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 ¤ Introduction
 ¤ Patients and Methods
 ¤ Results
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 Table of Contents     
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 4  |  Page : 269-272
 

Endoscopic gastric polypectomy assisted by laparoscopy for giant gastric and duodenal lesion treatment: Case series from two centres


1 Escuela Nacional de Medicina (National School of Medicine), Tecnologico de Monterrey (Monterrey Tech), Monterrey, Nuevo Leon, Mexico
2 Texas Endosurgery Institute, San Antonio, TX, USA
3 Escuela Nacional de Medicina (National School of Medicine), Tecnologico de Monterrey (Monterrey Tech), Monterrey; Escuela de Ingenieria (Engineering School), Tecnologico de Monterrey (Monterrey tech), Monterrey, Nuevo Leon, Mexico
4 Hospital Universitario (UANL Uimiversity Hospital) “Dr Jose Eleuterio Gonzalez”, UANL, Monterrey, Nuevo Leon, Mexico

Date of Submission27-Jan-2017
Date of Acceptance21-Mar-2017
Date of Web Publication5-Sep-2017

Correspondence Address:
Eduardo Flores-Villalba
Av. Morones Prieto Pte: #3000. Col. Los Doctores, 64710, Monterrey, Nuevo León
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_15_17

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 ¤ Abstract 

Background: Endoscopy has developed rapidly, generating new challenges. Today, there are several procedures done endoscopically with very good results. In the past, the assisted laparoscopic colon polypectomy has been described, reducing the morbidity of a bigger procedure. Nonetheless, little has been said about the use of hybrid surgery in the management of gastric or duodenal polyps.
Objectives: Evaluating the safety and efficacy of the assisted laparoscopic gastric endoscopic polypectomy.
Patients and Methods: A retrospective review of the database at our two centres was performed from 1996 to 2014. Thirteen patients were found in whom an assisted laparoscopic gastric or duodenal endoscopic tumour resection was performed.
Results: Thirteen patients, eight males and five females, with a median age of 61 years and average body mass index of 29.3. The procedure was done effectively and no need for further procedures was required for any patient. No complications were reported in the early post-operative period.
Conclusions: The study shows that assisted laparoscopic gastric endoscopic polypectomy is a feasible and safe procedure that can be used for the management of giant polyps, which cannot be resected with the classical endoscopic polypectomy reducing the morbidity and complications associated with larger procedures.


Keywords: Endoscopic-assisted laparoscopy, giant polyps, polypectomy


How to cite this article:
Topete-Gonzalez LA, Franklin ME, Balli-Martinez JE, Lammel-Lindemann J, Perez-Banuet-Farell S, Valles-Guerra O, Flores-Villalba E. Endoscopic gastric polypectomy assisted by laparoscopy for giant gastric and duodenal lesion treatment: Case series from two centres. J Min Access Surg 2017;13:269-72

How to cite this URL:
Topete-Gonzalez LA, Franklin ME, Balli-Martinez JE, Lammel-Lindemann J, Perez-Banuet-Farell S, Valles-Guerra O, Flores-Villalba E. Endoscopic gastric polypectomy assisted by laparoscopy for giant gastric and duodenal lesion treatment: Case series from two centres. J Min Access Surg [serial online] 2017 [cited 2020 Jan 25];13:269-72. Available from: http://www.journalofmas.com/text.asp?2017/13/4/269/209967



 ¤ Introduction Top


Endoscopy today is basically everywhere and well implemented, and as new diagnostic and therapeutic possibilities came with it, new challenges arose as well. As of today, most indications for endoscopic treatment have excellent results and present clear benefits, but some lesions are too big or located in places where the feasibility of the procedure can be maimed. Colonic laparoscopically assisted endoscopic polypectomy has been previously and vastly reported, reducing morbidities in patients otherwise undergoing major surgical interventions, but very little has been said about hybrid intervention for gastric or gigantic duodenal polyps. Giant gastric polyp definition varies in the literature but is generally regarded as a lesion measuring over 2.0 cm in its largest dimension.

What we define as minimally invasive endoscopic surgery started in 1969 when Hiromi Shinya performed the first endoscopic polypectomy using a snare to remove a colonic polyp.[1] Years later Kozarek et al. did the first pancreatic pseudocyst endoscopic drainage in 1985.[2] Then, in 1988, the endoscopic submucosal dissection technique (ESD) for nonsurgical treatment of early gastric cancer was described.[3] Soetikno et al. started, in 2003, endoscopic mucosal resection (EMR) for early stage gastric cancer treatment.[4]

ESD is a well-established procedure that allows for subepithelial gastrointestinal (GI) lesion resections. Compared to EMR, it is associated with a better en bloc resection rate, with both curative treatment and less local recurrence rates, but it presents a higher incidence of complications and adverse effects compared to other endoscopic techniques, and its use is limited by the lesion's depth.[5] Endoscopic full-thickness resection (EFTR) performed for lesions that have higher depths is limited by the lesion's size, as the wound closure after resection is a challenge for lesions over 30 mm.[6]

Hybrid resection technique was first performed in 2000 for colon polyp resection by performing a colonoscopy assisted by laparoscopy. The studies showed less post-operative pain, as well as decreased hospital stay length. This prevents patients that have benign lesions or low-grade dysplasia from otherwise undergoing major surgical interventions.[7] This technique was performed in stomach and duodenum later on as well.[8],[9]

Hizawa and Zea-Iriarte report a cancer incidence of about 1.8%–2% of all gastric hyperplastic polyps, and this rate is higher in polyps over 2 cm.[10] A multivariate analysis correlated patient age, polyp size and a lobar surface as independent factors related to neoplasm development.[11] In 2005, Novitsky et al. proved the safety of minimally invasive surgery for gastric GI stromal tumour (GIST) treatment. They performed wedge resection in anterior and posterior wall tumours using a stapler and reported a 92% survival rate 36 months after.[12] In 2013, Heo and Jeon. made a recommendation for hybrid surgery for intervening gastric lesions that present a challenge for endoscopic or laparoscopic individual treatment, as using both lowers complication rates.[13]

The purpose of this study is to measure safety and efficacy of laparoscopically assisted endoscopic polypectomy in gastric or duodenal giant polyps.


 ¤ Patients and Methods Top


A retrospective analysis was performed on two databases from our centres, from January 1996 to November 2014, where we found 13 patients that underwent gastric/duodenal laparoscopically assisted endoscopic polypectomy. These patients were chosen after they were referred by the gastroenterology service after an endoscopic resection attempt failed or was advised against because of complication risks, as per the treating endoscopist's assessment, bleeding and/or perforation risk in submucosal lesions. All procedures were performed electively. Procedure time consisted from the moment skin was incised up until the surgical sites were closed. Complications are defined as gastric leaks, bleeding, oral intake intolerance and wound infection up to 60 days after procedure.

Procedure

Pneumoperitoneum is performed by Veress needle introduction in Palmer's point. Three trocars are then placed: An umbilical 10 mm port, a 5 mm right hypochondrium port and a 5 mm epigastric port. The Treitz angle is identified and a bulldog clamp placed to stop air flow through it. The endoscope is introduced orally until the gastric chamber is identified, and insufflation is then started. Once the gastric chamber is under tension, a 10 mm trocar with balloon (Apple Medical Corporation, MA, USA) is placed through the stomach for the camera. Two 3 mm trocars are then placed through both the abdominal and the gastric walls. Using two 2 mm forceps, the polyp is manipulated with a grasper to expose the base [Figure 1]a, and a groove is made in it using scissors and electrocoagulation [Figure 1]b. The cutting snare is introduced through the endoscope's channel and placed using the forceps at the polyp's base, then sectioned using electrocautery [Figure 1]c. Gastric wall integrity is verified [Figure 1]d, and the polyp is extracted with the endoscope. Once the luminal resection is done, the trocars are removed and all the gastric orifices are sutured with 2–0 silk suture. Subcutaneous cellular tissue was sutured using 2–0 Vycril ® and skin using 2.0 Monocryl ®. Post-operative management consisted of liquid diet 6 h after procedure with acetaminophen and a proton pump inhibitor treatment as follow-up.
Figure 1: Procedure using two 2 mm forceps, the polyp is manipulated with a grasper to expose the base (a) and a groove is made in it using scissors and electrocoagulation (b). The cutting snare is introduced through the endoscope's channel and placed using the forceps at the polyp's base, then sectioned using electrocautery (c). Gastric wall integrity is verified (d) and the polyp is extracted with the endoscope

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 ¤ Results Top


The patients consisted of eight male and five female patients with a mean age of 61 years and a body mass index of 29.3 m2/kg. All 13 procedures were elective, and there was no need for a greater surgical intervention. The American Society of Anesthesiologists (ASA) Physical Status classification consisted of three patients ASA I, 7 with ASA II and 3 with an ASA III. The average intraoperative bleeding was of 45cc, had a procedure time of 144.5 min and a mean hospital stay of 3.8 days. Previous endoscopy was performed on all of them, computed tomography scan performed on five and one had an abdominal ultrasound done [Table 1].
Table 1: General information

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Eight of the 13 patients had no symptoms, three of them had melena, one with abdominal pain and one with dysphagia. Two of the patients that presented symptoms did 1–3 months previous to the procedure, one patient had melena 4 months prior and one presented melena for 10 months prior. One patient had abdominal pain for 1 year. Twelve out of the 13 patients had a gastric lesion diagnosis and one had a duodenal lesion, placed in the superior third of the stomach for eight patients, four in the middle third and one duodenal. Pathology reports described nine polyps as hyperplastic, two in situ carcinomas and two GISTs. All pieces were found to have clean surgical margins during transoperatory biopsy. The lesions size varied between 30 and 45 mm with an average of 36 mm. No complications were reported in the immediate post-operational time [Table 2] or follow-up.
Table 2: Symptoms and findings

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 ¤ Discussion Top


Laparoscopic minimally invasive surgery use is somewhat limited today because of how effective other techniques such as endoscopy have become. The hybrid surgery approach for high GI lesions is limited in its indication, but it does provide a solution for complicated lesions that cannot be resected by endoscopy or laparoscopy on their own.[13] The combined use of these techniques presents a minimally invasive treatment option that allows the surgeon to access the patient's lesions with minimal intrusion making ESD feasible when it was found to be too risky by the endoscopist while also being less disruptive to all the tissues and thus lowering comorbidities that the option of a wide gastric resection brings by itself, as well as hospital stay. This also presents an effective treatment option for lesions presented on the minor curvature that are too big for pure ESD resection that could not be wedge resected otherwise.

Our study with 13 patients shows that the procedure presented no complications such as leaks, haemorrhage or stenosis. Hiki et al. reported a series of seven patients where the combined procedure was performed for submucosal gastric tumours without complications, an average operating time of 169 min and a mean blood loss of 7cc.[14] Tsujimoto et al. also reported in a twenty patient case series minimal bleeding and no morbidity or mortality associated with the procedure.[14],[15] We found that in our series, very similar results with a mean operating time of 144.5 min per procedure, the longest being 360 min long; although this patient also had a cholecystectomy performed at that increased the operating time as well as the total bleeding, affecting both means partially.

Disease-free surgical margins (R0) were achieved in all cases. In a large case series performed in Asia with patients that had early gastric adenocarcinoma that underwent ESD, the en bloc dissection range was between 86% and 97% and the R0 resection (disease-free vertical and lateral margins) varied from 88% to 93%.[15],[16],[17] Out of the 13 patients in our study, all patients were followed up for 90 days without any complications during this time or any disease recurrence. Extended follow-up was not feasible in this case for GIST or early stage carcinoma recurrence and long-term survival.

Lesion size was in the limits for endoscopic resection capabilities, with a mean size of 3.6 cm. Endoscopic device such as GERDX (G-Surg, Seeon, Germany) and/or Apollo (Endosurgery Inc., Austin, TX, USA) have being used with EFTR endoscopic technique, and this has allowed for endoscopic resection of lesions over 30 mm. Nevertheless, the location of lesions in the gastric fundus renders the use of these instruments very difficult.[18]


 ¤ Conclusions Top


Hybrid minimally invasive surgery is a safe and effective way to remove gastric or duodenal lesions over 30 mm, and this avoids bigger surgical interventions. By combining both techniques, faster healing is achieved with less mean hospital stay and no reported complications. Although this has been widely performed in colonic lesions, no gastric and duodenal approach series have been reported to this extent. We believe more studies are still needed to determine the safety and effectivity of these procedures compared to conventional ones in the long run. All in all, we must consider this approach for lesions in patients where endoscopic resection has failed for technical difficulties or higher risk for the patients as a treatment option.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Sivak MV. Polypectomy: looking back. Gastrointest Endosc 2004;60:977-82.  Back to cited text no. 1
    
2.
Kozarek RA, Brayko CM, Harlan J, Sanowski RA, Cintora I, Kovac A. Endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 1985;31:322-7.  Back to cited text no. 2
    
3.
Hirao M, Masuda K, Asanuma T, Naka H, Noda K, Matsuura K, et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine. Gastrointest Endosc 1988;34:264-9.  Back to cited text no. 3
    
4.
Soetikno RM, Gotoda T, Nakanishi Y, Soehendra N. Endoscopic mucosal resection. Gastrointest Endosc 2003;57:567-79.  Back to cited text no. 4
    
5.
ASGE Technology Committee, Maple JT, Abu Dayyeh BK, Chauhan SS, Hwang JH, Komanduri S, et al. Endoscopic submucosal dissection. Gastrointest Endosc 2015;81:1311-25.  Back to cited text no. 5
    
6.
Mori H, Kobara H, Fujihara S, Nishiyama N, Ayaki M, Yachida T, et al. Pure endoscopic full-thickness resection with peritoneoscopy and omentectomy. J Dig Dis 2014;15:96-101.  Back to cited text no. 6
    
7.
Franklin ME Jr., Díaz-E JA, Abrego D, Parra-Dávila E, Glass JL. Laparoscopic-assisted colonoscopic polypectomy: the texas endosurgery institute experience. Dis Colon Rectum 2000;43:1246-9.  Back to cited text no. 7
    
8.
Tsujimoto H, Ichikura T, Nagao S, Sato T, Ono S, Aiko S, et al. Minimally invasive surgery for resection of duodenal carcinoid tumors: endoscopic full-thickness resection under laparoscopic observation. Surg Endosc 2010;24:471-5.  Back to cited text no. 8
    
9.
Abe N, Takeuchi H, Yanagida O, Masaki T, Mori T, Sugiyama M, et al. Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor. Surg Endosc 2009;23:1908-13.  Back to cited text no. 9
    
10.
Yriberry Ureña S, Vila Guitérrez S, Salazar Muente F. Polypectomy and endoscopic management of a giant gastric polyp. Rev Gastroenterol Peru 2010;30:167-71.  Back to cited text no. 10
    
11.
Ahn JY, Son DH, Choi KD, Roh J, Lim H, Choi KS, et al. Neoplasms arising in large gastric hyperplastic polyps: endoscopic and pathologic features. Gastrointest Endosc 2014;80:1005-13.e2.  Back to cited text no. 11
    
12.
Novitsky YW, Kercher KW, Sing RF, Heniford BT. Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors. Ann Surg 2006;243:738-45.  Back to cited text no. 12
    
13.
Heo J, Jeon SW. Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors. World J Gastrointest Endosc 2013;5:428-32.  Back to cited text no. 13
    
14.
Hiki N, Yamamoto Y, Fukunaga T, Yamaguchi T, Nunobe S, Tokunaga M, et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008;22:1729-35.  Back to cited text no. 14
    
15.
Tsujimoto H, Yaguchi Y, Kumano I, Takahata R, Ono S, Hase K. Successful gastric submucosal tumor resection using laparoscopic and endoscopic cooperative surgery. World J Surg 2012;36:327-30.  Back to cited text no. 15
    
16.
Chung IK, Lee JH, Lee SH, Kim SJ, Cho JY, Cho WY, et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc 2009;69:1228-35.  Back to cited text no. 16
    
17.
Ahn JY, Jung HY, Choi KD, Choi JY, Kim MY, Lee JH, et al. Endoscopic and oncologic outcomes after endoscopic resection for early gastric cancer: 1370 cases of absolute and extended indications. Gastrointest Endosc 2011;74:485-93.  Back to cited text no. 17
    
18.
Schurr MO, Baur F, Ho CN, Anhoeck G, Kratt T, Gottwald T. Endoluminal full-thickness resection of GI lesions: a new device and technique. Minim Invasive Ther Allied Technol 2011;20:189-92.  Back to cited text no. 18
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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