The aim of this study was to investigate the use of non-exposure endoscopic wall-inversion surgery (NEWS) and the combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET) in gastric tumors.
We reviewed all cases of NEWS and CLEAN-NET performed in the department of surgery of the Royal Vinohrady Teaching Hospital.
Our department performed 12 gastric tumor resections (NEWS,
NEWS and CLEAN-NET allow
Laparoscopic wedge resections have become an accepted mini-invasive surgical technique for resecting gastrointestinal stromal tumors (GIST) of the stomach [
Endoscopic submucosal dissection (ESD) circumvents this problem, as it directly visualizes the tumor from within the stomach. However, it often fails to achieve negative resection margins, as it does not remove the muscular layer or serosa of the stomach. Endoscopic full-thickness resections and laparoscopic-endoscopic cooperative surgery can remove the stomach wall in its full thickness. However, in doing so, they allow communication between the stomach lumen and peritoneal cavity, which brings the risk of infection and dissemination of tumor cells into the peritoneal cavity. Thus, non-exposure laparoscopic-endoscopic cooperative surgery was developed. Non-exposure techniques do not create communication between the gastric lumen and the peritoneal cavity; thus, they prevent peritoneal seeding and infection. In addition, as they visualize the tumor from the gastric lumen, can accurately achieve negative resection margins [
The first of these non-exposure techniques was developed by Inoue et al. in 2012 and is called “combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique” (CLEAN-NET) [
Twelve localized gastric tumor resections (NEWS,
The surgical protocol was approved by the ethics commission of the University Hospital Královské Vinohrady. All the patients included in the study provided informed consent for the examination and procedure.
The locations of the tumors were established using a flexible endoscope, and the lesion margins, including a safety rim, were marked using coagulation (DualKnife, KD-650L; Olympus Medical Systems, Tokyo, Japan). Following this, the extent of the tissue to be resected was marked on the serosal surface of the stomach. This was performed laparoscopically using a coagulation hook under guidance from the endoscope by applying pressure with the end of a DualKnife against the internal surface of the gastric wall. ESD was then performed, with the injection of saline, glycerol, and methylene blue solution in the coagulation marks peripherally around the tumor lesion. The serosa and muscle layer, including a safety margin, were dissected laparoscopically using the coagulation hook cutting settings. At this point, the lesions were located purely on the gastric mucosa itself and were then inverted into the gastric lumen. The stomach was then desufflated, and the gastric wall defect closed with uninterrupted sutures by using a Vicryl 3/0 thread in a single layer. The endoscopist then completed the resection using the ESD technique by dissecting the mucosa (muco-submucosa) externally from the coagulation marks, employing the DualKnife and IT Knife (KD-611L; Olympus Medical Systems). After investigating the suture integrity, the detached lesions were extracted perorally with a loop or a net (Roth Net polyp retriever; US Endoscopy, Mentor, OH, USA).
A single Redon drain was placed into the abdominal cavity at the end of each procedure and a final endoscopic inspection of suture sufficiency and resection line hemostasis was performed. After this, the laparoscopic ports were extracted and the capnoperitoneum was terminated. A nasogastric tube was placed into the patients’ stomachs and left for 24 hours after the operation, and, in accordance with the patient’s tolerance levels, sipping was initiated on the first postoperative day. All patients received proton pump inhibitors for the entire duration of the perioperative period.
The patients’ characteristics are summarized in
Histopathological findings are summarized in
All GISTs were spindle cell subtypes. All measured between 2 and 5 cm in diameter (stage T2) and had mitotic indexes of <5 per 50 high-power fields (grade 1). Thus, according to the Miettinen criteria, the risk of recurrence in all the cases was 1.9%.
Both early gastric cancers met the extended criteria for endoscopic resection according to the European Society of Gastrointestinal Endoscopy guidelines [
The surgical details are summarized in
No major intraoperative complications occurred. One patient had intraoperative bleeding from the resection line on the mucosal side, which was treated endoscopically with the application of hemoclips and Coagrasper forceps (Olympus Medical Systems). This was the longest NEWS procedure; the operation time was 120 minutes, and blood loss was 220 mL. No other intraoperative complications occurred, and in all the other cases, blood loss was <50 mL.
Postoperative complications occurred in two patients. In patient 4, a case of early postoperative bleeding from the resection line on the mucosal surface occurred. This was detected on the first postoperative day by the appearance of blood coming out of the nasogastric tube. Vital signs remained unchanged, and a fall in hemoglobin concentration did not occur. This patient was not receiving anticoagulant medication at the time of the bleeding. Urgent gastroscopy was performed on the same day, and the lesion was treated with argon plasma coagulation and hemoclips. Patient 3 developed a late, infected subcapsular hematoma of the left lobe of the liver, which was treated with CT-controlled percutaneous drainage. The mean postoperative period of hospitalization was 6.8 days (range, 4–10 days) for the entire cohort, 6.8 days (range, 5–10 days) for the NEWS procedures, and 6 days (range, 4–10 days) for the CLEAN-NET procedures.
Anastomotic insufficiency, late bleeding, perforation, delayed gastric emptying, and early superficial surgical site infections did not occur in any of the patients. Three months after the procedures, the patients underwent gastroscopy, which showed no signs of relapse or other pathology at the resection line. Following the procedure, all the patients remained asymptomatic with no need for dietary modifications or other changes.
Our study presents a cohort of patients who underwent operation at the University Hospital Královské Vinohrady between March 2016 to February 2017. In our experience, the most challenging part of these procedures is marking the lesion margins on the serosal surface of the stomach. This can be problematic especially after significant stomach desufflation, which makes the serosal markings difficult to identify. Such cases require deeper coagulation by the DualKnife.
The seromuscular laparoscopic incision is fairly easily performed with the use of the coagulation hook’s cutting setting, which proved to be most useful for this technique. As the dye injected in the submucosal space disperses into the gastric wall, it does not accurately delineate the tumor margins and thus makes the laparoscopic seromuscular incision more difficult to perform. The first few procedures revealed that it is rather difficult to correctly identify the necessary depth of the seromuscular incision, which needs to be sufficiently deep and extend all the way under the muscularis mucosae to allow for a simple inversion of the lesion into the gastric lumen. If resection line bleeding occurs or if lymph node sampling is required, we recommend using the LigaSure sealer.
Both CLEAN-NET and NEWS have their own advantages and disadvantages. The choice of technique is based on the size, location, and direction of tumor growth. Lesions with diameters >4 cm are difficult to remove endoscopically; thus, CLEAN-NET is preferred in these cases. However, if only one dimension is larger than 4 cm, it can still be easily removed endoscopically as long as the other two dimensions are <4 cm and the largest dimension is passed along the long axis of the lumen of the esophagus. Tumors on the posterior wall are difficult to resect endoscopically. On the contrary, NEWS is preferable for tumors in the subcardial part of the stomach and the pyloric region, where a laparoscopic approach is limited and technically demanding.
Endophytic tumors are better visualized using the endoscope and thus more easily removed using NEWS, whereas exophytic tumors are best visualized using the laparoscope and removed using CLEAN-NET. A further consideration to take into account when choosing the most suitable operative technique is cost; CLEAN-NET is considerably more expensive, as it necessitates the use of laparoscopically placed staples to resect the lesion. See
Although our data supports the fact that these mini-invasive techniques are relatively safe, precise, and technologically achievable, a much larger patient cohort will be needed to fully estimate the long-term safety of these procedures. However, the already published works clearly show that these techniques are effective and preserve the full function of the involved organs, which, without doubt, will be a significant future contribution to patients’ well-being.
A significant benefit of these techniques is their ability to produce full-thickness resection while minimizing the risk of cancer cell dissemination. It is also becoming clear that apart from submucosal lesions, these procedures can be a suitable modality for the treatment of early gastric carcinomas with low risk of lymph node involvement. However, the recommended follow-up method for patients where R0 resection was not achieved or where lymph node sampling is positive remains unclear. Where our patient cohort was concerned, this question need not be addressed. However, in the future, most definitely, recommended steps (e.g., radicalization of the procedure or application of adjuvant chemotherapy) need to be formulated. These decisions will surely be made on the basis of a multidisciplinary team, similarly to the decisions about indications for the procedure.
These new combined laparoscopic-endoscopic non-exposure techniques can bring significant benefits to patients with GIST or early gastric carcinomas, fully preserving the functions of the afflicted organs. This study should be followed up by larger case-controlled comparative studies to prove the benefit of these procedures.
This work was supported by the Research Project PROGRES-Q28, awarded by Charles University in Prague.
Position of the team.
Non-exposure endoscopic wall-inversion surgery. (A) Endoscopic view of a gastrointestinal stromal tumor of the stomach. (B) Marking the lesion with electrocautery. (C) Injection of methylene blue dye into the lesion. (D) Visualisation of the stained lesion on the serosal surface of the stomach. (E) A circumferential seromuscular incision around the lesion. (F) A suture placed around the lesion. (G) Inversion of the tumor into the stomach. (H) Circumferential muco-submucosal dissection. (I) Hemostatic clips applied to the stomach wall to achieve hemostasis.
Combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique. (A) Endoscopic view of a gastrointestinal stromal tumor of the stomach. (B) Marking the lesion with electrocautery. (C) Injection of methylene blue dye into the lesion. (D) A circumferential seromuscular incision. (E) Sutures placed around the lesion. (F) The tumor with the surrounding submucosa elevated away from the stomach wall. (G) Resection of the tumor with a stapler. (H) Suture of the stomach wall on the serosal surface. (I) Suture of the stomach wall on the mucosal surface.
Patient Characteristics and Histopathological and Surgical Details
Patient no. | Age (yr) | Sex | BMI (kg/m2) | Symptoms | Tumor type | Location | Diameter (mm) | Technique | Operation time (min) | Intraoperative complications | Postoperative complications | Length of hospitalisation (days) |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 73 | M | 30.8 | Asymptomatic | Ectopic pancreatic tissue | Anterior wall of antrum | 29 | NEWS | 80 | - | - | 6 |
2 | 73 | M | 26.6 | Asymptomatic | Lipoma | Prepyloric region | 70 | NEWS | 115 | - | - | 6 |
3 | 53 | M | 38.7 | Abdominal pain | Vanek's tumor | Prepyloric region | 29 | NEWS | 120 | Resection line bleeding | Infected liver hematoma | 6 |
4 | 60 | M | 27.4 | Anemia | Neuroendocrine tumor | Anterior wall of body | 30 | NEWS | 90 | - | Resection line bleeding | 6 |
5 | 54 | F | 31.4 | Asymptomatic | EGC | Posterior wall, upper body | 26 | NEWS | 70 | - | - | 5 |
6 | 60 | F | 39.1 | Abdominal pain | EGC | Posterior wall, middle body | 28 | NEWS | 105 | - | - | 7 |
7 | 68 | F | 34.2 | Anemia | GIST | Posterior wall, lower body | 45 | CLEAN-NET | 180 | - | - | 10 |
8 | 71 | M | 26.9 | Asymptomatic | GIST | Subcardial region | 22 | NEWS | 95 | - | - | 7 |
9 | 70 | F | 25.3 | Asymptomatic | GIST | Posterior wall, middle body | 35 | NEWS | 115 | - | - | 8 |
10 | 62 | F | 17.9 | Asymptomatic | GIST | Posterior wall, fundus | 30 | NEWS | 100 | - | - | 7 |
11 | 80 | F | 26.6 | Asymptomatic | GIST | Subcardial region | 28 | NEWS | 105 | - | - | 10 |
12 | 83 | F | 30.9 | Anemia | GIST | Posterior wall, upper body | 30 | CLEAN-NET | 120 | - | - | 4 |
BMI, body mass index; NEWS, non-exposure endoscopic wall-inversion surgery; EGC, early gastric cancer; GIST, gastrointestinal stromal tumors; CLEAN-NET, combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique.
Comparison of CLEAN-NET and NEWS
CLEAN-NET | NEWS | |
---|---|---|
Size | >4 cm | <4 cm |
Location | Posterior wall | Pyloric and subcardial regions |
Accuracy of resection | Lower | Higher |
Cost | More expensive | Cheaper |
Direction of tumor growth | Exophytic | Endophytic |
Operation time | Longer | Shorter |
CLEAN-NET, combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique; NEWS, non-exposure endoscopic wall-inversion surgery.