Non-exposed endoscopic wall-inversion surgery with one-step nucleic acid amplification for early gastrointestinal tumors: Personal experience and literature review

Abstract

Background: Laparoscopic and endoscopic cooperative surgery is a safe, organ-sparing surgery that achieves full-thickness resection with adequate margins. Recent studies have demonstrated the safety and efficacy of these procedures. However, these techniques are limited by the exposure of the tumor and mucosa to the peritoneal cavity, which could lead to viable cancer cell seeding and the spillage of gastric juice or enteric liquids into the peritoneal cavity. Non-exposed endoscopic wall-inversion surgery (NEWS) is highly accurate in determining the resection margins to prevent intraperitoneal contamination because the tumor is inverted into the visceral lumen instead of the peritoneal cavity. Accurate intraoperative assessment of the nodal status could allow stratification of the extent of resection. One-step nucleic acid amplification (OSNA) can provide a rapid method of evaluating nodal tissue, whilst near-infrared laparoscopy together with indocyanine green can identify relevant nodal tissue intraoperatively.

Aim: To determine the safety and feasibility of NEWS in early gastric and colon cancers and of adding rapid intraoperative lymph node (LN) assessment with OSNA.

Methods: The patient-based experiential portion of our investigations was conducted at the General and Oncological Surgery Unit of the St. Giuseppe Moscati Hospital (Avellino, Italy). Patients with early-stage gastric or colon cancer (diagnosed via endoscopy, endoscopic ultrasound, and computed tomography) were included. All lesions were treated by NEWS procedure with intraoperative OSNA assay between January 2022 and October 2022. LNs were examined intraoperatively with OSNA and postoperatively with conventional histology. We analyzed patient demographics, lesion features, histopathological diagnoses, R0 resection (negative margins) status, adverse events, and follow-up results. Data were collected prospectively and analyzed retrospectively.

Results: A total of 10 patients (5 males and 5 females) with an average age of 70.4 ± 4.5 years (range: 62-78 years) were enrolled in this study. Five patients were diagnosed with gastric cancer. The remaining 5 patients were diagnosed with early-stage colon cancer. The mean tumor diameter was 23.8 ± 11.6 mm (range: 15-36 mm). The NEWS procedure was successful in all cases. The mean procedure time was 111.5 ± 10.7 min (range: 80-145 min). The OSNA assay revealed no LN metastases in any patients. Histologically complete resection (R0) was achieved in 9 patients (90.0%). There was no recurrence during the follow-up period.

Conclusion: NEWS combined with sentinel LN biopsy and OSNA assay is an effective and safe technique for the removal of selected early gastric and colon cancers in which it is not possible to adopt conventional endoscopic resection techniques. This procedure allows clinicians to acquire additional information on the LN status intraoperatively.

Keywords: Early colorectal cancer; Early gastric cancer; Endoscopic full-thickness resection; Laparoscopic and endoscopic cooperative surgery; Non-exposed endoscopic wall inversion surgery; One-step nucleic acid amplification; Sentinel lymph node.

Figure 1

Preoperative endoscopy of prepyloric early gastric cancer. A: Endoscopy; B: Virtual chromoendoscopy; C: Endoscopic ultrasound.

Figure 2

Endoscopic injection of indocyanine green at cardinal points 1 cm from the margins of a prepyloric early gastric cancer lesion. A: First injection of indocyanine green (ICG); B: Second injection of ICG; C: Cardinal points of the lesion injected with ICG.

Figure 3

Sentinel lymph node biopsy. A: Level 4 d node; B: Level 4 d fluorescent node with near-infrared vision.

Figure 4

One-step nucleic acid amplification assay. A-F: Lymph nodes were prepared and placed in homogenized lysis buffer (Lynorhag; Sysmex) and then centrifuged. CK19 mRNA was extracted from the lysate and analyzed by reverse transcription-loop-mediated isothermal amplification in the RD-100i system (Sysmex) using the Lynoamp (Sysmex) reagent kit[59].

Figure 5

Laparoscopic and robotic surgical incision and reconstruction of the external gastric wall. A and B: Incision, representative views; C and D: Reconstruction, representative views.

Figure 6

Endoscopic full thickness resection of early gastric cancer using the non-exposed endoscopic wall-inversion surgery procedure. A: Mucosal markings placed around the tumor; B: Endoscopic incision of the internal layers of the gastric wall; C: Specimen.