Hybrid-Notes for Gastric Gist

Masanobu Hagiike, MD PhD, Hironori Mori, MD, Norikatsu Maeda, MD, Hironobu Suto, MD, Minoru Oshima, MD, Naoki Yamamoto, MD, Hirotaka Kashiwagi, MD, Shintaro Akamoto, MD, Keitaro Kakinoki, MD, Masao Fujiwara, MD, Takehiro Takama, MD, Keiichi Okano, . Dept of Gastroenterological Surgery and Endoscopy Center, Kagawa Univ., Japan

(Introduction) Basic surgical treatment for GIST is complete excision of the tumor. We performed 3 cases of gastric GIST excision by Hybrid-NOTES (H-NOTES) using the combination of endoscopic resection and laparoscopic procedure in cooperation with gastroenterologists. H-NOTES facilitates the identification of GIST from in and outside of the stomach and adequate surgical margin can be obtained without unexpected gastric deformity by unnecessary over resection.
(Technique) Insert a laparoscope from umbilical port and required laparoscopic procedures i.e. adhesiolysis, mesenteric resection and so forth were done prior to the endoscopic resection. Then, flexible endoscope is inserted per os and duodenal bulb is occluded by endoscopic balloon. Endoscopic full-thickness resection for GIST is performed using endoscopic submucosal resection technique with laparoscopic intervention. Gastric closure is done by laparoscopic intracorporeal suturing or automatic suture instruments to avoid the huge gastric deformity.
(Results) Surgical margin was enough for complete resection and gastric deformities were minimal to preserve its function. All patients were discharged without major complications.
Case 1: corpus anterior wall: Endoscopic resection was very easy, however, bleeding from muscle layer was technically impossible by endoscope. Laparoscopic hemostasis using LCS could help this trouble and the bleeding was controlled. Tumor was 2cm in diameter and collected orally. Gastric closure was done by hand sewn with single full layer.
Case 2: corpus posterior wall: Laparoscopic anterior wall hanging was needed during endoscopic full-thickness resection. LCS was useful for hemostasis and lymphatic tissue resection. Tumor was 4cm and collected from umbilical site. Gastric closure was also done by hand sewn with single full layer.
Case 3: fornix: Patient was placed right semi-lateral position and started with laparoscopic resection of gastro-splenic ligament. Endoscopic and laparoscopic procedures were simultaneously done for appropriate resection of GIST. Tumor was 5cm and collected from umbilical port. Gastric closure was done by automatic suture device under endoscopic intervention to avoid the stenosis of cardia.
(Conclusion) H-NOTES is feasible and useful procedure for gastric GIST to minimize postoperative gastric deformity without losing the curability.