Laparoscopic Intragastric Resection

An Alternative Technique for Minimally Invasive Treatment of Gastric Submucosal Tumors

Cindy Boulanger-Gobeil, MD; Jean-Pierre Gagné, MD, LLM; François Julien, MD; Valérie Courval, MD; Kaitlyn Beyfuss, BSc; Shady Ashamalla, MD, MSc; Julie Hallet, MD, MSc

Disclosures

Annals of Surgery. 2018;267(2):e12-e16. 

In This Article

Abstract and Introduction

Abstract

Objective: To present the technique for and early results of laparoscopic intragastric resection (LIGR).

Background: Treatment of confirmed or suspected submucosal gastric malignancies relies on clear margin resection, for which minimally invasive surgery is widely accepted. However, resection in some localization remains challenging.

Methods: We present the steps of LIGR for gastric submucosal tumors (GSMTs). We report the results of LIGR in consecutive patients operated at 2 institutions, including intraoperative, pathologic, 30-day major morbidity and mortality characteristics.

Results: After laparoscopic access to the abdominal cavity, cuffed gastric ports are placed to approximate the anterior gastric wall to the abdominal wall. A pneumogastrum is created. The tumor is resected in the submucosal plane and the deficit closed with intragastric suturing. Specimen extraction is performed perorally or through a gastrotomy site. In 8 proximal intraluminal GSMTs with median size of 3.1 cm (range: 1.8–6.0 cm), median operative time was 167.5 minutes (range: 120–300 mins). There was no major morbidity and no mortality. All resections were R0.

Conclusions: We illustrate the technique of a novel, feasible, and safe minimally invasive approach to GSMTs. LIGR is an alternative to resect challenging GSMTs by limiting surgical invasiveness and preserving gastrointestinal function.

Introduction

Gastric submucosal tumors (SMTs) include a wide spectrum of lesions, half of which are gastrointestinal stromal tumors (GISTs).[1–3] Surgical management remains the mainstay of curative treatment for GIST.[2] Because of the very low risk of lymphatic spread, resection with negative microscopic margins is the recommended approach.[4] With increasing use of upper gastrointestinal endoscopies and CT scans, a growing number of SMTs are being identified, and surgical excision might also be needed for pathologic examination to definitely rule out malignancy when they remain undiagnosed.[1,3]

Over the past few years, surgical management of gastric SMTs has evolved towards minimally invasive techniques. Laparoscopic partial gastrectomy is a now accepted for the treatment of SMTs, including GISTs. Patients can thus benefit from improved postoperative outcomes compared with the open approach, mostly caused by reduced pain, decreased blood loss, better bowel function recovery, and faster return to normal activities.[5,6]

Because of size and/or location, some SMTs are not readily amenable to limited surgical resection.[2] Tumors located proximally in the stomach, including at the gastroesophageal junction (GEJ), present unique challenges to balance the extent of resection and associated morbidity to the malignant potential of the tumor being treated. Lesions in this location are difficult to access for endoscopic resection, as they require a retroflexed view. Partial gastrectomy or wedge resection near the GEJ carries risks of debilitating stricture or lower esophageal sphincter trauma, and is technically difficult laparoscopically. Proximal gastrectomy leads to sub-optimal functional outcomes.[7,8] Thus, extensive resection with potential compromise of gastrointestinal function and significant morbidity can be required for small proximal lesions.

Laparoscopic intragastric resection (LIGR) has initially been described for the treatment of early gastric cancer.[9] We have developed expertise with this technique to manage SMTs in locations that preclude laparoscopic partial gastrectomy, would require an extensive resection, and/or would compromise gastrointestinal function. LIGR allows for resection of gastric SMTs in challenging locations whereas minimizing the extent, invasiveness, and morbidity of the procedure. This technique is not being used for invasive gastric cancers.

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