Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors

Abstract

Diagnosis of gastric subepithelial tumor (SET) has shown a rapid increase worldwide. Although, until now, endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET, the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection. However, endoscopic resection or laparoscopic wedge resection alone also has some limitations. Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large (larger than 25 mm diameter). On the other hand, gastric SET in a difficult location, such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection. The hybrid natural orifice transluminal endoscopic surgery (NOTES) technique is a combined method, including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs. This method may be performed safely with reasonable operation times, less bleeding, and adequate resection margin and regardless of tumor size. In particular, in the case of a difficult location for resection, such as the esophagogastric junction or pyloric ring, hybrid NOTES is currently believed to be an ideal treatment method.

Keywords: Endoscopic ultrasound; Hybrid natural orifice transluminal endoscopic surgery; Subepithelial tumor.

Figure 1

Procedures for hybrid natural orifice transluminal endoscopic surgery (laparoscopic assisted endoscopic full-thickness resection). A: Laparoscopic view during dissection of the attachment of the lesser omentum around the tumor site; B: Endoscopic view during precutting around the tumor using an O type knife (Finemedix, Daegu, South Korea); C, D: Laparoscopic view of a full-thickness incision from inside the stomach using the same knife; E: Laparoscopic view of the remaining full thickness incision from outside the stomach using a HARMONIC ACE^® (Ethicon Endo-Surgery); F: Laparoscopic view after laparoscopic handsewn closure of the gastric wall defect.