Conversion to laparoscopy in gastric endoscopic full-thickness resection: adverse event or routine step-up approach?

A 25-year-old woman was referred to our institute for evaluation of an incidental gastric submucosal tumor (SMT) located in the anterior wall of the antrum, proximal to the incisura angularis ([Fig. 1]). Endoscopic ultrasound (EUS) showed an inhomogeneous hypoechoic lesion with regular margins arising from the muscularis propria ([Fig. 2]). EUS-guided fine-needle biopsy with a 20-gauge needle (EchoTip ProCore, Cook Medical, Limerick, Ireland) was performed. Cytohystological examination was inconclusive. The patient refused long-term endoscopic surveillance. Therefore, after multidisciplinary evaluation, it was decided to perform free-hand endoscopic full-thickness resection (EFTR) with gastric defect closure using the OverStitch suturing device (Apollo Endosurgery, Austin, Texas, USA) ([Video 1]).

Fig. 1 Endoscopic view showing submucosal tumor (white dashed line) located in the anterior wall of the gastric antrum, proximal to the incisura angularis (red dashed line).

Fig. 2 B-mode endoscopic ultrasound view showing an inhomogeneous hypoechoic lesion (white arrows), 15 × 18 mm in diameter, originating from the muscularis propria layer.

Video 1 Conversion to laparoscopy in gastric endoscopic full-thickness resection as a possible and effective step-up approach.

The patient was informed that in case of failure of EFTR, the standard laparoscopic approach would be performed during the same general anesthesia. After 75 % of the resection, completion of the EFTR appeared technically unfeasible. Endoscopic peritoneal exploration showed the gastric SMT to have an extraluminal growth pattern and to be in close contact with the left liver lobe ([Fig. 3]). Attempts at countertraction were not effective in obtaining successful triangulation. Thus, conversion to laparoscopy was decided.

Fig. 3 Endoscopic peritoneal exploration revealed an extraluminal growth pattern of the tumor (asterisk: lesion; red dashed line: free-hand cutting line) and its close contact with the left liver lobe (blue dashed line). The endoscope retroflexed position allowed complete delineation of anatomic structures: gastro-colic ligament, falciform ligament, and the posterior layer of the abdominal wall (double asterisk).

The patient was promptly transferred to the operating room, and laparoscopic wedge resection was successfully performed during the same anesthesia ([Fig. 4]). No severe complications occurred, and the patient was discharged on Day 7. Final histology revealed complete resection of an ectopic pancreas.

Fig. 4 Conversion to laparoscopic surgery. a Laparoscopic view showing completion of tumor (asterisk) resection using linear stapler. b Laparoscopic view of specimen removal using endoscopic bag.

The laparoscopic approach is the gold standard for the management of SMTs but EFTR has demonstrated a good efficacy and safety profile in resection of deep gastric SMTs [1]. Few cases of conversion to laparoscopy in gastric EFTR have been reported [2] [3] [4] [5]. A step-up approach consisting of standard EFTR followed, if necessary, by laparoscopic resection or laparoscopy-assisted EFTR within the same operative session appears promising in the management of selected cases of gastric SMT.

Endoscopy_UCTN_Code_TTT_1AT_2AD

• References

• 1 Jain D, Mahmood E, Desai A. et al. Endoscopic full thickness resection for gastric tumors originating from muscularis propria. World J Gastrointest Endosc 2016; 8: 489-495
• 2 Ye LP, Yu Z, Mao XL. et al. Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria. Surg Endosc 2014; 28: 1978-1983
• 3 Cai MY, Xu JX, Zhou PH. et al. Endoscopic resection for gastric schwannoma with long-term outcomes. Surg Endosc 2016; 30: 3994-4000
• 4 Abe N, Takeuchi H, Ohki A. et al. Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor. Dig Endosc 2018; 30 (Suppl. 01) 7-16
• 5 Zhang H, Huang X, Qu C. et al. Comparison between laparoscopic and endoscopic resections for gastric submucosal tumors. Saudi J Gastroenterol 2019; 25: 245-250