Percutaneous endoscopic intragastric surgery: an organ preserving approach to submucosal tumors at esophagogastric junction

Abstract

As an organ preserving option in the treatment of submucosal tumor found at the esophagogastric junction (EGJ), percutaneous endoscopic intragastric surgery (PEIGS) plays an important role, while it is not commonly performed and there have been very few reports on this unique operation. The current authors have been performing PEIGS since 1993 and have reported on its short- and long-term outcomes from one of the world largest series. Herein its confusing terminology is discussed and techniques of three different types of PEIGS (original PEIGS, single incision PEIGS, and needlescopic PEIGS) are precisely described. Although reports on clinical outcomes of PEIGS have been rarely published, both short-term and long-term outcomes seem acceptable, as far as we review our own experiences and the past literatures. PEIGS needs to be accessed by the data from larger series or RCT to be further justified and spread for the patients with submucosal tumors at EGJ to salvage their stomach.

Keywords: Gastric submucosal tumor; endoluminal surgery; esophagogastric junction (EGJ); intragastric surgery; laparoendoscopic surgery; transgastric surgery.

Figure 1

Laparoscopic extragastric approach to a submucosal tumor on the posterior wall of cardia. (A) A GIST on the posterior wall of the cardia at 3 cm from EGJ is visualized by dividing the omentum and flipping the stomach over. This part can be approached from outside the stomach and not indicated for PEIGS; (B) the same tumor with Figure 1A is being wedge-resected by CLEAN-NET method with an endosurgical stapler.

Figure 2

The access routes of conventional percutaneous endoscopic intragastric surgery. (A) The port sites in original PEIGS; A 12 mm in navel, a 5 mm in left subcostal margin, and a 5 mm between them; (B) peroral endoscopic view in Original PEIGS; three ports percutaneously inserted into the gastric cavity are seen.

Figure 3

The operative technique of conventional percutaneous endoscopic intragastric surgery. (A) Percutaneous gastroscopic view in original PEIGS demonstrates a croissant-shape GIST measuring 4 cm in diameter at exact EGJ. Two 5 mm instruments are used to enucleate the tumor; (B) the enucleation needs meticulous dissection with attention not to break the surface of the tumor (pseudocapsule); (C) the defect after enucleation usually reaches the perigastric fat tissue. The muscle layers of esophagus and stomach must be precisely re-approximated by hand-sew; (D) the closure of the defect is carried out by hand-sew by interrupted sutures with 3-0 absorbable monofilament. The stitches are in radial direction to avoid stenosis. (E) the specimen is entrapped in a plastic bag and extracted via esophago-oral route with an aid of intraoperative endoscopy; (F) the three stab-wounds on the anterior gastric wall are closed by hand-sew.

Figure 4

The access routes of single incision percutaneous endoscopic intragastric surgery. (A) The port sites in single incision PEIGS; a 2.5 cm incision in the navel and a 2 mm puncture in the left subcostal margin; (B) a 2.5 cm gastrostomy is constructed by opening the anterior wall of the lower gastric body, fixed to the parietal incision in the navel; (C) X-Gate^® (a multichannel port for single incision endoscopic surgery) is fixed in the gastrostomy, through which a 5 mm telescope and a 5 mm instrument are brought in. In addition a 2 mm port is punctured in the left upper quadrant for the passage for 2 mm instruments.

Figure 5

The operative technique of single incision percutaneous endoscopic intragastric surgery. (A) A typical indication for single incision PEIGS. A 4 cm croissant-shaped GIST, 1/2 circumferentially occupying the exact EGJ. A 5 mm forceps and a 2 mm electro cautery hook are also visualized; (B) the full-thickness wall defect of EGJ after enucleation. The edges of muscular layers both of esophagus and stomach are seen; (C) the defect is being closed by hand-sew by interrupted suture. The operator is required to use left hand to drive the needle holder; (D) closure of the defect by hand-sew is being completed. As all stitches are in radial direction, risk of stenosis is minimized; (E) the specimen is entrapped in a plastic bag and extracted via x-Gate^®; (F) the gastrostomy is revised by extracorporeal suturing.

Figure 6

The access routes of needlescopic percutaneous endoscopic intragastric surgery. (A) The port-sites in needlescopic PEIGS; a 5 mm in the navel, a 2mm in the left subcostal margin, and a 2 mm between them; (B) needlescopic PEIGS is carried out with a 5 mm telescope and two 2 mm instruments.

Figure 7

The operative technique of needlescopic percutaneous endoscopic intragastric surgery. (A) A typical indication for needlescopic PEIGS; a 2.5 cm GIST at EGJ; (B) a 2.5 cm GIST is being enucleated with a 2 mm grasper (BJ Needle^®) and a 2mm high-frequency hook (BJ Hook^®); (C) after enucleation of GIST at EGJ a half circular anastomosis is performed by hand-sew with a 2 mm needle holder (BJ Pico^®) and another 2 mm grasper; (D) the specimen is entrapped in a home-made retrieval bag, which is eventually extracted via esophago-oral route by peroral flexible endoscope.