Laparoscopic endoscopic cooperative surgery (LECS) for the gastrointestinal tract: Updated indications

Abstract

Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure combining laparoscopic gastric resection with endoscopic submucosal dissection for local resection of gastric tumors with appropriate, minimal surgical resection margins. The LECS concept was initially developed from the classical LECS procedure for gastric submucosal tumor resection. Many researchers reported that classical LECS was a safe and feasible technique for resection of gastric submucosal tumors, regardless of tumor location, including the esophagogastric junction. Recently, LECS was approved for insurance coverage by Japan's National Health Insurance plan and widely applied for gastric submucosal tumor resection. However, the limitations of classical LECS are the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and tumor cell seeding in the peritoneum. The development of modified LECS procedures, such as inverted-LECS, non-exposed endoscopic wall-inversion surgery, a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique, and closed-LECS, has almost resolved these drawbacks. This has led to a recent increase in the indication of modified LECS to include patients with gastric epithelial neoplasms. The LECS concept is also beginning to be applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future. Sentinel lymph node mapping could also be combined with LECS, resulting in a portion of early gastric cancers being treated by LECS with sentinel node mapping.

Keywords: gastric cancer; laparoscopic endoscopic cooperative surgery; sentinel node navigation surgery; submucosal tumor.

Figure 1

A, Conceptual diagram of the classical laparoscopic and endoscopic cooperative surgery procedure (classical LECS). ESD, endoscopic submucosal dissection. B, Endoscopic submucosal resection around the tumor, using the insulation‐tipped diathermic knife‐2. C, Inverted‐laparoscopic and endoscopic cooperative surgery (inverted‐LECS). The gastric wall is lifted up circumferentially to the dissecting line, like a crown, by several stitches. D, Post‐resection of the tumor with a minimal margin and less stomach deformation

Figure 2

Conceptual diagram of a combination of nonexposed endoscopic wall‐inversion surgery (NEWS)

Figure 3

Conceptual diagram of a combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique (CLEAN‐NET)

Figure 4

A and B, Conceptual diagrams of closed‐laparoscopic and endoscopic cooperative surgery (closed‐LECS). ESD, endoscopic submucosal dissection