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Combined Endoscopic and Laparoscopic Intra-Gastric Tumor Removal: a Procedure for Sub-Epithelial Tumor Located Close to the Esophagogastric Junction
Ajjana Techagumpuch*1, Chadin Tharavej2, Patpong Navicharern2, Suppa-UT Pungpapong2, Suthep Udomsawaengsup2
1surgery, Thammasat University hospital, Bangkok, Thailand; 2surgery, king chulalongkorn memorial university hospital, Bangkok, Thailand
Introduction: Laparoscopic approach is applicable for sub-epithelial lesion on the anterior gastric wall or greater curvature however lesion located close to the esophagogastric junction is remained challenging.
Methods: Laparoscopic wedge resection was chosen for anterior and/or greater curvature lesions. The combined endoscopic and laparoscopic intra-gastric tumor removal was selected for the tumor located close to the esophagogastric junction. In brief, after completing the diagnostic endoscopy. The CRE dilator (18-20 mm) was applied to occlude the pylorus to maintain gastric inflation. The 5-mm and 10-mm blunted-tip trocars were carefully inserted directly into the gastric lumen. By laparoscopic instruments manipulation or by endoscopic manipulation of the tumor, Free margin resection was safely done using the Harmonic Scalpel or linear stapler under direct vision of a five-mm, 30-degree laparoscopy and gastroscope. Bleeding was secured and gastric wall defect was approximated with intra-gastric suturing. Tumor was then retrieved endoscopically. The procedure was concluded with laparoscopic repair of port site gastric defects .We collected patients who had gastric sub-epithelial tumor removed. Patients who underwent combined endoscopic and laparoscopic intra-gastric tumor removal were analyzed.
Results: From January 2010 to july 2013, there were 33 patients who had gastric sub-epithelial tumor removal by Chula Minimally Invasive Surgery Center. Eighteen had laparoscopic wedge resection. Fiftieth underwent combined endoscopic and laparoscopic intra-gastric tumor removal. Of these, 10 cases were female. Mean age was 43 years old (range; 37-82). All except one case had successfully performed without any major complication. One case that was failed the first attempt of port placement had a successful resection 3 months later. Three of patients were selected to preformed the operation by single intra-gastric port technique. The operative time was 83 minutes (range; 45-180). Blood loss was 20 ml (range; 2-200). Post-operative pain score at 1st post-operative day was 2.2 (range; 1-5). The mean hospital stay was 3.3 days (range; 3-6). The pathology results were 9 GISTs, 4 Leiomyomas, 1 ectopic pancreas and 1 carcinoid tumor. Average tumor size was 1.5 cm (range; 1-6)
Conclusion: Combined endoscopic and laparoscopic intra-gastric tumor removal is safe and effective for sub-epithelial tumor located next to the esophagogastric junction.
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