Combined Endoscopic and Laparoscopic Intragastric Tumor Removal: An Applied Technique to Manage Submucosal Gastric Tumor Located Next to the Ej Junction

Suriya Punchai, MD, Suppa-ut Pungpapong, MD, Chadin Tharavej, MD, Patpong Navicharern, MD, Suthep Udomsawaengsup, MD. Chula Minimally Invasive Surgery Center Chulalongkorn University, Bangkok, Thailand

 Introduction: Gastric submucosal tumor is arising from deeper layers of the stomach wall. Overlying mucosa is not involved and gastric biopsy provides less yields. Endoscopy and also endoscopic ultrasonography are complementary to make a diagnosis. Treatment of these tumors is depending on its location. Laparoscopic resection is usually applied but in some specific areas such as lesions located next to the EG junction, the management is challenging. The combined endoscopic and laparoscopic intragastric tumor resection is theoretically benefited to manage this specific situation.
Material and methods: The procedure started with the completing diagnostic endoscopy. Tumor was located and CRE dilator was then applied to occlude the pylorus to allow gastric inflation. Laparoscopic part was followed in step. Five-mm. blunt tip trocar was carefully inserted directly into the gastric lumen using a safe track technique. Follow by the introduction of another two 5-mm trocars into the intragastric cavity. Five-mm, 30 degree laparoscope; laparoscopic dissector forceps and Halmonic scalpel were applied to conduct the resection. Cure was to keep the tumor intact with free margin. Bleeding was secured and intragastric suturing was deployed. Tumor was then retrieved endoscopically. Finally, trocars were reduced into the peritoneal cavity and gastric defects were repaired laparoscopically. Outcomes were analyzed.
Results: From March 2010 to March 2011, there were 7 patients presented with submucosal gastric tumor that located next to the EG junction underwent combined Endoscopic and Laparoscopic intragastric tumor resection. Five were female. Mean age was 59 years (46-82). All patients were successfully done with the procedures. Operative time was 120 minutes (95-180). Operative blood loss was 70 ml (10-200). Tumor size was 1.9 cm (1-2.5). Pain score on the first operative date was 3.8 (2-5). Mean hospital stay was 4.4 days (range; 3-6). Pathologically, there were 4 GISTs, 2 leiomyomas and one carcinoid . The recovery was uneventful. There was no operative morbidity and mortality.
Conclusion: Combined endoscopic and laparoscopic intragastric submucosal resection is feasible and safe for management of submucosal tumor of stomach located next to the esophagogastric juction

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