Hybrid Natural Orifice Transluminal Endoscopic Surgery: Laparoscope-assisted Endoscopic Full-thickness Resection of Gastric Gist

Masao Fujiwara, MDPhD, Hirohito Mori, MDPhD, Yuji Nishizawa, MDPhD, Akihiro Kondo, MD, Keiichi Okano, MDPhD, Tsutom Masaki, MDPhD, Yasuyuki Suzuki, MDPhD. Department of Gastroenterological Surgery and Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan.

Natural orifice transluminal endoscopic surgery (NOTES) is a minimally invasive surgery, but the procedures using only a flexible endoscope are technically demanding. We have performed hybrid NOTES with laparoscope-assisted endoscopic full-thickness resection for 14 patients with a gastric gastrointestinal stromal tumor (GIST). Briefly, the tumor is resected with a full-thickness gastric wall endoscopically with the aid of a laparoscope. Then, suture closure of the stomach is completed laparoscopically. The specimen is usually removed through the mouth. All the tumors were resected en bloc with a negative surgical margin. Histologically, 3 cases were classified in the high-risk group, 2 in the medium-risk group, and 9 in the low-risk group according to Fletcher’s criteria. The mean tumor size was 27.5 mm (range 10 – 60 mm). Seven tumors were located in the upper stomach and 6 were in the middle stomach. The mean operating time and estimated blood loss were 305 min (range 205 – 420 min) and 4.2 ml (range 0 – 20 ml), respectively. The median hospital stay was 10 days (range 7 – 13 days). No cases were converted to open gastrectomy. The postoperative course was uneventful in all cases with no anastomosis leakage, stenosis, or bleeding. During a mean observation period of 19 months (range 3 – 35 months), no recurrence was detected in this series. We conclude that hybrid NOTES for resection of gastric GIST can be performed safely and that the success of this procedure does not depend on the tumor location.

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