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 border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Eneoscopic facilites</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>&#160;CLV-290</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic facilities</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 &#38; 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 &#38; Electrosurgical Generator</td>
			<td>Johnson &#38; 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

5.7K Views.  Sun Yat-sen University. 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.

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

Thermal Ablation for the Treatment of Abdominal Tumors

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ablation procedure, a thin applicator is guided into the target tumor under imaging guidance. Energy is then applied to the tissue until temperatures rise to cytotoxic levels (50-60 &deg;C). Various energy sources are available to heat biological tissues, including radiofrequency (RF) electrical current, microwaves, laser light and ultrasonic waves. Of these, RF and microwave ablation are most commonly used worldwide.
During RF ablation, alternating electrical current (~500 kHz) produces resistive heating around the interstitial electrode. Skin surface electrodes (ground pads) are used to complete the electrical circuit. RF ablation has been in use for nearly 20 years, with good results for local tumor control, extended survival and low complication rates1,2. Recent studies suggest RF ablation may be a first-line treatment option for small hepatocellular carcinoma and renal-cell carcinoma3-5. However, RF heating is hampered by local blood flow and high electrical impedance tissues (eg, lung, bone, desiccated or charred tissue)6,7. Microwaves may alleviate some of these problems by producing faster, volumetric heating8-10. To create larger or conformal ablations, multiple microwave antennas can be used simultaneously while RF electrodes require sequential operation, which limits their efficiency. Early experiences with microwave systems suggest efficacy and safety similar to, or better than RF devices11-13.
Alternatively, cryoablation freezes the target tissues to lethal levels (-20 to -40 &deg;C). Percutaneous cryoablation has been shown to be effective against RCC and many metastatic tumors, particularly colorectal cancer, in the liver14-16. Cryoablation may also be associated with less post-procedure pain and faster recovery for some indications17. Cryoablation is often contraindicated for primary liver cancer due to underlying coagulopathy and associated bleeding risks frequently seen in cirrhotic patients. In addition, sudden release of tumor cellular contents when the frozen tissue thaws can lead to a potentially serious condition known as cryoshock 16.
Thermal tumor ablation can be performed at open surgery, laparoscopy or using a percutaneous approach. When performed percutaneously, the ablation procedure relies on imaging for diagnosis, planning, applicator guidance, treatment monitoring and follow-up. Ultrasound is the most popular modality for guidance and treatment monitoring worldwide, but computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used as well. Contrast-enhanced CT or MRI are typically employed for diagnosis and follow-up imaging.

A thermal tumor ablation procedure is described. The entire procedure is detailed, including pretreatment planning and imaging studies, anesthesia, adjuvant techniques to facilitate a percutaneous approach, imaging guidance of the ablation device to the tumor, thermal treatment, post-treatment care and follow-up.

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ...

Ex Vivo Treatment Response of Primary Tumors and/or Associated Metastases for Preclinical and Clinical Development of Therapeutics

The molecular analysis of established cancer cell lines has been the mainstay of cancer research for the past several decades. Cell culture provides both direct and rapid analysis of therapeutic sensitivity and resistance. However, recent evidence suggests that therapeutic response is not exclusive to the inherent molecular composition of cancer cells but rather is greatly influenced by the tumor cell microenvironment, a feature that cannot be recapitulated by traditional culturing methods. Even implementation of tumor xenografts, though providing a wealth of information on drug delivery/efficacy, cannot capture the tumor cell/microenvironment crosstalk (i.e., soluble factors) that occurs within human tumors and greatly impacts tumor response. To this extent, we have developed an ex vivo (fresh tissue sectioning) technique which allows for the direct assessment of treatment response for preclinical and clinical therapeutics development. This technique maintains tissue integrity and cellular architecture within the tumor cell/microenvironment context throughout treatment response providing a more precise means to assess drug efficacy.

Ex Vivo Treatment Response of Primary Tumors and/or Associated Metastases for Preclinical and Clinical Development of Therapeutics

Established cancer cell lines and xenografts have been the mainstay of cancer research for the past several decades. However, recent evidence suggests that therapeutic response is greatly influenced by the tumor cell microenvironment. Therefore, we have developed an ex vivo analysis of primary tumor specimens for drug development purposes.

The molecular analysis of established cancer cell lines has been the mainstay of cancer research for the past several decades. Cell culture provides both ...

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

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 ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Stromal Vascular Fraction-enriched Fat Grafting for the Treatment of Symptomatic End-neuromata

The purpose of this study was to methodically illustrate and highlight the crucial steps of stromal vascular fraction (SVF)-enriched fat grafting as a novel treatment of symptomatic end-neuromata of peripheral sensory nerves, and in this study, specifically of the superficial branch of the radial nerve (SBRN). Despite a multitude of existing treatments, persistent postoperative pain and common pain relapse are still very common, independent of the procedure assessed. The neuroma is microsurgically excised accordingly to standardized protocol. Instead of the relocation of the regenerating nerve stump in neighboring anatomical structures, such as muscle or bone, a fat graft is applied perifocally and acts as a mechanical barrier. In order to reduce the fat resorption rate and boost the regenerative potential of the graft, the highly concentrated SVF is integrated in the grafting. The SVF is isolated from subcutaneous fat by enzymatic and mechanic separation of the lipoaspirate by a specific commercial isolation system. The SVF-enriched fat graft provides both a mechanical barrier and various biological effects at the cellular level, including improving angiogenesis, inflammation, and fibrosis. Both mechanical and biologic effects help to reduce the disorganized axonal outgrowth of the nerve stump during nerve regeneration and hence prevent the recurrence of painful end-neuromata.

The purpose of the study is to illustrate the technical procedure of stromal vascular fraction (SVF)-enriched fat grafting as a novel treatment of symptomatic end-neuromata. This technique provides advantages of both the mechanical barrier and the biological action at the cellular level by the processed and concentrated SVF.

The purpose of this study was to methodically illustrate and highlight the crucial steps of stromal vascular fraction (SVF)-enriched fat grafting as a ...

Trans-Tympanic Drug Delivery for the Treatment of Ototoxicity

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could interfere with the chemotherapeutic efficacy of the primary drugs. This is especially true for the drug cisplatin, whose anticancer actions are attenuated by antioxidants which provide adequate protection against hearing loss. Other current or potential otoprotective agents could pose a similar problem, if administered systemically. The application of various biologicals or protective agents directly to the cochlea would allow for high levels of these agents locally with limited systemic side effects. In this report, we demonstrate a trans-tympanic method of delivery of various drugs or biological reagents to the cochlea, which should enhance basic science research on the cochlea and provide a simple way of directing the use of otoprotective agents in the clinics. This report details a method of trans-tympanic drug delivery and provides examples of how this technique has been used successfully in experimental animals to treat cisplatin ototoxicity.

We present a technique for localized administration of drugs through the trans-tympanic route into the cochlea. Drug delivery through this route would not interfere with the anti-cancer efficacy of the chemotherapeutic drugs such as cisplatin.

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

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.