Laparogastroscopy-A Transgastric Laparoscopic Approach for Malignant Esophageal Stenosis

Abstract

This paper presents the laparogastroscopy procedure, a mini-invasive, palliative method as an alternative to gastrostomy to be recommended by gastroenterologists. Laparogastroscopic stenting with endoluminal transtumoral drilling solves the problem of oral nutrition in patients with unresectable esophageal cancer, avoiding percutaneous feeding. The results of this technique are presented in a retrospective analysis of a study group of 63 patients with advanced esophageal carcinoma admitted between January 2015 and December 2020 at Department of General Surgery of Emergency County Hospital Sibiu, Romania, in terms of post-operative morbidity and mortality. The type of stents used were Pezzer prostheses (48.6%), silicone prostheses (31.9%), and self-expanding metal stents (6.9%). Eight patients (12.7%) had fistulas (at admission to the clinic), which were successfully sealed. Post-operative dysphagia was absent in most patients and minimal in 16.6% of patients, so all patients could initiate oral feeding, improving their nutritional status. The average length of hospitalization for all patients was 9.22 ± 5.05 days. The most frequent local complications were restenosis (9.5%), stent displacement (7.9%), and bleeding (4.8%). The mean survival time was 10.75 ± 15.72 months. Laparogastroscopic stenting could be a valuable alternative in palliative esophageal cancer surgery, improving the quality of life and nutritional status in patients unsuitable for endoscopic stenting.

Keywords: cancer; esophageal; laparogastroscopy; palliation; surgery.

Figure 1

(a) Gastric anchorage with crocodile clamp and left subcostal eternalization and fixation. (b) Visualization of the cardia through which the telescope with the working channel and the elastic catheter are inserted in view of the cranial passage of the tumor and its oral extraction.

Figure 2

(a) Telescope with working channel. (b) Telescope with working channel with probe for retrograde catheterization (single-port system). (c) Auxiliary surgical instruments with single-port system. (d) Instruments used for the thermoregulation of stents. (e) Single-port system with 2 and 3 holes. (f) Anchoring assembly: tent-anchored oral fixation wire, stent, and intermediate segment crossed by endoluminal wire anchored by stent (upper pole) and lower-pole catheter. (g) Traction: complex proximal tension wire system, stent, intermediate tube and distal traction wire, and traction catheter.

Figure 3

(a) Self-expanding metal stent. (b) Prosthesis with successive diameters. Stents used for esophageal stenting with laparogastroscopy—the original method used since 1996. (c) Pezzer prepared at funnel level and dimensionally adapted (3–18 mm in diameter) according to possibilities, 10–15 cm in length. (d) Migrated and extracted stents.

Figure 4

(a) Endogastric image of distal end of SEMS prosthesis crossing the cardial orifice. (b) Collection of bioptic material after drilling. (c) Proximal endoprosthetic view and SEMS. (d) Silicone prosthesis distal end—endogastric image. (e) Endogastric image of distal end of flexometallic prosthesis through the cardial orifice—tumor at ⅓ of distal esophagus.

Figure 5

(a) Endogastric fixation of stent and (b) transparietogastric fixation of stent.