Feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body endoscopic submucosal dissection: A porcine model

Sang-Ho Jeong, Ji-ho Park, MD, Young-Joon Lee, MD, Chang Yoon Ha, MD, Sang-Kyung Choi, MD, Soon-Chan Hong, MD, Eun-Jung Jung, MD, Young-tae Ju, MD, Chi-Young Jeong, MD, Woo-Song Ha, MD

Department Surgery, Department Internal Medicine of Postgraduate School of Medicine, Gyeongsang National University, Jinju, South Korea

Background: The incidence of early gastric cancer has been increasing in the Republic of Korea and Japan owing to the presence of national cancer screening programs. However, cancer of the upper body of the stomach is mostly operated on with total gastrectomy even if the tumor is within the absolute criteria of endoscopic submucosal dissection (ESD), because of the high complication rate of ESD.We planned this study to investigate a new approach in the endoscopic treatment of early gastric cancer of the upper body of the stomach.To verify (i) the feasibility of the trans-umbilical route compared with the transoral route in gastric upper body ESD and (ii) the non-inferiority of single-port LLND compared with conventional multiport LLND and (iii) the safety of 2-basin LLND (upper greater and lesser curvature) using survival porcine models.

Methods: We separated healthy female White Landrace pigs (approx. 40 kg each) into 2 groups: conventional and experimental (n = 5 per group). We performed trans-oral ESD in 2 areas (fundus and upper body anterior wall, UBAW) and multiport LLND (LN 1, 2, 3, 4sa, 4sb) in the conventional group. We also performed trans-umbilical ESDs in the same areas by gastrostomy using OCTO Port (OT301; Dalim Surg Net, Seoul, Republic of Korea). We chose the gastrostomy site that corresponds to the greater curvature side of the antrum anterior wall in humans, under pneumoperitoneum. We retracted the stomach and performed gastrostomy. We inserted the OCTO Port through the gastrostomy site to create a pneumoperitoneum. A single-port LLND was also performed in the same areas in the experimental group by using double-bend instruments.

Results: The completion rates, tissue weights, and specimen diameters of both routes had no statistical differences in both the fundus and UBAW. The operation time was shorter with the trans-umbilical route than the trans-oral route in both areas (p < 0.05). In LLND, there were no differences in surgical outcomes between the multiport and single-port groups. One case of intraoperative perforation, in both the fundus and UBAW areas, was seen in the trans-oral route group; however, there was no perforation in the trans-umbilical group. There were 2 cases of delayed perforation in the trans-oral route group and 1 case in the trans-umbilical route group. In the trans-oral group, 1 case showed an impending perforation in the fundus ESD site, which had necrotic change without wound healing, and another case showed perforation in the UBAW ESD site with peritonitis. In the trans-umbilical group, one case showed perforation in the UBAW ESD site without peritonitis, due to adhesion of the liver.

Conclusions: The trans-umbilical route resulted in shorter operation times and lesser complication rates than the trans-oral route in gastric upper body ESD. We also found that single-port upper body perigastric LLND is not inferior to conventional multiport LLND in terms of operation times, resection rates, and tissues weights. Additionally, one-side-basin dissection is safer than 2-basin dissection in gastric upper body sentinel LLND due to delayed perforation.

Session: Poster Presentation

Program Number: ETP003

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