With recent improvements in the survival of patients after esophagectomy, the occurrence
of secondary malignancies arising in the gastric tube has been increasing [1]
[2]. However, resection of the reconstructed gastric tube with lymphadenectomy for gastric
tube cancer (GTC) is an invasive procedure associated with high morbidity and mortality
[3]. Local resection without lymphadenectomy may be reasonable in high risk patients.
We have developed a novel thoracoscopic and endoscopic cooperative surgery (TECS)
technique as a minimally invasive alternative.
Two patients underwent TECS for GTC after esophagectomy. Patient #1 had a 25 mm, undifferentiated,
submucosal invasive adenocarcinoma ([Fig. 1], [Fig. 2]), which was considered difficult to resect completely by endoscopic submucosal dissection
(ESD). Patient #2 had undergone ESD for a 10 mm depressed GTC ([Fig. 3]); however, histopathological analysis revealed noncurative resection because of
submucosal invasion to 1150 μm, with a positive vertical margin.
Fig. 1 Endoscopic view of a depressed lesion (arrows) with an irregular surface observed
in Patient #1.
Fig. 2 Endoscopic ultrasonographic image of a low-echoic tumor with deep invasion of the
submucosal layer (arrows).
Fig. 3 Endoscopic view of a slightly depressed lesion (arrows) observed in Patient #2.
The absence of metastasis was confirmed preoperatively using computed tomography.
The TECS steps ([Video 1]) were: 1) exposure of the gastric tube by thoracoscopy; 2) mucosal incision around
the involved site and submucosal trimming using ESD technique, followed by full-thickness
incision by endoscopy (ITknife 2; Olympus, Tokyo, Japan); 3) thoracoscopic resection
with Harmonic scalpel (Ethicon, Somerville, New Jersey, USA); 4) suturing.
Video 1 Thoracoscopic and endoscopic cooperative surgery procedure in Patient #2 with gastric
tube cancer after noncurative endoscopic submucosal dissection.
Both TECS procedures were performed under general anesthesia with orotracheal intubation
and were successfully completed in 250 and 420 minutes, respectively. Blood loss was
minimal. No perioperative complications such as anastomotic leaks, bleeding, or stricture
were observed. Oral intake was started on postoperative days 7 and 8. The patients
were discharged 14 and 25 days after the procedure.
ESD for GTC is sometimes technically difficult with fibrosis [4], and the long-term outcomes for noncurative patients are reportedly less satisfactory
[5]. Although careful follow-up for possible metastasis is necessary in our patients,
TECS was a feasible, safer, and less invasive therapeutic option for patients with
noncurative GTC.
Endoscopy_UCTN_Code_TTT_1AT_2AF
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
