J Gastric Cancer.  2015 Dec;15(4):278-285. 10.5230/jgc.2015.15.4.278.

Endoscopic and Laparoscopic Full-Thickness Resection of Endophytic Gastric Submucosal Tumors Very Close to the Esophagogastric Junction

• Kwon OK
• Yu W

• KMID: 2391563
• DOI: http://doi.org/10.5230/jgc.2015.15.4.278

Abstract

PURPOSE
Gastric submucosal tumors (SMTs) located very close to the esophagogastric junction (EGJ) are a challenge for gastric surgeons. Therefore, this study reports on the experience of using endoscopic and laparoscopic full-thickness resection (ELFR) with laparoscopic two-layer suturing in such tumors.
MATERIALS AND METHODS
Six patients with gastric SMTs very close to the EGJ underwent ELFR with laparoscopic two-layer suturing at Kyungpook National University Medical Center. With the patient under general anesthesia, the lesser curvature and posterior aspect adjacent to the EGJ were meticulously dissected and visualized using a laparoscopic approach. A partially circumferential full-thickness incision at the distal margin of the tumor was then made using an endoscopic approach under laparoscopic guidance. The SMT was resected using laparoscopic ultrasonic shears, and the gastric wall was closed using two-layer suturing. Thereafter, the patency and any leakage were checked through endoscopy.
RESULTS
All the ELFR procedures with laparoscopic two-layer suturing were performed successfully without an open conversion. The mean operation time was 139.2+/-30.9 minutes and the blood loss was too minimal to be measured. The tumors from four patients were leiomyomas, while the tumors from the other two patients were gastrointestinal stromal tumors with clear resection margins. All the patients started oral intake on the third postoperative day. There was no morbidity or mortality. The mean hospital stay was 7.7+/-0.8 days.
CONCLUSIONS
ELFR with laparoscopic two-layer suturing is a safe treatment option for patients with an SMT close to the EGJ, as major resection of the stomach is avoided.

Keyword

Gastric submucosal tumor; Esophagogastric junction

MeSH Terms

Academic Medical Centers
Anesthesia, General
Endoscopy
Esophagogastric Junction*
Gastrointestinal Stromal Tumors
Gyeongsangbuk-do
Humans
Leiomyoma
Length of Stay
Mortality
Stomach
Ultrasonics

Figure

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  Fig. 1 Preoperative endoscopic findings.

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  Fig. 2 Laparoscopic procedures. Application of intestinal clamps to the proximal jejunum (A), dissection of the lesser curvature of the esophagogastric junction (arrow) (B), perforation of the gastric wall using a needle-knife (arrow) (C), partially circumferential full-thickness incision using an insulation-tipped knife (arrow) (D), laparoscopic resection of the tumor using ultrasonic shears (E), identification of the esophageal opening (arrow) (F), closure of the mucosa and submucosa (G), and closure of the seromuscular layer (H).

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  Fig. 3 Endoscopic procedures. Submucosal tumor (arrow) close to the esophagogastric junction before resection (A), submucosal injection of 0.9% saline solution mixed with epinephrine (B), formation of submucosal incision at the distal margin (arrow) of the tumor using a needle-knife (C), partially circumferential full-thickness incision of the gastric wall using a diathermic electrosurgical (insulation-tipped) knife, visible peritoneal cavity, and padded gauze (arrow) (D), and after resection and closure, showing a well-approximated gastric mucosa (arrows) (E, F).

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  Fig. 4 Follow-up endoscopic findings after 6 months showing no stenosis or deformity.

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