World J Surg (2008) 32:1709–1713 DOI 10.1007/s00268-008-9607-8
Laparoscopic Intraluminal Surgery for Gastrointestinal Malignancies Morris E. Franklin Jr. Æ Guillermo Portillo Æ Jorge M. Trevin˜o Æ John J. Gonzalez Æ Jeffrey L. Glass
Published online: 20 May 2008 Ó Socie´te´ Internationale de Chirurgie 2008
Abstract Introduction Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery. Materials and Method The data for all patients with early gastric and duodenal cancers who underwent laparoscopyassisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for
endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing. Results From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with diseasefree margins. No recurrence of the original pathology have been reported, and the complications were minimal. Conclusion Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.
Electronic supplementary material The online version of this article (doi:10.1007/s00268-008-9607-8) contains supplementary material, which is available to authorized users.
Introduction
M. E. Franklin Jr. G. Portillo (&) J. M. Trevin˜o J. J. Gonzalez J. L. Glass Texas Endosurgery Institute, 4242 East Southcross Boulevard, Suite 1, San Antonio, TX 78222, USA e-mail:
[email protected]
Surgery has faced numerous changes throughout history. The latest and probably one of the most important changes has been laparoscopic surgery, which began in 1986 with the advent of laparoscopic cholecystectomy and evolved dramatically to include almost every known abdominal
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surgical procedure. Today’s trend toward increasingly more minimally invasive surgery has set the stage for endoluminal surgery, a discipline that is likely to become widespread in the field of digestive surgery in the upcoming years [1–8]. Starting with removing the organ that contains the disease, surgeons are moving toward a less invasive procedure that will result in less morbidity and improved patient outcomes [9–13]. Endoluminal surgery started with the development of endoscopy. As diagnostic upper and lower endoscopy became more prevalent, therapeutic endoscopy quickly emerged as the next logical step. However, endoscopic endoluminal surgical techniques have their limitations. When these procedures fail, conventional open surgery must be performed. Disadvantages of an open approach include more trauma to the patient; and as an incision is required, the presence of wound infections and incisional hernias are increased. Laparoscopy-assisted intraluminal surgery may be the next step in the management of selected patients [9, 13–15]. By offering all the proven advantages of minimally invasive surgery, such as a shorter hospital stay, decreased wound infections and decreased incisional hernias formation, this technique is potentially a more precise operation. The experience of the Texas Endosurgery Institute (TEI) with treating early gastric and duodenal cancers, including large malignant polyps and carcinoid, with laparoscopyassisted endoluminal surgery is presented here. We include our technique and the patients’ outcome.
Materials and methods Materials Data for all patients with early gastric and duodenal cancers who had laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were analyzed. All of the patients were referred by the endoscopist as noncandidates for endoscopic resection. The preoperative diagnosis, operating time, surgical technique including the number and size of trocars, estimated blood loss, postoperative complications, final pathologic diagnosis, length of hospital stay, and recurrence rate were recorded in a prospective manner. Each patient was subsequently followed with an endoscopic study at 3, 6, and 12 months after the surgery; thereafter, endoscopy was performed on a yearly basis.
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clamps were applied distal to the viscus; in the case of gastric involvement, this was usually at the ligament of Treitz to prevent insufflation of the small bowel during the procedure. Upper endoscopy was performed to insufflate the organ, to identify the lesion, and for guided placement of the trocars under direct vision. The pathology within the viscus was then identified and assessed. A decision is made whether to complete the case intraluminally based on the size, mobility, consistency, and other laparoscopic findings. A 5-mm balloon trocar (Marlowe Surgical Technologies, Willoughby, OH, USA) was inserted through the anterior abdominal wall and the anterior wall of the stomach under direct visualization. This trocar was then inflated to keep the port in place and secure the viscus to the anterior abdominal wall. Care was taken not to injure the posterior wall of the viscus upon trocar placement. Insufflation with carbon dioxide was maintained via a highflow laparoscopic insufflator at a pressure of 10 to 15 mmHg. The gastroscope was left in place during the procedure to assist with visualization, snaring, and removal of specimens. Additional port and trocars 2 mm in size were then introduced into the field via the abdominal wall and appropriately positioned to access the lesion. These 2mm working ports did not necessarily need to be ballooned or secured. The pneumoperitoneum was released only after all of the intraluminal trocars were in place. The lesion was removed with a 1-cm margin circumferentially using diathermy and scissor dissection. The submucosa was injected if needed to assist removal, but it was not always necessary. The specimen was retrieved with the endoscope if possible (Fig. 1). Upon completion of the intraluminal portion of the operation, the organ in question was deflected, pneumoperitoneum reestablished, and the ports removed. Port sites in the viscus were oversewn intracorporeally with a 3-0 absorbable braided suture. It has been reported that 2-mm port sites do not need to be closed; however, we believe it is safer to do so. All patients underwent intraoperative postresection endoscopy to test and evaluate potential leakage from the areas of the biopsy or gastric port sites with simultaneous observation via the laparoscope. The portion of the stomach or duodenum that was operated on was inspected with the laparoscope to ensure that there was no evidence of diathermy burn; when present, the area was properly repaired with absorbable suture. The bowel clamp was then removed, the pneumoperitoneum released, and the skin incisions closed.
Technique for Intraluminal Gastroduodenal Surgery Results After establishing a pneumoperitoneum, the peritoneal cavity was explored and the affected organ identified. Adhesiolysis was performed as required. Atraumatic bowel
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From July 1996 to January 2007, a total of 12 patients underwent laparoscopic intraluminal surgery: 7 women and
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Fig. 1 Duodenal tumor resection
6 men with a mean age of 60 years (range 41–96 years). All cases were completed successfully, including five early gastric cancer resections (stage I), two wedge resections of a carcinoid tumor, three resections of duodenal adenocarcinoma, and two resections of malignant polyps at the gastroesophageal junction. All cases were completed with disease-free margins. There were no conversions to an open procedure, although in two cases of carcinoid tumor the surgery was progressed to full-thickness wedge excision because of the impossibility of resecting the tumor with free margins intraluminally. Intraoperative frozen sections of both patients showed positive margins, as suspected, and disease-free margins were completed. The wedge excisions was performed with a laparoscopic linear stapler using staple line reinforcement Seamgard (W.L. Gore, Flagstaff, AZ, USA) guided with direct endoluminal endoscopic vision. The mean operating time was 121 minutes (range 90– 180 minutes), and the estimated blood loss was 27.14 ml (range 10–50 ml). The mean hospital stay was 3.5 days (range 2–6 days). The final pathology results demonstrated negative margins in all patients. Follow-up upper endoscopy was performed in all patients (at 6 months, 1 year, and every year thereafter) to evaluate the surgical sites. All patients had well healed surgical sites with no evidence of recurrence. The median follow-up was 36 months (range 10–108 months). In all, 100% (12 patients) were followed for more than 10 months, 92% (11 patients) for more than 1 year,
60% (7 patients) for more than 2 years, 45% (5 patients) for more than 3 years, and 25% (3 patients) for more than 5 years. To date, there have been no recurrences in any of the 12 patients. Two patients developed atelectasis and were successfully treated medically. One patient developed ileus but was treated medically without further complications. One patient with early gastric cancer excision experienced a 4% drop in her hematocrit on postoperative day 1 but did not require transfusion or reoperation.
Discussion Laparoscopy-assisted intraluminal surgery was introduced in 1994 by Ohashi [10]. Eight patients with mucosal and submucosal gastric lesions underwent successfully excision with outcomes and survivals equivalent to cases performed via laparotomy [10]. The same year, two independent reports were published describing endoluminal pancreatic cystogastrostomy [16, 17]. Treatment of early gastric cancer using similar or slightly different techniques of intraluminal surgery had been described before [18] . We consider laparoscopic monitoring to be an important part of this procedure for evaluating leaks, port placement, and stage of the disease, although some of the previous authors did not perform simultaneous laparoscopy for all cases. Our technique incorporates the use of needlescopic instruments, thereby minimizing the gastrostomy closure, as well as the use of a ballooned trocar to secure the
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stomach to the anterior abdominal wall. We place the intraluminal trocars under direct visualization with a laparoscope to prevent bowel or vascular injury and to ensure appropriate closure of the port sites. Our initial experience included placing a 10-mm trocar site intraluminally, which could facilitate specimen bag placement and specimen removal; subsequently, however, we found that a 10-mm port was not necessary. If a ballooned trocar is not available, an alternative is to place two sutures through the abdominal wall of the organ and back though the abdominal wall to secure it to the anterior abdominal wall. Securing the 5-mm intraluminal port is vital for uninterrupted and trouble-free intraluminal maneuvers and may be important for oncologic reasons. No port-site implantations have been observed after this procedure. It is an advantage to have two skilled surgeons working together to perform the intraluminal laparoscopic surgery. Furthermore, advanced laparoscopic skills are absolutely necessary when using 2-mm instruments as they are difficult to manipulate in the confined space. Laparoscopy-assisted intraluminal surgery can be applied to any hollow viscus. Our experience reported here is limited to the foregut, but this technique can be expanded to the small bowel and colon by following the same general principles [19, 20]. Laparoscopy-assisted intraluminal surgery was an adequate alternative for the selected patients in our small series. We were able to treat 84% (n = 10) of the patients successfully with low morbidity and mortality rates. The other two patients required wedge resection because of the impossibility of completely resecting the tumor intraluminally, but direct endoscopic vision was critical to ensure adequate resection margins. In all of the patients, an adequate oncologic resection was ultimately completed and proven, including the two carcinoid cases. There have been few articles published on intralauminal resection for gastric and duodenal malignancies. The ones that have are limited to case reports with variable follow-up, although they certainly demonstrated feasibility [18, 21–26]. Our study is limited by the small number of patients but represents one of the largest series ever published for early gastric and duodenal malignancies with intention to treat. To demonstrate an advantage effectively, more patients and longer follow-up are needed. Although technically demanding, laparoscopy-assisted intraluminal surgery could be the stepping stone to future skill acquisition and a multitude of additional procedures.
Conclusion Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open
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conventional therapies and has a lower incidence of incisional hernia formation and a lower infection rate.
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