A 67-year-old woman presented to the outpatient clinic with new-onset epigastric pain,
with an initial abdominal ultrasound revealing a probable gastric mass. At endoscopy,
we observed an approximately 5-cm subepithelial gastric tumor on the lesser curvature
of the stomach and performed bite-on-bite biopsy, with a resulting histopathologic
diagnosis of gastric leiomyoma being made ([Fig. 1]). We considered submucosal tunneling techniques for removal, but, owing to the large
tumor size and its position, our team opted for laparoscopic and endoscopic cooperative
surgery (LECS) [1]
[2] for local tumor resection ([Fig. 2]; [Video 1]).
Fig. 1 Endoscopic view showing a large subepithelial tumor protruding from the lesser curvature
of the stomach.
Fig. 2 Schema showing the steps involved in the laparoscopic and endoscopic cooperative surgical
procedure: a establishment of capnoperitoneum; b delineation of the tumor and formation of a submucosal cushion; c semicircumferential dissection of the luminal oral side; d controlled perforation of the gastric wall; e laparoscopic completion of circumferential dissection; f specimen retrieval, and laparoscopic suturing and closure of the wall defect.
Laparoscopic and endoscopic cooperative surgery (LECS) is performed for a large gastric
tumor, with steps involving semicircumferential submucosal dissection, controlled
gastric wall perforation, and laparoscopic-assisted tumor resection, followed by specimen
retrieval and gastric wall defect closure.Video 1
The patient was prepared using the standard approach for laparoscopic upper gastrointestinal
surgery. After capnoperitoneum had been established by the surgical team, the endoscopist
marked the tumor margins and proceeded with a semicircumferential submucosal injection
on the oral side and submucosal dissection with an IT2-knife. We then performed controlled
perforation of the gastric wall with a needle-knife, and performed further circumferential
endoscopic dissection with laparoscopic assistance ([Fig. 3]). The surgical team flipped the tumor into the peritoneal cavity and completed the
resection. The specimen was retrieved through a laparoscopic port in a protective
plastic bag, and the gastric wall defect was sutured. The total procedure time was
130 minutes. The patient was discharged after 6 days, having experienced no adverse
events.
Fig. 3 Simultaneous endoscopic and laparoscopic views during circumferential dissection.
Pathology confirmed an R0 resection of a 5-cm gastrointestinal stromal tumor (GIST)
with a low mitotic index (Ki-67 of 1%) ([Fig. 4]). In contrast to the initial diagnosis of leiomyoma, gastric GIST carries a theoretical
risk of tumor seeding when resected without a true “no-touch” technique; however,
because of the intact specimen and the absence of risk factors, the multidisciplinary
team recommended follow-up gastroscopy and computed tomography scanning in 6 months.
Fig. 4 Microscopic appearance of the resected specimen showing a gastric gastrointestinal
stromal tumor with clear resection margins and the typical spindle-cell architecture.
This case highlights the safety and effectiveness of underused collaborative techniques
such as LECS in achieving complete tumor resection, while preserving organ function
and the patient’s quality of life.
Endoscopy_UCTN_Code_TTT_1AT_2AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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