Laparoscopic endoscopic cooperative surgery as a minimally invasive treatment for gastric submucosal tumor

Abstract

Laparoscopic wedge resection is a useful procedure for treating patients with submucosal tumor (SMT) including gastrointestinal stromal tumor (GIST) of the stomach. However, resection of intragastric-type SMTs can be problematic due to the difficulty in accurately judging the location of endoluminal tumor growth, and often excessive amounts of healthy mucosa are removed; thus, full-thickness local excision using laparoscopic and endoscopic cooperative surgery (LECS) is a promising procedure for these cases. Our experience with LECS has confirmed this procedure to be a safe, feasible, and minimally invasive treatment method for gastric GISTs less than 5 cm in diameter, with outcomes similar to conventional laparoscopic wedge resection. The important advantage of LECS is the reduction in the resected area of the gastric wall compared to that in conventional laparoscopic wedge resection using a linear stapler. Early gastric cancer fits the criteria for endoscopic resection; however, if performing endoscopic submucosal dissection is difficult, the LECS procedure might be a good alternative. In the future, LECS is also likely to be indicated for duodenal tumors, as well as gastric tumors. Furthermore, developments in endoscopic and laparoscopic technology have generated various modified LECS techniques, leading to even less invasive surgery.

Keywords: Cooperative surgery; Endoscopy; Gastrointestinal tumor; Laparoscopy; Submucosal tumor.

Figure 1

Laparoscopic endoscopic cooperative surgery for gastric submucosal tumor. A: The tumor is located in the lesser curvature of the middle third of the stomach; B: The stomach was mobilized by dividing the gastrocolic omentum and the lesser curvature vessels near the tumor by laparoscopic dissection; C: A circumferential incision was made around the tumor by an endoscopic submucosal dissection technique using an insulation-tipped diathermic electrosurgical knife; D: The seromuscular layer of the stomach was dissected along the incision line using the laparosonic coagulating shears; E, F: The post-excisional hole in the stomach was closed using a laparoscopic linear stapling device.

Figure 2

Gross appearance of the resected specimen. The tumor is a mixed-type, with a predominant intragastric component. The resection margin of healthy gastric wall is limited to the minimum necessary. The pathological diagnosis confirmed a gastrointestinal stromal tumor, classified as low risk.