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Method Article
The article introduces the surgical method, endoscopic submucosal dissection (ESD) for the complete removal of intra-abdominal tumors using natural orifice transluminal endoscopic surgery (NOTES). The procedure reaches the stomach by using gastrointestinal endoscopy, creating a controlled perforation for tumor removal, followed by stitching the gastric incision.
Gastrointestinal stromal tumors (GISTs) typically occur in the stomach and proximal small intestine but can also be found in any other part of the digestive tract, including the abdominal cavity, albeit rarely. In the present case, the tumor was resected endoscopically through the anterior gastric wall. Computed tomography (CT) scan and gastroscopy of a 60-year-old woman revealed submucosal lesions in the gastric body. The possibility of a stromal tumor was considered more likely. The endoscopic surgery was performed under endotracheal anesthesia. After a solution had been injected at the lesion site in the stomach, the entire gastric wall was dissected to expose the tumor. As the lesion was in the abdominal cavity and its base was attached to the abdominal wall, it was accessed using a sterilized PCF colonoscope. A sodium chloride injection was administered at the base. The tumor was then peeled along its boundaries using the hooking and excision knife combined with the precutting knife. Subsequently, the tumor was pulled into the stomach through the incision made in the stomach and then extracted externally through the upper digestive tract using the ERCP spiral mesh basket. After confirming the absence of bleeding at the incision site, the endoscope was returned to the stomach, and the stomach opening was closed using purse-string sutures. The patient recovered satisfactorily following the surgery and was discharged on day 4. Histological examination revealed a low-risk stromal tumor (spindle cell type, <5 mitosis/50 high-power fields [HPF]). Immunohistochemistry revealed positive staining for CD34 and CD117, negative staining for SMA, positive staining for DOG1, and negative staining for S100. Additionally, the expression of ki67 was 3%.
Gastrointestinal stromal tumors (GISTs) originate from the mesenchymal tissue of the gastrointestinal wall. GISTs contain pluripotent mesenchymal stem cells and exhibit the potential for malignant behavior. GISTs can manifest in various locations along the digestive tract, with the stomach being the most common site, and occasionally appear in the omentum, mesentery, and peritoneum. Histologically, GISTs contain spindle cells, epithelioid cells, and occasionally pleomorphic cells arranged in a bundle-like or diffuse pattern, reflecting their non-directional differentiation. GIST risk is stratified based on tumor size and nuclear mitotic count1.
Historically, surgical interventions for GISTs primarily comprised open surgery and laparoscopic procedures2. However, recent advancements in digestive endoscopic treatment techniques introduced the possibility of endoscopic resection for certain GISTs, either alone or combined with laparoscopy3. Digestive endoscopy uses the natural body orifices to minimize interference with the abdominal cavity, leading to quicker recovery compared to traditional or laparoscopic surgery. Furthermore, developing active perforation and endoscopic suturing techniques enables endoscopy to access the abdominal cavity and effectively remove intra-abdominal lesions following the principles of natural orifice transluminal endoscopic surgery (NOTES). Endoscopic resection of GISTs is based on endoscopic submucosal dissection (ESD) and tunnel endoscopy techniques. Through endoscopic examination, gastrointestinal tumors or lesions can be precisely located within the digestive lumen. The endoscopic instruments are then used to accurately incise the mucosa, identify lesions located in the submucosal layer, intrinsic muscle layer, or even originating from the serosal layer, and completely remove them along the borders of the lesions. Due to the minimally invasive nature of endoscopy, there is minimal disturbance to the abdominal cavity. Compared to traditional surgery, endoscopic techniques not only ensure the complete removal of lesions but also maximize the preservation of the integrity and continuity of the digestive tract. Patients can resume early oral intake, experience quick recovery, and have significantly shortened hospital stays.4,5,6 With the development of endoscopic active perforation and endoscopic suturing techniques, endoscopy can penetrate into the abdominal cavity through natural orifices, explore and resect intra-abdominal lesions, achieving the effects of NOTES7,8.
As endoscopic treatment techniques continue to evolve, along with related instrument refinement and increased focus on screening, endoscopic submucosal resection is poised to become a mainstream approach for managing such lesions. This article reports a case of a rare intra-abdominal GIST adjacent to the stomach. Successful tumor resection was achieved using digestive endoscopic treatment techniques, showcasing the potential of endoscopy in this domain.
This protocol follows the ethical principles of the Shantou Second People's Hospital and has obtained approval from the Hospital Ethics Committee, as well as informed consent from both patients and their families for this study and related videos.
1. Preoperative preparation and surgical approach planning for GIST resection
2. Aseptic preparation for GIST resection surgery
NOTE: Meticulous adherence to aseptic principles is paramount during such surgeries, given the presence of bacteria within the upper gastrointestinal tract juxtaposed with the sterile nature of the abdominal cavity. This condition necessitates stringent measures to maintain sterility.
3. Prophylactic antibiotic administration for preoperative care
4. Instrumentation and equipment considerations
5. Operation procedure
6. Postoperative care and follow-up
With meticulous preoperative groundwork in place, digestive endoscopic treatment techniques and the innovative approach of controlled perforation have facilitated the feasibility of intraperitoneal GIST resection adjacent to the stomach. Notably, this surgical approach not only features rapid postoperative recovery but also capitalizes on the merits of NOTES.
The fusion of advanced endoscopic methodologies and innovative techniques has redefined the GIST resection landscape. This approach is c...
Despite the demonstrated efficacy of targeted agents such as imatinib for treating GISTs1,2, surgical resection remains the primary therapeutic approach for primary GISTs2,9. Recent advancements in endoscopic diagnostic and therapeutic techniques combined with the evolution of NOTES principles have generated a spectrum of intracavitary endoscopic surgical techniques7,
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Name | Company | Catalog Number | Comments |
Disposable Endoscope Injection Needle | Boston Scientific Corporation | ||
Dual knife | Olympus | KD-650L | |
Endoscopic Ligation Device (Nylon Suture) | Leao Company | ||
IT2 knife | Olympus | KD-611L | |
Olympus 290 Host System | Olympus | ||
Olympus Endoscope Dedicated Insufflator | Olympus | ||
Olympus Endoscope Dedicated Water Pump | Olympus | ||
Olympus Therapeutic Gastroscope GIF-Q260J | Olympus | GIF-Q260J | |
Rotatable Reusable Endoscope Metal Clip | Nanjing Micro-Invasive Medical Co., Ltd |
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