for the LECS procedure for gastric benign tumors according to the protruding type. In the exophytic type, endoscopic-assisted wedge resection can be performed. In the endophytic type, endoscopic-assisted wedge resection of the anterior wall is relatively easy to perform, and endoscopic-assisted transgastric resection, laparoscopic-assisted intragastric surgery, or single-incision intragastric resection in the posterior wall and esophagogastric junction (EG Jx) can be attempted. We propose an algorithm for the LECS procedure for early gastric cancer according to the tumor location. The endoscopic submucosal dissection (ESD) procedure can be adapted for all areas of the stomach, and single-incision ESD can be performed in the mid to high body and the EG Jx. In full-thickness gastric resection, laparoscopy-assisted endoscopic full-thickness resection can be adapted for the entire area of the stomach, but it cannot be applied to the pyloric and EG Jx. In conclusion, surgeons need to select the LECS procedure according to tumor type, tumor location, the surgeon's individual experience, and the situation of the institution while also considering the advantages and disadvantages of each procedure.

A bleeding GIST in pandemic times, a cooperative approach to a delayed complication, a case report

INTRODUCTION

Upper gastrointestinal bleeding is one of the major manifestations of the stomach's gastrointestinal stromal tumors; when gastric GISTs bleed, they are associated with a poor prognosis and must be treated promptly to avoid dangerous complications. A worrisome side effect of the Covid-19 pandemic is the delay in surgical treatment for seriously ill patients, a rise in surgical complications due to delayed care, lack of access to the healthcare system, and patients' hesitancy to seek care due to fear of the virus. In Ecuador, where limitations were present even in the absence of a pandemic, we are yet to fully know the full extent of the damage this pandemic has caused to ourselves and our patients.

PRESENTATION OF CASE

We present the case of a 51-year-old female; she presented with upper gastrointestinal bleeding, and a gastric GIST was diagnosed. Due to the size and the symptoms, surgery was planned. Nonetheless, as Ecuador was hit hard by the Covid-19 pandemic to cope with the respiratory patients, surgeries were delayed or canceled. Our patient surgery was delayed for five months until she presented with severe gastrointestinal bleeding that required urgent action and care. Thankfully, she completely recovered.

DISCUSSION AND CONCLUSIONS

This case is an example of the many complications we expect due to the pandemic; delay in treatment leads to troublesome complications. In these emergencies, time is of the essence, and surgical services must rise to the challenge; in a particular way, this case also proves that if there are the necessary tools to enhance the patient's recovery, we should hesitate to use them. Complete resection of the gastric GIST in a prompt matter must be done to avoid these potentially deadly complications.

Endoscopic or laparoscopic resection for small gastrointestinal stromal tumors: a cumulative meta-analysis

Background

Despite the recent large number of studies comparing endoscopic and laparoscopic resection for small gastrointestinal stromal tumors (GISTs) (diameter ≤ 5 cm), the results remain conflicting. The objective of this work was to perform a cumulative meta-analysis to assess the advantages and disadvantages of endoscopic resection vs. laparoscopic resection.

Methods

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched medical databases up to January 2020. Meta-analytical random or fixed effects models were used in pooled analyses. Meta-regression, cumulative meta-analyses, and subgroup analyses were performed to improve the accuracy of the conclusion. Sensitivity analyses were applied to assess the robustness of the results.

Results

A total of 12 cohort studies with 1383 participants comparing endoscopic resection and laparoscopic resection were identified, while three cohort studies with 167 participants comparing endoscopic resection and laparoscopic and endoscopic cooperative surgery were found. We found that endoscopic resection had shorter operation times (weighted mean difference [WMD] = –27.1 min, 95% confidence interval [CI]: –40.8 min to –13.4 min) and lengths of hospital stay (WMD = –1.43 d, 95% CI: –2.31 d to –0.56 d) than did laparoscopic resection. The results were stable and reliable. There were no significant differences in terms of blood loss, hospitalization costs, incidence of complications or recurrence rates. For tumor sizes 2 – 5 cm, endoscopic resection increased the risk of positive margins (relative risk [RR] = 5.78, 95% CI: 1.31 – 25.46). Although operation times for endoscopic resection were shorter than those of laparoscopic and endoscopic cooperative surgery (WMD = –41.03 min, 95% CI: –59.53 min to –22.54 min), there was a higher incidence of complications (RR = 4.03, 95% CI: 1.57 – 10.34).

Conclusions

In general, endoscopic resection is an alternative method for gastric GISTs ≤ 5 cm. Laparoscopic and endoscopic cooperative surgery may work well in combination. Further randomized controlled trials are recommended to validate or update these results.

Results of laparoscopic intragastric surgery

BACKGROUND

Technological and operative advancements have allowed laparoscopic intragastric surgery (LIGS) to be applied in the treatment of superficial gastric or submucosal lesions. The aim of this study was to evaluate short- and long-term outcomes following LIGS.

METHODS

From 2000 to 2013, 25 LIGSs were performed for superficial gastric lesions. Clinical records were reviewed retrospectively for peri-operative course and long-term outcomes with particular attention to the oncological follow-up for patients with malignant lesions.

RESULTS

Nineteen (76%) lesions were located close to the EGJ, three (12%) in the lesser curvature, two (8%) in the posterior wall and one (4%) in the prepyloric-antral region. A multiport technique was used in 15 (60%) patients and a single-access approach in 10 (40%) patients. The median operative time was 140 (50-210) minutes. No conversion to open or conventional laparoscopic surgery was needed. Mortality was nil, and severe morbidity occurred in one (4%) patient. The median length of stay was 6 (3-10) days. Indications of LIGS were adenocarcinoma in 11 (44%) patients, gastrointestinal stromal tumors (GISTs) in 6 (24%) patients and benign lesions in eight (32%) patients. En bloc resection was obtained in 24 (96%) patients with R0 margins in 23 (92%) patients. After a median follow-up of 76 (26-171) months, recurrence was detected in 4 (36%) patients with advanced malignant adenocarcinoma.

CONCLUSION

LIGS provides an interesting alternative to major gastric and EGJ resection when endoscopic resection is not suitable for highly selected patients with superficial gastric lesions.

Two duodenal gastrointestinal stroma tumors: Management by minimally invasive surgery and then by conservative surgery

We report the case of a 48-year-old woman treated for a gastrointestinal stroma tumor of the duodenum after presenting with upper gastrointestinal bleeding. She was treated with a combination of a radiological and endoscopic approach and minimally invasive surgery. During follow-up, the patient developed a second metachronous duodenal gastrointestinal stroma tumor, distinct from a local recurrence. This tumor was treated with a conservative surgical approach.

Intragastric laparoscopy for oesophageal eroded mesh removal: An approach to avoid resection

The augmentation of hiatal repair for large hiatus hernia with mesh is controversial. There is some evidence that recurrence rates are less with mesh repair; however, there is a risk of mesh erosion. Complicated erosion may require complex revisional surgery and oesophagogastric resection. We present a novel approach to the treatment of oesophageal mesh erosion, by utilising a combined approach of endoscopy and intragastric laparoscopy. The symptomatic relief from this procedure may obviate the need for foregut resection in some patients.

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

INTRODUCTION

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.

METHOD

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.

RESULTS

No abdominal drain is used, and a nasogastric tube is left in place for the first 24 h 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.

CONCLUSION

In this technical paper, the procedure is described in detail and demonstrated with video.

Endoscopy-assisted laparoscopic submucosal dissection for a duodenal epithelial tumor

We present the case of a 46-year-old obese woman with a 3.5-cm adenoma in the descending part of the duodenum who was treated with a totally laparoscopic approach. The preoperative examination revealed a pedunculated superficial tumor on the side of pancreas from the inferior duodenal angulus to 5 cm proximal to the papilla that was associated with massive blood flow. We chose not to perform endoscopic submucosal dissection, pancreaticoduodenectomy, or transduodenal tumor excision with laparotomy for this obese patient because of the poor exposure, risk of bleeding, and substantial invasiveness. We performed endoscopy-assisted laparoscopic submucosal dissection as a novel laparoscopic-endoscopic cooperative surgical approach in this patient. This surgery was surgically and oncologically safe.

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.

Laparoscopic-endoscopic Rendezvous Procedures for Upper Gastrointestinal Tumors Guided by Laser-supported Reverse Diaphanoscopy: A Modified Technique

INTRODUCTION

Precisely locating benign upper gastrointestinal tumors during laparoscopic-endoscopic surgery remains difficult and inaccurate. We describe reverse laser-supported diaphanoscopy (RLSD) for locating gastrointestinal tumors during laparoscopic surgery and present prospective evaluation results of the first cases.

MATERIALS AND METHODS

We studied 13 patients [women:men=7:6; mean age, 67 (range, 41 to 83) y] who underwent gastroscopic-laparoscopic rendezvous procedures during 2015 to 2018. Surgery duration, marking duration, and specimen resection size were recorded. The largest and smallest specimen resection margins were measured.

RESULTS

After locating tumors using RLSD, patients underwent successful resections. Histopathologic examination confirmed 5 cases of gastrointestinal stromal tumor; 3, neuroendocrine tumors; 2, heterotopic pancreatic tissue; 1, leiomyoma; 1, adenoma; 1, hyperplastic polyp. We employed 4 to 6 marks, depending on tumor location and size. The average marking duration was 14 minute (1 to 21 min); the average surgery duration, 73 minute (37 to 143 min). The smallest resection median margin was 2.0 mm (1.0 to 5.0 mm); the largest, 7.0 mm (2.0 to 12.0 mm).

CONCLUSIONS

RLSD precisely locates gastric benign tumors during laparoscopic-endoscopic rendezvous procedures.

Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome

BACKGROUND

Gastroparesis is a rapidly increasing problem with sometimes devastating consequences. While surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity, they require general anesthesia, advanced skills, and can lead to leaks. Peroral pyloromyotomy is a less invasive alternative; however, this technique is technically demanding and not widely available. We describe a hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow endoluminal stapled pyloroplasty as an alternative treatment option for gastric outlet obstruction.

METHODS

Under general anesthesia, six pigs (mean weight 33 kg) underwent endoscopic placement of intragastric ports using a technique similar to percutaneous endoscopic gastrostomy. A 5 mm laparoscope was used for visualization. A functional lumen imagine probe was used to measure the cross-sectional area (CSA) and diameter of the pylorus before, after, and at 1 week after intervention. Pyloroplasty was performed using a 5 mm articulating laparoscopic stapler. Gastrotomies were closed by endoscopic clips, endoscopic suture, or combination. After 6-8 days, a second evaluation was performed. At the end of the protocol, all animals were euthanized.

RESULTS

Six pyloroplasties were performed. In all cases, this technique was effective in achieving significant pyloric dilatation. The median pre-pyloroplasty pyloric diameter (D) and cross-sectional area (CSA) were 8 mm (4.9-11.6 mm) and 58.6 mm² (19-107 mm²), respectively. After the procedure, these values increased to 13.41 mm (9.8-17.6 mm) and 147.7 mm² (76-244 mm²), respectively (p = 0.0152). No important intraoperative events were observed. Postoperatively, all animals did well, with adequate oral intake and no relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent.

CONCLUSIONS

Hybrid endoluminal stapled pyloroplasty is a feasible, safe, and effective alternative method for the treatment of gastric outlet obstruction syndrome.

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.

Surgery for Gastrointestinal Stromal Tumors: State of the Art of Laparoscopic Resection and Surgery for M1 Tumors

BACKGROUND

The principles of surgery for primary gastrointestinal stromal tumor (GIST) are resection with clear margins without lymphadenectomy, thus enabling organ-preserving resection in many cases. Tumor rupture needs to be avoided, because it entails peritoneal sarcomatosis. Given these preconditions, there is a rationale for laparoscopic resection of primary GIST. In metastatic GIST, surgery cannot achieve cure, but constitutes an important cornerstone of treatment. Resection can be performed either for residual lesions in responding patients, for focally progressive lesions, or as palliative measure in generalized progression.

METHODS

Selective literature review.

RESULTS

There is ample evidence on laparoscopic resection of gastric GIST, but none from randomized trials. The studies show favorable perioperative outcomes and suggest adequate oncological results; however, a direct comparison to open resection is difficult. For surgery in M1 stages, survival outcomes are better for resection in generalized response than in focal progression. Perioperative morbidity is acceptable. Surgery in generalized progression does not prolong survival and bears relevant morbidity risks.

CONCLUSION

Laparoscopy seems an adequate surgical approach for primary gastric GIST, as long as the surgical principles relevant for this entity are respected. For other tumor sites, there is no sufficient evidence available. In M1 stages, selected patients may benefit from surgery. Survival differences between resection at different stages probably mirror the biology of the disease rather than the effect of the timing of the operation.

Endoscopically Assisted Laparoscopic Gastric Resection for Benign and Malignant Lesions: A Report of Two Cases

BACKGROUND The first gastric resection for stomach cancer was performed in 1879, and the first gastric resection for gastric ulcer disease was performed in 1882. During the 1990s, the first laparoscopic gastrostomies were reported. During the past decade, laparoscopic techniques have developed rapidly, gaining wide clinical acceptance. Minimally invasive surgery is now shifting the balance away from traditional open methods. We report 2 cases of endoscopically assisted laparoscopic local gastric resections for both gastric cancer and gastric ulcer disease. CASE REPORT The first case involves a 67-year-old male patient who suffered from recurrent bleeding from a gastric ulcer located 4-5 cm from the gastroesophageal junction. The patient was subjected to endoscopically assisted laparoscopic wedge resection of the affected part of the stomach, had an uneventful recovery and was discharged on the third postoperative day. The second case involves a 60-year-old female patient who was diagnosed with intramucosal gastric adenocarcinoma and was also subjected to endoscopically assisted laparoscopic wedge gastrectomy. This patient also had an uneventful recovery and was discharged on the second postoperative day. CONCLUSIONS Endoscopically assisted laparoscopic local gastric resection is a minimally invasive procedure which allows the surgeon to operate under direct visualization of the internal part of the stomach. Thus, it enables the surgeon to safely remove the affected part within healthy margins, providing the patient with all the advantages of laparoscopic surgery.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Laterally spreading tumour of the distal stomach: a case report

Background

Laterally spreading tumours (LSTs) are superficial neoplasms that usually extend laterally along the intra-luminal wall of the gastrointestinal tract. Recently, the incidence of LSTs in the colorectal mucosa has greatly increased. However, LSTs in the stomach are exceedingly rare and have never been previously reported.

Case presentation

Here, we report a 69-year-old male with epigastric pain and a gastric LST 6 cm in diameter located in the distal stomach and grossly extended into the duodenal bulb. The stomach lesion was initially diagnosed as high-grade intraepithelial neoplasia, while the duodenal lesion was diagnosed as a tubulovillous adenoma. A therapeutic strategy of endoscopic submucosal dissection and distal gastrectomy was applied. The surgeries and postoperative course were uneventful, and the patient remained asymptomatic 1 year after surgery.

Conclusions

This is a clinically significant case, as it provides detailed information regarding laterally spreading early gastric cancer and emphasizes the diagnostic and therapeutic approaches for early gastric cancerous lesions.

Short- and Long-Term Outcomes of Endoscope-Assisted Laparoscopic Wedge Resection for Gastric Submucosal Tumors Adjacent to Esophagogastric Junction

BACKGROUND

Laparoscopic wedge resection (LWR) is used to treat gastric submucosal tumors (SMTs). However, LWR can injure the cardia if tumors are near the esophagogastric junction (EGJ), resulting in gastric stenosis. This study's purpose was to summarize our experience with endoscope-assisted LWR for gastric SMTs within 3 cm of the EGJ and to verify the procedure's feasibility and safety.

METHODS

Data from 91 consecutive patients with gastric SMTs within 3 cm of the EGJ who underwent endoscope-assisted LWR at our hospital from 2007 to 2017 were obtained from a prospectively maintained database. The clinicopathological results, perioperative data, and long-term follow-up data were analyzed.

RESULTS

All patients successfully underwent endoscope-assisted LWR. The mean distance from tumor to EGJ was 2.43 ± 0.80 cm. Eighty-two patients underwent laparoscopic exogastric wedge resection (LEWR) and nine underwent laparoscopic transgastric wedge resection (LTWR). Mean operative time was 112.4 ± 48.8 min; mean blood loss was 36.8 ± 53.5 ml. Mean time to first flatus was 2.04 ± 0.68 days. Mean time to liquid intake was 2.53 ± 0.85 days. Mean postoperative hospital stay was 4.97 ± 1.80 days. Three patients (3.3%) had postoperative complications, all Clavien-Dindo grade I. The mean maximum tumor diameter was 3.00 ± 1.96 cm (range 0.5-10). LTWR was used more often than LEWR for SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ. The mean follow-up time was 36.86 ± 29.73 months (range 3-126). There was no stenosis of EGJ or tumor recurrence. Sixteen patients (17.6%) complained of upper gastrointestinal symptoms during the follow-up, which were all relieved by usage of acid suppressive medications.

CONCLUSIONS

Endoscope-assisted LWR is safe, feasible, and effective for gastric SMTs near the EGJ. LTWR is preferable to LEWR for gastric SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ.

Preoperative gastric lavage in gastric cancer patients undergoing surgical, endoscopic or minimally invasive treatment: An oncological measure preventing peritoneal spillage of intragastric cancer cells and development of related metastases

In addition to classical metastatic pathways, recently gastric cancer was described having an alternative route called "endoluminal exfoliation". Provisional analyses demonstrated, in fact, this kind of shedding is associated with several clinico-pathological features indicative of aggressive behavior and resulted to be an independent prognostic factor entailing poor prognosis. Compared with non-sowing counterparts, in fact, patients affected with exfoliating early and advanced gastric carcinomas met with shorter overall survival, disease free survival, progression free survival and time to tumor progression. In spite of these interesting results, however, the clinico-pathological and oncological significance of this unconventional metastatic route is still to be clarified. Such an investigation is further urged by the increasing widespread employment of minimally invasive treatments for gastric cancer which include a wide spectrum of intragastric interventions and maneuvers. Indeed, endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, intragastric laparoscopic surgery and hybrid procedures all take place inside of the stomach. However, iatrogenic perforations can occur during execution of these treatments leading to spillage of malignant cells from gastric to the peritoneal cavity or trocar insertion sites. Furthermore, many other gastric conditions and interventions can collide with endogastric presence of floating cancer cells: spontaneous ulceration or perforation, laparotomy surgery, gastrointestinal occlusion, diverticula. Viability, migration and intraluminal transportability of the intragastric floating cancer cells represents another original and intriguing topic. All these considerations led us to entertain the hypothesis that removing the exfoliated cancer cells from the gastric lumen could save patients from the dreaded potential risk of spillage. Performing gastric lavage before starting any kind of tumor intervention could be the most appropriate procedure to adopt with prophylactic intent. Should our speculation prove to be clinically significant, preoperative gastric lavage should be pointed out as a simple but cogent method useful for preventing oncological mishaps such as spillage of gastric cancer cells and development of related recurrences or metastases.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Novel approach of laparoscopic and endoscopic cooperative surgery (LECS) for cholecystectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) techniques, such as generating an artificial space between digestive tract layers for safer dissection, were thought to be safer for the resection of organs in cholecystectomy. We investigated whether combinations of endoscopic techniques and laparoscopic techniques could be performed more safely and rapidly.

MATERIAL AND METHODS

Laparoscopic and endoscopic cooperative-cholecystectomy (LEC-chole) and conventional laparoscopic cholecystectomy (Lapa-chole) were performed in six dogs. Operation time was defined as the time from the creation of the first port to the retrieval of the resected gallbladder (GB); and GB bed dissection time was the time from local injection of natural saline to the clipping of the cystic duct. The main roles of the endoscope in LEC-chole were to obtain a sufficient cutting space via local injection of natural saline to the GB bed and to monitor the operative view without laparoscopic camera, thus omitting the umbilical port.

RESULTS

The operation times were 60 ± 18.3 minutes for LEC-chole and 95 ± 7.0 for Lapa-chole (p = .036). The GB bed dissection times were 31 ± 8.54 minutes in LEC-chole and 50.6 ± 7.37 minutes in Lapa-chole (p = 0.048). There were significant differences in liver damage and bleeding (p = 0.116), but there were no significant differences in one-month survival.

CONCLUSIONS

The application of LEC-chole may be expanded to cholecystectomy.

Technological review on endoscopic submucosal dissection: available equipment, recent developments and emerging techniques

Endoscopic submucosal dissection (ESD) is widely practiced in Japan and the Eastern World and is rapidly expanding in western countries for the management of early malignancies of the upper and lower gastrointestinal tube. In addition, novel therapeutic applications deriving from ESD have emerged including the treatment of achalasia, of submucosal tumors, of diverticula, of strictures and of reflux disease. An ESD procedure necessitates not only skills and specific training, but also familiarization with a vast spectrum of devices (endoscopes, high-frequency generators and their settings, endoknives, hoods, irrigation devices) and techniques (such as countertraction, artificial ulcer closure), that render the procedure faster, more efficient and safer. This technological article gives an overview on current and novel equipment for an ESD and associated techniques.

Gastric lipoma: an unusual cause of dyspeptic symptoms

Gastric lipomas are rare tumours accounting for 2-3% of all benign gastric tumours. These are usually submucosal in origin but in rare cases may be subserosal in origin. Although a majority of gastric lipomas are asymptomatic and usually detected incidentally, occasionally these can cause abdominal pain, dyspeptic disorders, obstruction, invagination and haemorrhages. In the literature, only 200 cases of gastric lipomas have been reported so far. We report a case of a 56-year-old female with a submucosal symptomatic gastric lipoma presenting with disabling dyspeptic symptoms.

Management of gastric subepithelial tumors: The role of endoscopy

With the wide use of esophagogastroduodenoscopy, the incidence of gastric subepithelial tumor (SET) diagnosis has increased. While the management of large or symptomatic gastric SETs is obvious, treatment of small (≤ 3 cm) asymptomatic gastric SETs remains inconclusive. Moreover, the presence of gastrointestinal stromal tumors with malignant potential is of concern, and endoscopic treatment of gastric SETs remains a subject of debate. Recently, numerous studies have demonstrated the feasibility of endoscopic treatment of gastric SETs, and have proposed various endoscopic procedures including endoscopic submucosal dissection, endoscopic muscularis dissection, endoscopic enucleation, endoscopic submucosal tunnel dissection, endoscopic full-thickness resection, and a hybrid approach (the combination of endoscopy and laparoscopy). In this review article, we discuss current endoscopic treatments for gastric SETs as well as the advantages and limitations of this type of therapy. Finally, we predict the availability of newly developed endoscopic treatments for gastric SETs.

Endoscopic resection versus surgery for early gastric cancer and precancerous lesions: a meta-analysis

Aim

To compare the efficacy and safety of endoscopic resection (ER) and surgery for the treatment of early gastric cancer and precancerous lesions.

Methods

Databases, such as PubMed, EMBASE, Cochrane Library, and Science Citation Index, from 2000 to 2016, were searched for eligible articles. In this meta-analysis, the main outcome measurements were local recurrence, complications, metachronous lesions, hospital stay, and 5-year overall survival.

Results

Nine trials were identified and a total of 2748 patients were included. The rate of complication was higher in the surgery group compared with the ER group (OR 0.41; 95 % CI 0.30–0.55). The rates of local recurrence and metachronous lesions were lower in the surgery group (OR 0.03; 95 % CI 0.00–0.06; OR 8.76; 95 % CI 4.17–18.41). The hospital stay was shorter in the ER group (mean difference −6.96; 95 % CI −7.94 to −5.99). The 5-year overall survival rate did not significantly differ between the two groups (OR 1.23; 95 % CI 1.03–1.47).

Conclusions

We provided evidence that, ER was comparable to surgery in terms of the 5-year overall survival. In addition, ER had a lower rate of complications and shorter hospital stay, but a higher rate of local recurrence and metachronous lesions for the treatment of early gastric cancer and precancerous lesions.