Laparoscopic assisted approach for gastrointestinal malignancies. Intraluminal surgery.

Miguel A Hernandez, MD, Morris E Franklin Jr., MD, FACS, Jeffrey L Glass, MD, FACS. Texas Endosurgery Institute

Background: Intraluminal surgery began with the advent of endoscopy. Endoscopic intraluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopic assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a field endoscopic intraluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and the inability to obtain adequate margins without risking perforation. These cancers potentially can be treated by laparoscopic assisted intraluminal surgery without resorting to major gastric or duodenal resection. We present the experience of the Texas Endosurgery Institute in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors.

Materials and methods: the data for all patients with early gastric and duodenal cancers who underwent laparoscopic assisted intraluminal surgery at Texas Endosurgery Institute between January 1996 and August 2014 were prospectively recorded. All the patients were referred by endoscopists as noncandidates for endoscopic resection. We prospectively collected the following data: preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology and recurrence rate. All patients underwent intraluminal port placement under direct visualization after establishment of pneumoperitoneum. Operations were performed in conjunction with upper endoscopy for assistance with port placement under intraluminal visualization, insufflation and specimen retrieval. After the intraluminal portion of the operation was completed, the intraluminal port sites were closed with laparoscopic intracorporeal sutures or staples.

Results: From January 1996 and January 2014 a total of 24 patients underwent laparoscopic intraluminal surgery. The procedures consisted of 10 resections for early gastric cancer (stage I), 6 wedge resections for carcinoid tumor, 4 resections for duodenal adenocarcinoma and 4 resections for malignant polyps at the gastroesophageal junction. All procedures were completed successfully with disease free margins. No recurrence of the original pathology has been reported and the complications were minimal.

Conclusion: Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapy. It is associated with a lower incidence of incisional hernia formation and a lower infection rate.