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Ma L, Liu R, Hu C, Zhang L, Qu P, She J. Clinical outcomes and cost-effectiveness analysis of robotic and endoscopic cooperative surgery for treating gastric submucosal tumors: a longitudinal nested cohort study. Surg Endosc 2025; 39:3959-3969. [PMID: 40360899 PMCID: PMC12116666 DOI: 10.1007/s00464-025-11775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2025] [Accepted: 04/27/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND Robotic and endoscopic cooperative surgery (RECS) is an emerging and promising therapeutic approach for treating gastric submucosal tumors (GSMTs). However, the efficacy of RECS has not been well established, and its high medical costs significantly limit its application. METHODS This nested cohort study examined patients with GSMTs managed with different surgical techniques. A total of 314 consecutive patients were enrolled in this study, including 61 patients treated with RECS, 196 patients treated laparoscopically, and 57 patients treated with open surgery. To mitigate confounding bias, 1:1:1 propensity score matching (PSM) was utilized. The perioperative outcomes, postoperative gastrointestinal symptoms, long-term outcomes, and cost-effectiveness among the three groups were compared. RESULTS After PSM, 51 patients were included in each group. Compared with the laparoscopic and open surgical groups, the RECS group presented significantly lower intraoperative bleeding volumes, times to first flatus, times to liquid intake, and postoperative hospital stay. The severity of gastrointestinal symptoms in the RECS group was notably better than that in the laparoscopic and open groups 3, 6, and 12 months postsurgery. Regarding long-term outcomes, there were no differences in overall or relapse-free survival among the three groups. The total hospitalization cost was significantly greater in the RECS group, primarily due to surgical cost differences. The incremental cost-effectiveness ratios per quality-adjusted life year for the RECS group relative to the laparoscopic and open groups were 18,244 and 56,914 Chinese yuan (CNY), respectively. Analysis of the cost-effectiveness acceptability curves indicated that across all willingness-to-pay thresholds, the probability that RECS was cost-effective exceeded 90%. CONCLUSIONS RECS is a safe and effective method for treating GSMTs, offering faster postoperative recovery and fewer gastrointestinal symptoms than laparoscopic and open surgeries. Despite the increased costs associated with the introduction of RECS technology, it remains a cost-effective option.
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Affiliation(s)
- Lei Ma
- Department of General Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ruihan Liu
- Department of General Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
- Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chenhao Hu
- Department of General Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Lei Zhang
- Department of General Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Penghong Qu
- Department of General Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Junjun She
- Department of General Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China.
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Gupta S, Gauci J, O'Sullivan T, Cronin O, Whitfield A, Craciun A, Awadie H, Yang J, Kwan V, Lee EYT, Burgess NG, Bourke MJ. A subepithelial lesion algorithm for endoscopic (SAFE) resection in the upper gastrointestinal tract. Endoscopy 2025; 57:95-106. [PMID: 39029913 DOI: 10.1055/a-2369-7854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
BACKGROUND Complete excision of upper gastrointestinal subepithelial lesions (U-SELs) eliminates diagnostic uncertainty, obviates the need for surveillance, and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. We describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection. METHODS U-SELs were enrolled prospectively over 115 months until March 2023. All subjects underwent axial (computed tomography) imaging and endoscopic ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria (MP) involvement. RESULTS 106 U-SELs (41 esophageal, 65 gastric) were resected (mean patient age 60.6 [SD 13.4]; 51.9% male). Esophageal U-SELs underwent endoscopic submucosal dissection (ESD; n = 22) or submucosal tunneling endoscopic resection (STER) if MP involvement was suspected (n = 19). Gastric U-SELs underwent STER (n = 6 at cardia), ESD (n = 47), or exposing endoscopic full-thickness resection (e-EFTR; n = 12). Technical success rates were 97.6% and 92.3%, respectively. Among the noncardiac gastric U-SELs, five resections (9.6%) were completed laparoscopically owing to deep and broad full-thickness involvement; five (9.6%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure owing to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation, or recurrence at 13 months. CONCLUSION U-SELs may be effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Esophageal U-SELs suspected of involving the MP should undergo STER. Gastric SELs are best managed by ESD, with a view to proceeding to e-EFTR. A laparoscopic upper gastrointestinal surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Julia Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Ana Craciun
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Jing Yang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Vu Kwan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
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Wang L, Huang W, Zhao JJ. A nomogram prediction model for the risk of intra-abdominal infection after endoscopic full-thick resection of gastric submucosal tumors. Heliyon 2024; 10:e38362. [PMID: 39512459 PMCID: PMC11539246 DOI: 10.1016/j.heliyon.2024.e38362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 09/08/2024] [Accepted: 09/23/2024] [Indexed: 11/15/2024] Open
Abstract
Background This study aimed to investigate the risk factors for complication of intra-abdominal infection (IAI) after endoscopic full-thickness resection of gastric submucosal tumors (GSMT) and to establish a nomogram prediction model for the occurrence of IAI. Methods Clinical data of patients with GSMT who underwent endoscopic full-thick resection (EFR) from January 2018 to July 2023 were retrospectively analyzed. The patients were divided into IAI and non-IAI groups according to whether IAI occurred during postoperative hospitalization. Univariate and multivariate logistic regression analyses were performed on the relevant clinical data of patients in the two groups to screen the independent influencing factors for the occurrence of IAI. The nomogram model was constructed based on the independent influencing factors. Model discrimination was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. The consistency of model-predicted risk with actual risk was evaluated using the Hosmer-Lemeshow goodness-of-fit test. The clinical performance of the nomogram model was evaluated using decision curve analysis. Results A total of 240 GSMT patients who underwent EFR procedures were finally included in this study, including 14 patients (5.83 %) in the IAI group and 226 patients in the non-IAI group. Univariate and multivariate logistic regression analyses showed that age (OR = 1.283, 95 % CI = 1.029-1.600), preoperative albumin (OR = 0.575, 95 % CI = 0.395-0.837), duration of operation (OR = 1.222, 95 % CI = 1.060-1.409), and hospitalization time (OR = 4.089, 95 % CI = 1.190-14.043) were independent influencing factors for the incidence of IAI in GSMT patients undergoing EFR surgery (P < 0.05). A Nomogram model was established based on the above factors. The Hosmer ⁃ Lemeshow test value of this model was 4.230 (P = 0.836). The AUC value of the predictive model was 0.992 (95 % CI: 0.983 to 1.000), with a C-index of 0.992 (95 % CI: 0.983-1.000), indicating that the nomogram model had good accuracy and discrimination. Decision curve analysis showed that the nomogram model had a good predictive performance. Conclusions Age, preoperative albumin, duration of operation, and hospitalization time were independent influences on the occurrence of IAI in GSMT patients undergoing EFR surgery. A nomogram model based on these factors had a high predictive efficacy and may provide a guiding intervention for the prevention of postoperative IAI in GSMT patients.
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Affiliation(s)
- Liang Wang
- Corresponding author. Health Road No. 147, Zhujing Town, Jinshan District, Shanghai, 201599, China.
| | | | - Jing-jing Zhao
- Department of Gastroenterology, Shanghai Jinshan Branch of the Sixth People's Hospital, Shanghai, 201599, China
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Lee E, Lim D, Kang SH, Hwang D, Yoo M, Park YS, Ahn SH, Suh YS, Kim HH. Single-port intragastric wedge resection using the tunnel method: a novel surgical approach for treating endophytic gastric subepithelial tumors. Surg Endosc 2024; 38:1106-1112. [PMID: 38110795 DOI: 10.1007/s00464-023-10583-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/04/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Intragastric wedge resection is an effective method for treating endophytic gastric subepithelial tumors (SETs). However, retracting the stomach wall to the umbilicus is difficult in certain patients. In response, we developed a novel surgical technique for single-port intragastric wedge resection, which we termed the "tunnel method." METHODS A transumbilical incision is made, and a wound retractor is applied. After diagnostic laparoscopy, a gastrostomy is made on the greater curvature, lower body. Another small wound retractor is inserted into the gastrostomy, and extracted through the transumbilical incision, creating a tunnel from the gastrostomy site to the umbilicus. Articulating laparoscopic instruments are inserted via the tunnel, and intragastric wedge resection is performed. We collected and analyzed the clinicopathologic and operative data of patients who underwent intragastric wedge resection via the tunnel method. RESULTS Twenty-seven patients who underwent single-port intragastric wedge resection via the tunnel method in a single tertiary referral hospital were included in this study. The mean age of the patients was 54.6 ± 11.4 years, body mass index was 26.5 ± 3.4 kg/m2. Twenty-four (88.9%) patients had tumors located in the upper third of the stomach. The average operative time was 65.0 ± 24.2 min. None of the patients experienced Clavien-Dindo grade IIIa or higher postoperative complications. The average postoperative hospital stay length was 2.5 ± 0.8 days. Thirteen gastrointestinal stromal tumors, nine leiomyomas, and one neuroendocrine carcinoma, schwannoma, lipoma, spindle cell proliferative lesion, and fibrotic lesion were pathologically diagnosed. The average tumor size was 2.6 ± 1.3 cm. All cases had negative resection margins. CONCLUSIONS Single-port intragastric wedge resection by the tunnel method is a feasible and safe approach for treating endophytic gastric SETs.
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Affiliation(s)
- Eunju Lee
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
| | - Donghyun Lim
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - So Hyun Kang
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Duyeong Hwang
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Mira Yoo
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Ho Kim
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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Narlapati H, Martino BR, Manibusan P. A Rare Variant of Gastric Adenocarcinoma Presenting as a Symptomatic Early-Stage Submucosal Tumor in the Gastric Antral Primary. Cureus 2024; 16:e53114. [PMID: 38283778 PMCID: PMC10822694 DOI: 10.7759/cureus.53114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 01/30/2024] Open
Abstract
Gastric adenocarcinomas are a well-known malignancy, with the vast majority presenting as primary mucosal invasions. However, a rare form of this cancer presents from the submucosal layer and mimics submucosal tumors (SMTs). This variant of gastric adenocarcinoma is not only rare, but it is also frequently misdiagnosed as other conditions such as gastrointestinal stromal tumors, lymphoma, or sarcoma. This case report describes a unique case of early gastric adenocarcinoma that presented as a submucosal tumor without invasion into the muscularis propria or primary involvement from the gastric mucosa. Additionally, this raises an important clinical question of whether this variant of gastric adenocarcinoma behaves differently from mucosal-origin cancers in terms of invasion and metastasis. This case highlights the diagnostic challenges and the importance of early detection and accurate diagnosis of this rare presentation of gastric adenocarcinoma. This case also provides valuable insights into the clinical variability of submucosal gastric adenocarcinomas and the need for further research to optimize its management and improve patient outcomes.
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Affiliation(s)
- Hema Narlapati
- Internal Medicine, Tripler Army Medical Center, Honolulu, USA
| | | | - Pedro Manibusan
- Gastroenterology, Tripler Army Medical Center, Honolulu, USA
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Liu J, Tan Y, Liu D, Li C, Le M, Zhou H. Factors predicting technical difficulties during endoscopic submucosal excavation for gastric submucosal tumor. J Int Med Res 2021; 49:3000605211029808. [PMID: 34488485 PMCID: PMC8427932 DOI: 10.1177/03000605211029808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/14/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Endoscopic submucosal excavation (ESE) has been established as an effective method for removal of gastric submucosal tumors (SMTs). The aim of the present study was to explore risk factors for technical difficulties in ESE. METHODS In this retrospective study, we collected clinical data from patients who underwent ESE for gastric SMTs. Difficult ESE was defined as a procedure time ≥90 minutes, piecemeal resection, and/or occurrence of major adverse events. Univariate and multivariate analyses were performed to explore the risk factors for a difficult ESE. RESULTS ESE was successfully performed in 96.5% (195/202) of patients from April 2011 to December 2019. The average tumor size was 17.41 mm, and en bloc resection was achieved in 97.4% of patients (190/195). Five patients (2.56%, 5/195) had complications, including two with delayed bleeding, two with fever, and one with chest pain accompanying ST-T changes in an electrocardiogram. Twenty-four patients (11.88%, 24/202) had a difficult ESE. Logistic analysis showed that outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE. CONCLUSION ESE may be safe and effective to treat patients with gastric SMTs. Outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.
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Affiliation(s)
- Jia Liu
- Department of Gastroenterology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, P.R. China
| | - Yuyong Tan
- Department of Gastroenterology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, P.R. China
| | - Deliang Liu
- Department of Gastroenterology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, P.R. China
| | - Chenjie Li
- Department of Gastroenterology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, P.R. China
| | - Meixian Le
- Department of Gastroenterology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, P.R. China
| | - Hejun Zhou
- Department of Gastroenterology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, P.R. China
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Wang SF, Cheng HT, Hsu JT, Wu CH, Chen CW, Lin CJ, Sung KF. Simple and Reliable Method for Gastric Subepithelial Tumor Localization Using Endoscopic Tattooing before Totally Laparoscopic Resection. J Pers Med 2021; 11:855. [PMID: 34575632 PMCID: PMC8469339 DOI: 10.3390/jpm11090855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Totally laparoscopic surgery for early gastric cancer and subepithelial tumors has been popularized worldwide, yet localization of early or small-sized tumors is a persistent challenge due to difficulty being identified with the lack of manual tactile sensation. Thus, accurate localization with tattooing before the surgery would help improve efficiency during surgery. There are multiple methods to localize tumors before laparoscopy, each with varying advantages and disadvantages. The use of endoscopic tattooing with dye has been carried out for several decades due to its safety, lower cost, and convenience. However, there is a lack of studies on endoscopic tattooing before totally laparoscopic resection. AIMS To evaluate the effect of endoscopic tattooing with dye for gastric subepithelial tumors localization before laparoscopic resection and to evaluate the tattooing effect on different locations of tumors in stomach. METHOD We retrospectively collected data of patients with gastric subepithelial tumors who underwent endoscopic tattooing before totally laparoscopic resection from 2017 to 2020 in a university affiliated medical center. All patients were analyzed for preoperative characteristics and then categorized into two groups based on tumor locations concerning the difficulty of laparoscopic surgery. The independent t test and Chi-square test were performed to compare perioperative outcome and complications between these two groups. RESULT A total of 19 patients were included retrospectively at our center. The individuals were 5 male and 14 female patients with a mean age of 58.2 years old. Most patients had no symptoms, and the tumors were found incidentally in 12 patients (63%). All tumors were identified clearly during laparoscopic resection. The mean tumor size was 2.3 cm. The surgeries took an average of 111 min and a mean of 7 mL blood loss was found. All tumors had negative resection margins with no recurrence during follow-up. Gastrointestinal stromal tumor was the major pathologic diagnosis, found in 12 patients (63%), followed by the leiomyoma in 5 patients (26%). Only three patients had mild adverse effects after surgery and the symptoms were self-limited. Our analysis found no significant difference in preoperative patient characteristics and perioperative outcomes between patients with differing tumor locations. CONCLUSION This study is the first and largest report on endoscopic tattooing with dye before laparoscopic resection of gastric subepithelial tumor resection. Our results emphasize that endoscopic tattooing with dye is a safe and reliable method for localizing subepithelial tumors in the stomach prior to totally laparoscopic resection, with no correlation to where the tumor is located.
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Affiliation(s)
- Sheng-Fu Wang
- Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan; (S.-F.W.); (C.-H.W.); (C.-W.C.); (C.-J.L.)
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
| | - Hao-Tsai Cheng
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
- Department of Gastroenterology and Hepatology, New Taipei Municipal TuCheng Hospital, New Taipei City 236, Taiwan
| | - Jun-Te Hsu
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
- Department of General Surgery, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan; (S.-F.W.); (C.-H.W.); (C.-W.C.); (C.-J.L.)
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
| | - Chun-Wei Chen
- Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan; (S.-F.W.); (C.-H.W.); (C.-W.C.); (C.-J.L.)
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
| | - Chun-Jung Lin
- Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan; (S.-F.W.); (C.-H.W.); (C.-W.C.); (C.-J.L.)
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
| | - Kai-Feng Sung
- Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan; (S.-F.W.); (C.-H.W.); (C.-W.C.); (C.-J.L.)
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan 333, Taiwan; (H.-T.C.); (J.-T.H.)
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Tsuboi K, Yano F, Omura N, Misawa T, Kashiwagi H. Reduced-port surgery with the cowboy technique for a gastric submucosal tumor. Asian J Endosc Surg 2021; 14:154-157. [PMID: 32608164 DOI: 10.1111/ases.12826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/15/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Laparoscopic surgery is considered safe and effective for a gastric submucosal tumors, and reduced-port surgery (RPS) is being increasingly performed to treat these tumors. Herein, we present laparoscopic RPS with the cowboy technique for the removal of gastric submucosal tumors. MATERIALS AND SURGICAL TECHNIQUE A single-port access device was inserted at the naval (three 5-mm trocars), and a 5-mm trocar was inserted in the left lateral abdominal wall. A ligature was placed at the neck of the tumor, the loop was then tightened, and the knot was finally secured-a process referred to as the cowboy technique. This technique enables complete surgical excision and can be used for exophytic submucosal tumors of the stomach. Four patients underwent RPS with this technique, and the outcomes were good. DISCUSSION Our cowboy technique enables the safe full-thickness excision of gastric submucosal tumors with exophytic growth and is very useful in performing RPS.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, Kashiwa, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Saitama, Japan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University School of Medicine, Kashiwa, Japan
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Marcella C, Sarwar S, Ye H, Shi RH. Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract. Clin Endosc 2020; 53:458-465. [PMID: 32178486 PMCID: PMC7403013 DOI: 10.5946/ce.2019.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 11/21/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic treatment (ET) has been applied for decades to treat subepithelial tumors, including gastrointestinal stromal tumors (GISTs). However, the efficacy of ET remains debatable. In this study, we evaluated the efficacy and safety of ET for GISTs in the upper gastrointestinal tract. METHODS This retrospective single-center study included 97 patients who underwent ET. All patients were enrolled from July 2014 to July 2018. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time, total cost, and follow-up were investigated and analyzed. RESULTS Our study achieved 100% en bloc resection and 77.4% (72/93) R0 resection. The most common location was the fundus with a mean tumor size of 2.1±1.43 cm. The mean age, procedure time, hospital stay, and cost were 59.7±11.29 years, 64.7±35.23 minutes, 6.8 days, and 5,337 dollars, respectively. According to National Institutes of Health classification, 63 (64.9%), 26 (26.8%), 5 (5.2%), and 3 (3.1%) patients belonged to the very low, low, intermediate, and high risk classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 21.3±13.0 months showed no recurrence or metastasis. CONCLUSION ET is effective and safe for curative removal of GISTs in the upper gastrointestinal tract, and it can be a treatment of choice for patients with no metastasis.
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Affiliation(s)
- Cicilia Marcella
- Department of Gastroenterology, Southeast University Affiliated Zhongda Hospital, Nanjing, China
| | - Shakeel Sarwar
- Department of Orthopedics, Southeast University Affiliated Zhongda Hospital, Nanjing, China
| | - Hui Ye
- Department of Gastroenterology, Southeast University Affiliated Zhongda Hospital, Nanjing, China
| | - Rui Hua Shi
- Department of Gastroenterology, Southeast University Affiliated Zhongda Hospital, Nanjing, China
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Supsamutchai C, Setthalikhit T, Wilasrusmee C, Ovartchaiyapong P, Jirasiritham J, Choikrua P, Hiranyatheb P. Wedge gastrectomy: Robot-assisted with a hand-sewn repair versus a laparoscopic linear stapler technique for gastric subepithelial tumors. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2020. [DOI: 10.1016/j.lers.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Li J, Tang J, Lua GW, Chen J, Shi X, Liu F, Li Z. Safety and efficacy of endoscopic submucosal dissection of large (≥3 cm) subepithelial tumors located in the cardia. Surg Endosc 2017; 31:5183-5191. [PMID: 28597288 DOI: 10.1007/s00464-017-5585-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Upper gastrointestinal subepithelial tumors (SETs) may harbor potential malignancy. Although it is well recognized that large SETs should be resected, the treatment strategy remains controversial. Compared to surgical resection, endoscopic resection has many advantages such as less invasive, shorter hospital stay, lower costs, and better quality of life. However, Endoscopic resection of large SETs in the cardia is challenging. The purpose of this study was to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) in the treatment of such SETs. METHODS A total of 41 patients with large SETs (≥3 cm in diameter) located in the cardia were involved in the study. All patients underwent ESD. Data on therapeutic outcomes and follow-up were collected, for analysis of risk factors of complication rates. RESULTS The average tumor size was 4.7 ± 1.7 cm. The average procedure time was 69.3 ± 32.7 min and the average postoperative hospital stay was 3.5 ± 1.1 days. A total of 41 tumors were removed successfully, in which 35 were leiomyomas, three were gastrointestinal stromal tumors, two were lipomas, and one was gastritis cystica profunda. The en bloc resection rate was 90.2%, and was significantly higher for tumors with a round or oval shape (100%) than for those with an irregular shape (75.0%) (P < 0.05). Five patients experienced complications (12.2%), all of which were managed conservatively. The complication rates were significantly higher in patients with a tumor originating from the deep muscularis propria layer and demonstrating a trans-cardia growth pattern. No residual or tumor recurrence was observed and no stricture occurred during the follow-up period (average, 26.7 ± 18.4 months). CONCLUSIONS ESD is safe and effective to curatively remove most large SETs in the cardia, and may serve as an accurate histopathology measurement to direct future therapy.
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Affiliation(s)
- Jun Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jian Tang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - G W Lua
- Department of Gastroenterology, Raja Perempuan 2 Hospital, Kelantan, Malaysia
| | - Jie Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xingang Shi
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Feng Liu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Caron PHL, Martins MID, Bertevello PL. Preliminary analysis of hybrid laparoscopic procedure for resection of gastric submucosal tumors. Rev Col Bras Cir 2017; 43:129-35. [PMID: 27275595 DOI: 10.1590/0100-69912016002010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 03/18/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE to evaluate the feasibility, safety and benefits of minimally invasive surgery for resection of gastric submucosal tumor (GSMT). METHODS we conducted a retrospective study of medical records of patients undergoing endoscopy-assisted laparoscopic resection of gastric submucosal tumors (prospectively collected) from 2011 to 2014. We evaluated clinical data, surgical approach, clinicopathological characteristics of the GSMT (size, location, histopathological and immunohistochemical exams), outcome and patients follow-up. RESULTS we evaluated six patients, 50% male, mean age 52±18 years and common symptoms of heartburn and gastric fullness. All patients underwent hybrid procedure without anatomical impairment of the organ. The average length of stay was 3.5 days and the average size of the tumors was 2.0±0.8cm, five of them (83%) in the proximal third of the stomach. The surgical specimens pathological and immunohistochemistry examination revealed one case of ectopic pancreas (17%), one grade 2 neuroendocrine tumor (17%), one lipoma (17%), one GIST (17%) and two leiomyomas (32%). There were no episodes of tumor rupture or intraoperative complications and no conversion to open surgery. During the postoperative follow-up period, none of the patients had recurrence, metastasis, fistula or stenosis. CONCLUSION the results showed that endoscopy-assisted laparoscopic resection is feasible and safe for patients with GSMT. Endoscopy proved to be essential in the location of lesions and as intraoperative support, especially when attempting to preserve the pylorus and cardia during surgery. OBJETIVO avaliar a viabilidade, segurança e vantagens da cirurgia minimamente invasiva para ressecção de tumores submucosos gástricos (TUSG). MÉTODOS estudo retrospectivo dos prontuários de pacientes submetidos à ressecção videolaparoscópica assistida por endoscopia digestiva alta para tumores submucosos gástricos (coletados prospectivamente) de 2011 a 2014. Os fatores avaliados foram dados clínicos, abordagem cirúrgica, características clinicopatológicas dos TUSG (tamanho, localização, exame anatomopatológico e imuno-histoquímico), resultados e acompanhamento dos pacientes. RESULTADOS foram avaliados seis pacientes, 50% do sexo masculino, com média de idade 52±18 anos e sintomas comuns de pirose e plenitude gástrica. Todos os pacientes foram submetidos ao procedimento híbrido e sem comprometimento anatômico do órgão. O tempo médio de internação foi 3,5 dias e o tamanho médio dos tumores foi 2,0±0,8cm, cinco deles (83%) no terço proximal do estômago. Os exames anatomopatológicos e imuno-histoquímicos das peças cirúrgicas demonstraram um caso de pâncreas ectópico (17%), um tumor neuroendócrino grau 2 (17%), um lipoma (17%), um GIST (17%) e dois leiomiomas (32%). Não houve episódios de ruptura do tumor nem complicações intraoperatórias e nenhuma conversão para cirurgia aberta. Durante o período de acompanhamento pós-operatório nenhum dos pacientes apresentou recidiva, metástase, fístula ou estenose. CONCLUSÃO os resultados obtidos mostraram que a ressecção laparoscópica assistida por endoscopia é viável e segura para pacientes com TUSG. A endoscopia mostrou-se fundamental na localização das lesões e suporte intraoperatório, principalmente na tentativa de preservar a cárdia e o piloro durante a cirurgia.
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Affiliation(s)
- Pedro Henrique Lambach Caron
- Hospital Beneficência Portuguesa de São Paulo - Pro Gastro, São Paulo, SP, Brasil, Hospital Beneficência Portuguesa de São Paulo, São Paulo SP , Brasil
| | - Mariana Ismael Dias Martins
- Hospital Beneficência Portuguesa de São Paulo - Pro Gastro, São Paulo, SP, Brasil, Hospital Beneficência Portuguesa de São Paulo, São Paulo SP , Brasil
| | - Pedro Luiz Bertevello
- Hospital Beneficência Portuguesa de São Paulo - Pro Gastro, São Paulo, SP, Brasil, Hospital Beneficência Portuguesa de São Paulo, São Paulo SP , Brasil
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Lee CM, Park S. Laparoscopic techniques and strategies for gastrointestinal GISTs. J Vis Surg 2017; 3:62. [PMID: 29078625 DOI: 10.21037/jovs.2017.03.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/08/2017] [Indexed: 12/12/2022]
Abstract
The laparoscopic approach is widely accepted surgical treatment for gastrointestinal submucosal tumors (SMTs). In this chapter, we will introduce laparoscopic techniques and strategy for gastrointestinal SMTs, in accordance with those for gastrointestinal stromal tumors (GISTs). The indication for a laparoscopic approach has been related to tumor size. The upper limit of tumor size has increased, according to recent trends, and there is no established guideline for a lower limit. All patients undergoing laparoscopic surgery receive preoperative examinations including gastrofiberscopy, upper gastrointestinal radiography, computed tomography (CT), and endoscopic ultrasonography (EUS). Gastric tumors <20 mm in diameter measured by EUS or CT are preoperatively localized by gastrofiberscopic clipping of the mucosa covering the SMT. While maintaining the principle of local resection with a negative resection margin, different surgical techniques are required depending on the location and configuration of the tumor. A single dose of a second-generation cephalosporin is administered to patients as a prophylactic antibiotic before or immediately after operation. If a patient undergoes wedge resection, a semi-bland diet will be provided within 48-72 hours. However, in cases of proximal or distal gastrectomy, the diet will be restricted for several days. A "no-touch" technique, by which the risk of tumor dissemination can be minimized, includes grasping the surrounding tissues, holding the threads sutured at the normal serosa around the tumor, and using a laparoscopic stapler or bag during laparoscopic resection.
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Affiliation(s)
- Chang Min Lee
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Sungsoo Park
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Nasa M, Choksey A, Phadke A, Sawant P. Gastric lipoma: an unusual cause of dyspeptic symptoms. BMJ Case Rep 2016; 2016:bcr-2016-215297. [PMID: 27335362 DOI: 10.1136/bcr-2016-215297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Gastric lipomas are rare tumours accounting for 2-3% of all benign gastric tumours. These are usually submucosal in origin but in rare cases may be subserosal in origin. Although a majority of gastric lipomas are asymptomatic and usually detected incidentally, occasionally these can cause abdominal pain, dyspeptic disorders, obstruction, invagination and haemorrhages. In the literature, only 200 cases of gastric lipomas have been reported so far. We report a case of a 56-year-old female with a submucosal symptomatic gastric lipoma presenting with disabling dyspeptic symptoms.
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Affiliation(s)
- Mukesh Nasa
- Department of Gastroenterology, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Ajay Choksey
- Department of Gastroenterology, Vedant Hospital, Ahmedabad, Gujarat, India
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Kim SY, Kim KO. Management of gastric subepithelial tumors: The role of endoscopy. World J Gastrointest Endosc 2016; 8:418-424. [PMID: 27298713 PMCID: PMC4896903 DOI: 10.4253/wjge.v8.i11.418] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 04/28/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
With the wide use of esophagogastroduodenoscopy, the incidence of gastric subepithelial tumor (SET) diagnosis has increased. While the management of large or symptomatic gastric SETs is obvious, treatment of small (≤ 3 cm) asymptomatic gastric SETs remains inconclusive. Moreover, the presence of gastrointestinal stromal tumors with malignant potential is of concern, and endoscopic treatment of gastric SETs remains a subject of debate. Recently, numerous studies have demonstrated the feasibility of endoscopic treatment of gastric SETs, and have proposed various endoscopic procedures including endoscopic submucosal dissection, endoscopic muscularis dissection, endoscopic enucleation, endoscopic submucosal tunnel dissection, endoscopic full-thickness resection, and a hybrid approach (the combination of endoscopy and laparoscopy). In this review article, we discuss current endoscopic treatments for gastric SETs as well as the advantages and limitations of this type of therapy. Finally, we predict the availability of newly developed endoscopic treatments for gastric SETs.
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Efficacy and safety of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors: a systematic review and meta-analysis. Surg Endosc 2016; 31:49-63. [PMID: 27287907 DOI: 10.1007/s00464-016-4978-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/09/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND In recent years, submucosal tunneling endoscopic resection (STER) has emerged as a novel therapeutic endoscopic technique for upper gastrointestinal submucosal tumors (SMTs). The aim of this study was to evaluate the safety and efficacy of STER for upper gastrointestinal SMTs. METHODS A systematic search of both English and Chinese databases was performed until November 15, 2015. Complete resection and en bloc resection rates were considered the primary outcome measures. Prevalence of complications was considered the secondary outcome measure. A random-effects model was used to generate conservative estimates of the prevalence of the main outcome variables. All data analyses were performed using Meta-Analyst software (version beta 3.13). RESULTS A total of 28 studies were included in the final meta-analysis. The pooled complete resection and en bloc resection rates were 97.5 % (95 % CI 96.0-98.5 %) and 94.6 % (95 % CI 91.5-96.7 %), respectively. The common complications associated with STER were air leakage symptoms and perforation. The pooled prevalence of air leakage symptoms was 14.8 % (95 % CI 10.5-20.5 %) for subcutaneous emphysema and pneumomediastinum, 6.1 % (95 % CI 4.0-9.0 %) for pneumothorax and 6.8 % (95 % CI 4.7-9.6 %) for pneumoperitoneum. Additionally, the pooled prevalence of perforation was 5.6 % (95 % CI 3.7-8.2 %). Only a few cases of bleeding were reported in two studies. CONCLUSIONS STER is a highly feasible and safe treatment option for upper gastrointestinal SMTs.
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Namikawa T, Hanazaki K. Laparoscopic endoscopic cooperative surgery as a minimally invasive treatment for gastric submucosal tumor. World J Gastrointest Endosc 2015; 7:1150-1156. [PMID: 26468339 PMCID: PMC4600181 DOI: 10.4253/wjge.v7.i14.1150] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/05/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Laparoscopic wedge resection is a useful procedure for treating patients with submucosal tumor (SMT) including gastrointestinal stromal tumor (GIST) of the stomach. However, resection of intragastric-type SMTs can be problematic due to the difficulty in accurately judging the location of endoluminal tumor growth, and often excessive amounts of healthy mucosa are removed; thus, full-thickness local excision using laparoscopic and endoscopic cooperative surgery (LECS) is a promising procedure for these cases. Our experience with LECS has confirmed this procedure to be a safe, feasible, and minimally invasive treatment method for gastric GISTs less than 5 cm in diameter, with outcomes similar to conventional laparoscopic wedge resection. The important advantage of LECS is the reduction in the resected area of the gastric wall compared to that in conventional laparoscopic wedge resection using a linear stapler. Early gastric cancer fits the criteria for endoscopic resection; however, if performing endoscopic submucosal dissection is difficult, the LECS procedure might be a good alternative. In the future, LECS is also likely to be indicated for duodenal tumors, as well as gastric tumors. Furthermore, developments in endoscopic and laparoscopic technology have generated various modified LECS techniques, leading to even less invasive surgery.
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