| BackgroundGastric submucosal tumors (SMTs) of less than 2 cm of intraluminal growth remains challenging even with the development of laparoscopic and interventional endoscopy.。The LECS technique can provide alternative approach for permitting localization, verification of the resection line in avoiding stenosis and in the visualization of the manipulated area to permit RO resection when the tumor is difficult tom reach such as the EGJ, lessercurvature, pylorus and tumors located at posterior part of the stomach。Laparoscopy for gastric intraluminal submucosal tumors (SMTs) is a complexgastrointestinal operation that can be associated with a high risk of stenosis, bleeding and deformation of gastric lumen.The specific type of laparoscopic endoscopic cooperative surgery (LECS) for SMTs is based on the location and the growth type of the tumors. Endoscopic Submucosal Dissection (ESD) for SMTs has been performed.Hight riske of intraopearative complications has led to reconsider the importance this technique for the efficacity for tumors erasing from muscularis propria.Numerous individuals refined and popularized the approach for laparoscopic since the start of computer chip television which was a seminal event in the laparoscopy field.。Minimallyinvasive laparoscopic surgery is becoming popular due to its advantage in reducing haemorrhaging which reduce the needing of blood transfusion, provide lowerpost operative morbidity rates and rapid post-operative recovery.The benign gastric lesions, especially for gastro intestinal stromal tumors (GISTs) which rarely metastasis at the regional lymph nodes is indicated for minimally invasive surgery because of unnecessary lymphadectomy. Even if Gastric Submucosal Tumors (SMT) has been resected laparoscopically, the technique is still having some difficulties. Sometimes laparoscopy is notable to deal with intraluminal growthpattern of gastric SMTs. The limitation for laparoscopy to detect small intraluminal lesions affectsconsiderably the success of operation. Endoscopy assistancegive an alternative approach forresection of tumors especially at the pylorus, duodenum and EGJ. LECS is a new technique havingthe advantage of combining these two techniques together in the accomplishment ofthe operation. All the tumors were GIST in the study and the rarely developed metastasis around the regional lymph node.The margin status, not playing adetermining role in theprediction of patients surviving a first GIST resection therefore leads us to the understanding that the success of laparoscopy wedge resection depends on the complete resection of the tumor, and that endoscopy assistance is needed in the localisation, especially at the cardia and EGJ where there is a high risk of complication.Laparoscopic wedge resection of grossly GIST has been reported.Gastric submucosal tumor can be resected at the tumor site with a resection as small aspossible. LECS is very efficient for patients with other conditions such as early stage gastric cancer with no risk of lymph node metastasis, and for incomplete endoscopic resection who can present severe ulcerative change and risk of perforation due to proximity of the muscle layer. All the GIST in this study were <5cm and it is knownthat they also have a very little limitation between the malignant and benign, biological manifestations leading to the tendency of gist to progress to malignancy even if they are less than 5cm and showing the importance of surgical resection in the treatment of GIST. With the development of sentinel lymph node (SLN) concept for the treatment of early gastro intestinal cancer which allows us to know about lymph node metastasis in the regional lymph node it is possible to have recourse to LECS. SLN is the first of thelymph nodes to be drained in this group, and it is strongly believed to have animportance in the determination of regional nodal metastasis. This technique is used soas to efficiently reduce the unwanted extensive lymphadenectomy.LECS has strong and good outcomes in the management of GISTsaccording to what have been done in the field of minimally invasive surgery independent of the position of the tumor even if the tumor is located at the posterior ofthe fundus or for tumors close to the duodenum, pyloric ring or EGJ.Most of the time the management is indicated by the location of the tumors and the growth type. The role of laparoscopy in the resection of gastric submucosal tumors is important. The value of systematic lymph node dissection and anatomical resection has been largely refuted for what was historically known as gastric leiomyosarcoma after numerous reports failed to show lymphatic metastasis or any survival benefit from lymphadenectomy. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome Although upper GI endoscopy is considered to be safe procedure, it has been associated with the risk of serious complications such as perforation, bleeding and incomplete resection that lead to postoperative abdominal distention, melena,ect.This concern has been raised, especially for gastric Endoscopic Submucosal Dissection (ESD) of gastric SMTs because ESD requires a relatively long procedure time and optimal sedation to keep the patient stable. Little is known about the clinical and oncologic outcomes of LECS compared with ESD in patients with gastric submucosal tumors GISTs.Many studies have been published about the use of minimally invasive surgicaltechniques to perform the resection of gastric SMTs. There are several factors that permit the more widespread adoption of the cooperation such as tumors locations; size and growth type. Moreover, Laparoscopic endoscopic cooperative surgery could eliminate the need for open resection and will satisfy the oncologic demands at very complicated specific regionObjective of the studyTo assess the intraoperative complications of laparoscopic endoscopic cooperative surgery versus endoscopic submucosal dissection for selected gastric gastrointestinal stromal tumors. The specific objective of this proposal study is to show that LECS can lead to a potential and satisfactory outcomes for intraluminal tumor located at specific site with different growth type and where RO satisfaction is involve.Patients and methods1.PatientsBetween 2004 and 2014, a total of 134 consecutive patients undergoing LECS or ESD for small gastric GISTs smaller than 2 cm were enrolled in a retrospective single-center study. Patients underwent detailed laboratory evaluation including blood count, medical history review, endoscopic ultrasonography (EUS) and computed tomography (CT) of the abdomen. The standard demographic and clinicopathologic data were collected including sex, age, and body mass index (BMI), symptoms, tumor location, size, and pathological results. Operation details, including operating time, estimated blood loss, complications, and length of hospital stay, were recorded. For the recurrence analysis, we collected the data of the last follow-up, recurrence events and survival. Complications were defined as intraoperative perforation and major bleeding. All patients were discussed and informed consent was given during multidisciplinary team conferences including surgical oncologists, pathologists, and medical oncologists.2. surgical strategy2.1 Laparoscopic operative techniquesThe type of techniques use for the LECS, operating procedures included laparoscopic intragastric wedge resection, laparoscopic seromuscular dissection and distal gastrectomy. With the patient anesthetised, the endoscope was inserted through the mouse. The mucosae of the oesophagus and stomach were viewed and with less air into the stomach. All liquid and gas was drained out after localisation of the SMTs forbetter manipulation of the stomach.Laparoscopic intragastric wedge resection.This procedure is performed for intragastric growth type.After localisation of the tumor by endoscopic procedure, the gastric wall around the tumors were Circumferentially dissected using harmonic scapel (ETHICON ENDO SURGERY).Resection of the tumors after the eversion by endoscopic linear staplers close the gastrostomy with the excision simultaneously.Seromuscular dissection.This technique is used for extragastric, mixed tumors, tumors located at the duodenum and prepylorus. After entering the lesser sac the fusion line between the posterior wall of the gastric and transverse mesocolon was divided. The mesogastrium was dissected off the mesocolon until the exposition of the pancreas head and duodenum before local resection with mucosa preservation was applied.Laparoscopic distal gastrectomy.This procedure is performed for gastric antral early cancer or SMTs with Billroth I type reconstruction after localisation of tumors by endoscope as describe bellow.Endoscopic proceduresPatients were sedated using propofol (1.0 mg/kg) or midazolam (0.035 mg/kg) with cardiorespiratory functions monitored closely during the procedure. ESD was performed using a standard method.ASA Physical Status (PS) Classification SystemThe American Society of Anaesthesiologists (ASA) Physical Status classification system was initially created in 1941 by the American Society of Anaesthetists, an organization that later became the ASA. The purpose of the grading system is simply to assess the degree of a patient’s "sickness" or "physical state" prior to selecting the anaesthetic or prior to performing surgery. Describing patients’ preoperative physical status is used for recordkeeping, for communicating between colleagues, and to create a uniform system for statistical analysis. The grading system is not intended for use as a measure to predict operative risk. The modern classification system consists of six categoriesStatistical analysesPSM was conducted to overcome the different distributions of covariates among individuals allocated to specific interventions in the study. A total of 102 patients who underwent ESD were chosen by PSM to match 32 LECS group members. We selected 5 covariates (age, gender, BMI, tumor location, and American Society of Anesthesiology Classification [ASAJgrade) that could affect allocation in the different groups with the aim to draw more reliable results. Logistic regression models were used to evaluate propensity scores, and nearest neighbor matching was performed for 1:1 matching, yielding 28 matched patients for further statistical analysis.Some controversies regarding the selection of variables for the PSM are noted.To decrease the variance of an estimated exposure effect without increasing the bias; confounding variables that are unrelated to the exposure but related to the outcomes should be included in the score model. Continuous variables were described as mean and standard deviation and categorical variables were described with frequencies (percentages). Characteristics were compared between groups using a chi-squared test or Fisher’s exact test for categorical variables and a t-test for continuous variables. Univariate logistic regression analysis and multivariate logistic regression analysis were performed for postoperative complications after small gastric submucosal resection for GISTs. DFSrates were calculated using the Kaplan-Meier method and were compared using a log-rank test and Breslow’s test. Data management and statistical analyses were performed with the SPSS statistical program (SPSS 20.0, Chicago, IL, USA). PSM was achieved using SAS (9.2). Values with P<0.05were considered statistically significant,except P<0.1 was chosen for the univariate analysis.ResultsAfter the PSM,no significance differences in age, gender, BMI, ASA grade, tumor location, circumferences and pathological manifestations were noted. Both groups were balanced regarding baseline variables. The rate of Rl resection between the two groups was increased in the ESD group, and this effect was significantly different (0.0%vs.32.1%, P=0.002). However, patients who underwent ESD experienced reducedabdominal discomfort compared with LECS patients, and this effect was significantly different (14.3%vs.78.6%, P<0.001). The LECS group had fewer pulmonary disease cases compared with ESD patients (17.9%vs.50.0%, P=0.001). Less cardiac disease was observed in the LECS group (10.7%vs.42.9%, P=0.007). No difference in tumor sizeswas noted between the two groups (P=0.267). Tumor location and circumference did not show any statistically significant difference between the compared groups (P=0.172 and P=0.236, respectively). No significant differences were observed in the postoperative recovery course (the time to first ambulation, flatus, liquid diet, and soft diet) between the two groups. Postoperative hospital stayswere similar between the two groups (6.0days [range: 4.3-8.0days] vs.6.0days [range:5.0-6.8days], P=0.841). Intraoperative bleeding times were reduced in the LECS group compared with the ESD group (20 ml [range: 10.0-50.0 ml] vs.32.0 ml [range:20.8-54.0 ml], P=0.018). The ESD group exhibited better operative times compared with the LECS group, and a significant difference was noted between the two groups (55.0 min [range:35.0-65.0 min] vs.104.5 min [range:75.5-139.8 min], P<0.001). The number of intraoperative complications was reduced in the LECS group (1[3.6%]) compared with the ESD group (9 [32.1]), which included 3 bleeding cases and 6 perforations. This effect was significantly different (P=0.007). To treat the major complications, reoperation was needed for 6 cases of perforation and 2 major bleeding cases in the ESD group. This phenomenon led to a significant difference in terms of reoperations because there were no reoperations in the LECS group (0 [0.0%]vs.8 [28.6%]; P=0.004).The univariate was associated with perioperative comorbidity ≥2 and age. On multivariate analysis, age and perioperative comorbidity ≥2 were retained in the final model. Specifically, compared with patients without perioperative comorbidity ≥2, other perioperative comorbidities were more likely to experiencepostoperative complications (odds ratio [OR]=0.037; 95% confidence interval [CI]=0.037-0.866,P=0.032).Age was an additional risk factorfor postoperative complications (OR=5.072,95%CI=1.101-23.356, P=0.037). After resection of GISTs, clinical assessments were made during 59.8(±24.9) months of follow-up, and the duration of follow-up was not significantly different between the 2 groups. One case recurred in the matched ESD group, and the Kaplan-Meir curves for DFS did not exhibit any statistically significant difference between the two groups (P=0.418; Fig.2).ConclusionOur study showed that LECS potentially offers better intraoperative outcomes and an equal postoperative course.We provided evidence on the safety and efficacy of LECS compared with ESD. |
PDF Full Text Request