This work was supported by the National Natural Science Foundation of China (No. 82172637), the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (No. 2021-JKCS-004) and the Guangdong Provincial Key Laboratory of Digestive Cancer Research (No. 2021B1212040006).

This study was conducted with the approval of the Research Ethics Committee (Institutional Review Board) of The First Affiliated Hospital, Sun Yat-sen University (Guangzhou, China) (No. 2022085) and the Seventh Affiliated Hospital, Sun Yat-sen University (Shenzhen, China) (No. KY-2022-006-01).
1. Preoperative preparation
<ol>
	<li>Put the patient on 3 h of preoperative fasting for fluid and 6 h fasting for solid food.</li>
	<li>Administer general anesthesia via tracheal intubation.</li>
	<li>Administer prophylactic antibiotics with second-generation cephalosporins 30 min before surgery.</li>
</ol>
2. Gastroscopic exploration
<ol>
	<li>After administering general anesthesia, perform gastroscopy on the patient with CO2 insufflation.</li>
	<li>Next, aspirate the residual gastric fluid, and confirm the location of the tumor.</li>
	<li>After the exploration, completely aspirate the CO2 and fluid in the stomach and the fluid and mucus in the esophagus and throat. 
	NOTE: In this hospital, GI surgeons perform gastroscopy.</li>
</ol>
3. Laparoscopic exploration
<ol>
	<li>Place the patient in a supine position with legs open. Have the surgeon stand to the left, the assistant to the right, and the camera holder between the patient&#39;s legs.</li>
	<li>Use a four-trocar method with two 10 mm and two 5 mm trocars, and apply a CO2 pressure of 10 to 12 mmHg.</li>
	<li>First, confirm the location and boundary of the tumor in the stomach with the help of gastroscopy, if necessary. Then, perform a wide intraabdominal exploration to exclude any other lesions.</li>
</ol>
4. Laparoscopic tumor resection guided by gastroscopy
<ol>
	<li>Dissect the omentum tissue around the mass. Ensure the dissection plane is just above the muscle to avoid vagal trunk injury.</li>
	<li>Resect the mass en bloc with a 5 mm visual negative margin.</li>
	<li>After resection, place the specimen in the gastric cavity through the gastric wall defect. 
	&#8203;NOTE: Before resection, it is recommended to make a 4-0 absorbable seromuscular suture ~5 mm from the tumor margin to facilitate retraction during the resection.</li>
</ol>
5. Laparoscopic closure of the gastric wall defect
<ol>
	<li>First, perform a full-thickness running suture with an absorbable 3-0 V-lock suture to close the defect in the gastric wall.</li>
	<li>Then, perform a seromuscular running suture with the same 3-0 V-lock suture to strengthen the closure.</li>
</ol>
6. Stomach wound check
<ol>
	<li>After laparoscopic closure, conduct a leakage test using a combination of laparoscopy and gastroscopy.</li>
	<li>Laparoscopically check if there are any bubbles coming out of the wound after flushing with water.</li>
	<li>Check if there is wound bleeding, whether the suture is satisfactory, and whether the gastric cavity has been deformed by the gastroscopy.</li>
</ol>
7. Oral specimen harvest
<ol>
	<li>Pull the specimen out through the mouth using an endoscopic basket. 
	&#8203;NOTE: If the tumor size is more than 3 cm, temporary deflation of the intubation tube sac may be necessary.</li>
</ol>
8. Specimen management
<ol>
	<li>After the procedure, check the specimen visually to confirm the margin status.</li>
	<li>Then, immerse the specimen in a neutral 10% formalin solution. 
	NOTE: Slice the tumor every 1 cm if the tumor is more than 2 cm in size to ensure full fixation.</li>
</ol>

<ol>
	<li>Rubin, B. P., Heinrich, M. C., Corless, C. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastrointestinal+stromal+tumour.">Gastrointestinal stromal tumour.</a> Lancet. 369 (9574), 1731-1741 (2007).</li><li>Chen, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+safety+and+efficacy+of+laparoscopic+resection+for+gastrointestinal+stromal+tumors+of+the+stomach.">Systematic review and meta-analysis of safety and efficacy of laparoscopic resection for gastrointestinal stromal tumors of the stomach.</a> Surgical Endoscopy. 29 (2), 355-367 (2015).</li><li>Koh, Y. X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+and+meta-analysis+comparing+laparoscopic+versus+open+gastric+resections+for+gastrointestinal+stromal+tumors+of+the+stomach.">A systematic review and meta-analysis comparing laparoscopic versus open gastric resections for gastrointestinal stromal tumors of the stomach.</a> Annals of Surgical Oncology. 20 (11), 3549-3560 (2013).</li><li>Zhou, P. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+full-thickness+resection+without+laparoscopic+assistance+for+gastric+submucosal+tumors+originated+from+the+muscularis+propria.">Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria.</a> Surgical Endoscopy. 25 (9), 2926-2931 (2011).</li><li>Li, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chinese+consensus+guidelines+for+diagnosis+and+management+of+gastrointestinal+stromal+tumor.">Chinese consensus guidelines for diagnosis and management of gastrointestinal stromal tumor.</a> Chinese Journal of Cancer Research. 29 (4), 281-293 (2017).</li><li>Mantese, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastrointestinal+stromal+tumor:+epidemiology,+diagnosis,+and+treatment.">Gastrointestinal stromal tumor: epidemiology, diagnosis, and treatment.</a> Current Opinion in Gastroenterology. 35 (6), 555-559 (2019).</li><li>Karakousis, G. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+gastric+resections+for+primary+gastrointestinal+stromal+tumors+(GISTs):+a+size-matched+comparison.">Laparoscopic versus open gastric resections for primary gastrointestinal stromal tumors (GISTs): a size-matched comparison.</a> Annals of Surgical Oncology. 18 (6), 1599-1605 (2011).</li><li>Melstrom, L. G., Phillips, J. D., Bentrem, D. J., Wayne, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+resection+of+gastric+gastrointestinal+stromal+tumors.">Laparoscopic versus open resection of gastric gastrointestinal stromal tumors.</a> American Journal of Clinical Oncology. 35 (5), 451-454 (2012).</li><li>Shoji, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Optimal+minimally+invasive+surgical+procedure+for+gastric+submucosal+tumors.">Optimal minimally invasive surgical procedure for gastric submucosal tumors.</a> Gastric Cancer. 21 (3), 508-515 (2018).</li><li>Hiki, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+endoscopic+cooperative+surgery.">Laparoscopic endoscopic cooperative surgery.</a> Digestive Endoscopy. 27 (2), 197-204 (2015).</li><li>Ntourakis, D., Mavrogenis, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cooperative+laparoscopic+endoscopic+and+hybrid+laparoscopic+surgery+for+upper+gastrointestinal+tumors:+Current+status.">Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status.</a> World Journal of Gastroenterology. 21 (43), 12482-12497 (2015).</li><li>Aisu, Y., Yasukawa, D., Kimura, Y., Hori, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+and+endoscopic+cooperative+surgery+for+gastric+tumors:+Perspective+for+actual+practice+and+oncological+benefits.">Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits.</a> World Journal of Gastrointestinal Oncology. 10 (11), 381-397 (2018).</li></ol>

The authors have nothing to disclose.

LECS has natural advantages for the treatment of G-GISTs that are less than 5 cm in size. The accurate judgment of tumor location and boundary greatly improves the complete resection rate of the tumor. The process substantially reduces the risk of tumor rupture and significantly improves the long-term prognosis. The method allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient&#39;s postoperative rehabilitation is greatly accelerated, and oral feeding can be resumed on the day of operation. The specimen is taken out through the mouth to avoid removal through an extended abdominal incision. This greatly reduces the patient&#39;s postoperative pain and scarring. The process greatly shortens the postoperative hospital stay (allowing the patient to be discharged on the first day after the operation) and speeds up the turnover of hospital beds9,10,11,12.
Some technical elements are noteworthy. First, complete suction of the residual fluid in the stomach during gastroscopic exploration is essential to prevent intraoperative pollution. Second, continuously holding the tumor with a seromuscular suture during laparoscopic resection is also necessary to prevent intraoperative pollution. Third, when closing the gastric wall defect, suture as little of the gastric mucosal tissue as possible to ensure the inversion effect of suturing and eventually guarantee the postoperative healing quality of the wound.
All patients in this cohort received excellent oncological results with minimal invasiveness and reservation of stomach function, no positive tumor margin or recurrence, intraoperative blood loss of less than 10 mm, and operation duration of less than 2 h. All patients had an enhanced and smooth postoperative recovery, with the average postoperative hospital stay being three days.
There are some limitations to this method. First, compared with other forms of LECS without opening the gastric wall, such as NEWS or CLEAN-NET, this method has the risk of intraoperative gastric content dissemination. However, the risk is very low with complete gastroscopic suction before opening the stomach. Moreover, this low risk is reasonable and acceptable compared to the far-shortened operation duration. Second, although the maximum tumor diameter of this cohort reached up to 4.5 cm, tumors more than 4 cm diameter are challenging for oral retrieval. Third, although laparoscopic resection guided by gastroscopy is safe and efficient in most cases, gastroscopic preresection may be needed for some tumors with ingrown patterns.
We did not discuss the application of LECS in the treatment of G-GISTs that are more than 5 cm in size. Future application of LECS may include comparisons to endoscopic or laparoscopic surgery in prospective randomized trials. In conclusion, laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors that are less than 5 cm in size, achieving the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

Gastrointestinal stromal tumors (GISTs) are the most common subepithelial lesions in the gastrointestinal tract1. Endoscopic or laparoscopic surgeries are common surgical methods for treating gastric gastrointestinal stromal tumors (G-GIST) less than 5 cm in size2,3,4. However, endoscopic surgery alone has some disadvantages, such as inaccurate tumor localization and boundary judgment, tumor rupture, low-quality wound closure, bleeding. Therefore, according to the guidelines, endoscopic surgery alone is not presently recommended as a surgical method for the treatment of G-GISTs5,6. There are also disputes regarding the treatment of G-GISTs through endoscopic surgery alone in practical clinical work. Compared to endoscopic surgery, laparoscopic surgery has the advantages of a clearer field of vision, fuller exposure, and larger resection range7,8. However, laparoscopic surgery alone also has difficulties in terms of judging the tumor location (for endogenous tumors) and inaccurate judgment of tumor boundaries, resulting in tumor rupture, especially when the tumor is located near the lesser curvature or cardia of the posterior wall of the stomach. Additionally, if the tumor boundary is not judged correctly, the resection range will be too large, resulting in gastric deformation.
In view of the shortcomings of endoscopic and laparoscopic surgeries performed separately, we developed an innovative, improved approach in the treatment of G-GISTs less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to organically combine endoscopic and laparoscopic surgical techniques, fully leveraging their respective advantages while avoiding their respective drawbacks. The goals of this method include reducing trauma, preserving gastric function, promoting postoperative rehabilitation, and improving postoperative quality of life while still safely and accurately removing G-GISTs less than 5 cm in size.

<table><tbody><tr><td>&lt;strong&gt;Eneoscopic facilites&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Camera Control Unit</td><td>Olympus, Tokyo, Japan</td><td>CV-290</td><td></td></tr><tr><td>Disposable Grasping Forceps with Net</td><td>Changzhou Jiuhong Medical Instrument, Changzhou, China</td><td>JHY-FG-25-230-C1-5</td><td></td></tr><tr><td>Electronic Gastroscope</td><td>Olympus, Tokyo, Japan</td><td>GIF-HQ290</td><td></td></tr><tr><td>LCD Monitor</td><td>Olympus, Tokyo, Japan</td><td>OEV262H</td><td></td></tr><tr><td>Xenon Light Source</td><td>Olympus, Tokyo, Japan</td><td>&amp;nbsp;CLV-290</td><td></td></tr><tr><td>&lt;strong&gt;Laparoscopic facilities&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Camera Control Unit</td><td>Olympus, Tokyo, Japan</td><td>OTV-S400</td><td></td></tr><tr><td>Camera Head</td><td>Olympus, Tokyo, Japan</td><td>CH-S400-XZ-EB</td><td></td></tr><tr><td>HARMONIC ACE+7</td><td>Johnson &amp;amp; Johnson, New Brunswick, USA</td><td>HARH36</td><td></td></tr><tr><td>LCD Monitor</td><td>Olympus, Tokyo, Japan</td><td>LMD-X550S/LMD-X310S</td><td></td></tr><tr><td>Ultrasonic Surgical &amp;amp; Electrosurgical Generator</td><td>Johnson &amp;amp; Johnson, New Brunswick, USA</td><td>GEN11CN</td><td></td></tr><tr><td>ULTRA Telescope</td><td>Olympus, Tokyo, Japan</td><td>WA4KL130</td><td></td></tr><tr><td>V-Loc Suture</td><td>Medtronic, Minneapolis, USA</td><td>3-0.</td><td></td></tr><tr><td>Xenon Light Source</td><td>Olympus, Tokyo, Japan</td><td>CLV-S400</td><td></td></tr></tbody></table>

laparoscopy-endoscopy cooperative surgery for the treatment of gastric gastrointestinal stromal tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

From 2017 to 2020, 10 patients with G-GISTs received LECS (Table 1). Every GIST diagnosis was confirmed through pathological examination. None were converted to open surgery. The average age was 49 years. The average tumor size was 2.7 cm. Location of the tumor: 7 at the anterior wall, 2 at the posterior wall, and 1 at lesser curvature. The average operation duration was 112 min, and the average intraoperative blood loss was 8 mL. All patients resumed oral fluid consumption 2 h after surgery, and the average postoperative hospital stay was 73 h. All cases had negative tumor margins, and there were no perioperative complications. Every patient received regular follow-up, including gastroscopy. There were no gastric deformities (Figure 1) or recurrences.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63280/63280fig01.jpg" /> 
Figure 1: Gastroscopy of the same patient demonstrated in the video three months after surgery. (A) The green arrow indicates the healed wound. (B) The gastric cavity shows no deformity. <a href="https://www.jove.com/files/ftp_upload/63280/63280fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Case</td>
			<td>Gender</td>
			<td>Age (years)</td>
			<td>Tumor Size (cm)</td>
			<td>Operation Duration (min)</td>
			<td>Blood Loss (mL)</td>
			<td>Postoperative Hospital Stay (h)</td>
		</tr>
		<tr>
			<td>1</td>
			<td>F</td>
			<td>46</td>
			<td>2</td>
			<td>80</td>
			<td>5</td>
			<td>46</td>
		</tr>
		<tr>
			<td>2</td>
			<td>F</td>
			<td>33</td>
			<td>2.5</td>
			<td>80</td>
			<td>5</td>
			<td>67</td>
		</tr>
		<tr>
			<td>3</td>
			<td>F</td>
			<td>71</td>
			<td>1.5</td>
			<td>105</td>
			<td>2</td>
			<td>42</td>
		</tr>
		<tr>
			<td>4</td>
			<td>F</td>
			<td>47</td>
			<td>2.5</td>
			<td>130</td>
			<td>10</td>
			<td>70</td>
		</tr>
		<tr>
			<td>5</td>
			<td>M</td>
			<td>35</td>
			<td>4</td>
			<td>185</td>
			<td>20</td>
			<td>134</td>
		</tr>
		<tr>
			<td>6</td>
			<td>F</td>
			<td>42</td>
			<td>4</td>
			<td>190</td>
			<td>10</td>
			<td>69</td>
		</tr>
		<tr>
			<td>7</td>
			<td>M</td>
			<td>63</td>
			<td>4.5</td>
			<td>135</td>
			<td>20</td>
			<td>69</td>
		</tr>
		<tr>
			<td>8</td>
			<td>F</td>
			<td>57</td>
			<td>2.2</td>
			<td>88</td>
			<td>5</td>
			<td>68</td>
		</tr>
		<tr>
			<td>9</td>
			<td>M</td>
			<td>51</td>
			<td>1.8</td>
			<td>65</td>
			<td>5</td>
			<td>93</td>
		</tr>
		<tr>
			<td>10</td>
			<td>M</td>
			<td>46</td>
			<td>2.1</td>
			<td>63</td>
			<td>5</td>
			<td>74</td>
		</tr>
		<tr>
			<td>Average</td>
			<td></td>
			<td>49</td>
			<td>2.7</td>
			<td>112</td>
			<td>8</td>
			<td>73</td>
		</tr>
	</tbody>
</table>
Table 1: Clinical parameters of 10 cases.

Watch this Scientific Journal Video about Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors at JoVE.com

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

laparoscopy-endoscopy-cooperative-surgery-for-treatment-gastric

Research

JoVE Journal

Medicine

5.8K Views.  Sun Yat-sen University. Na het toedienen van algemene anesthesie, voert u gastroscopie uit op de patiënt met kooldioxide-insufflatie. Zuig vervolgens de resterende maagvloeistof op en bevestig de locatie van de tumor. Adem na de verkenning de koolstofdioxide en vloeistof in de maag en het vocht en slijm in de slokdarm en keel volledig op.Bevestig eerst de locatie en grens van de tumor in de maag met behulp van gastroscopie, indien nodig. Voer vervolgens een buikverkenning van één inch uit om andere laesies...

Video: Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function

We describe a novel esophagogastric anastomotic technique (&ldquo;side-to-side: staple line-on-staple line&rdquo;, STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution.
The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures.
There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p&lt;0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients.
The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.

We describe a novel intrathoracic esophagogastric anastomotic technique designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply to minimize the incidence of anastomotic leaks and strictures. Construction and orientation of the stomach conduit designed to optimize upper gastrointestinal tract function is also described.

We describe a novel esophagogastric anastomotic technique (&ldquo;side-to-side: staple line-on-staple line&rdquo;, STS) for intrathoracic anastomoses ...

Cancer Research

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Surgical Treatment of Gastroparesis

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are combined in a multidisciplinary fashion to improve the quality of life in this patient population. Starting with lifestyle changes, adjustments are made to the types and amounts of food consumed, medical conditions are optimized, and the use of narcotic pain medications as well as smoking is discontinued. For many, these changes are not enough, and antiemetics and promotility agents are used to control symptoms. Finally, when these measures fail, patients turn to surgery, which can include surgical alterations to the stomach, implantation of a gastric stimulator, placement of drainage tubes, and possibly even the complete removal of different organs, including the stomach or gallbladder. In our clinic, patients not only see a surgeon but also a gastroenterologist, dietitian, and psychologist. We strongly believe in a multidisciplinary approach to this condition. The goal is to provide patients with hope and help them live fuller and happier lives.
The study primarily addresses technical considerations and the surgical approach for patients diagnosed with gastroparesis. It outlines the entire process, starting from preparations before the surgery, encompassing the preoperative work-up, and detailing the steps involved in the surgical procedure. One of the key diagnostic challenges faced in treating gastroparesis patients is determining the underlying cause of the condition, as this information is critical for selecting the appropriate surgical intervention. Once the patient&#39;s condition has been categorized based on the cause, the medical team engages in a discussion with the patient regarding potential treatment options, which may include endoscopic procedures, minimally invasive techniques, or open surgery.

Gastroparesis is a condition in which the stomach does not empty properly. While it is initially managed with lifestyle modifications and medications, some patients eventually require surgical intervention. This study focuses on the technical considerations and surgical approaches for dealing with gastroparesis patients, which include endoscopic, minimally-invasive, and open surgical techniques.

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

Transumbilical Endoscopic Resection of Intra-abdominal Mesenchymal Tumor

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, &lt;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%.

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 ...

Single Incision Plus One Port Laparoscopic Proximal Gastrectomy with Double Channel Anastomosis for Gastric Cancer Treatment

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for treating proximal gastric cancer. This technique includes comprehensive laparoscopic resection of the proximal stomach, lymph node dissection, and double-tract anastomosis. By integrating single-port laparoscopic surgery with an auxiliary operating hole, SILT-DT reduces procedural difficulty while facilitating the placement of an abdominal drainage tube. Compared to the traditional five-port laparoscopic gastrectomy, SILT-DT requires fewer ports and results in shorter incision lengths, contributing to reduced postoperative pain and faster recovery. A thorough preoperative evaluation was conducted to ensure procedural success, with factors such as tumor size, stage, location, and patient BMI carefully considered. This comprehensive assessment allowed for optimal patient selection and surgical planning. Postoperative follow-up demonstrated no significant complications, underscoring the safety and efficacy of SILT-DT. This innovative technique offers a promising minimally invasive alternative for managing proximal gastric cancer while maintaining excellent clinical outcomes.

The single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis was initially employed for the radical resection of proximal gastric cancer. This study demonstrated the feasibility of the procedure and laid a foundation for further research.

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for ...

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...

Gastroscope-assisted Trans-Trocar Gastrostomy and Abdominal Exploration

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic interventions. Gastrostomy is a classic clinical technique for patients with swallowing impediments due to obstructions in the cardiac or esophageal regions and has evolved significantly with the establishment of percutaneous endoscopic gastrostomy (PEG). While PEG offers reduced trauma and swift recovery, it falls short of exploratory capabilities and risks damaging adjacent organs. Therefore, we developed an innovative approach-gastroscope-assisted trans-Trocar gastrostomy (GTTG), which not only takes full play to the advantages of PEG with less trauma and faster postoperative recovery but also takes into account the advantages of laparoscopic gastrostomy with a good exploration of the abdominal cavity. This technique is characterized by ease of operation, minimal trauma (including short operation time and no redundant incision), rapid recovery, the ability to explore the abdominal cavity, and avoidance of injury to adjacent organs, which is quite worthy of widespread promotion in clinical settings.

Here, we introduce a novel technique of gastrostomy, which integrates laparoscopic and gastroscopic techniques, offering a streamlined approach with reduced invasiveness, expedited recovery, and the capacity for abdominal exploration while minimizing the risk of adjacent organ injury.

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

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