A New Technique of Endoscopic Full-Thickness Resection Using a Flexible Stapler

• Introduction
• Procedure
• Case Reports
• Patient 1
• Patient 2
• Discussion
• References

There is a significant need for a safe and easy technique for endoluminal endoscopic resection of gastrointestinal lesions, but such procedures are usually restricted to resection of the mucosal layer in order to preserve the integrity of the wall of the gastrointestinal tract. We present two patients, one with early cancer and one with a carcinoid tumor, who were treated by endoscopic full-thickness resection. We used a stapling device, consisting of a flexible shaft, which was positioned intraluminally, and a remote control. After pilot investigations in pigs and in human anatomical preparations, we performed a full-thickness resection of the gastric wall in these patients, using the flexible stapling device under gastroscopic control. Gastric wall specimens up to 4 cm × 4 cm in size were resected with the use of two to three stapler magazines. Both procedures followed an uneventful course and the patients made an uncomplicated recovery. Further studies are necessary to test the applicability of the technique in the management of other gastric neoplastic lesions.

Introduction

For many years clinical research has focused on the development of minimally invasive techniques for the removal of early tumors of the gastrointestinal tract at endoscopy [1] [2] [3] [4] [5] [6] [7] [8]. To maintain the integrity of the organ wall, however, endoscopic resections of intraperitoneal organs have been limited to the mucosal and submucosal layers. A number of Japanese authors have reported the successful treatment of T1 gastric carcinomas using endoscopic resection, with satisfactory technical success rates and promising long-term survival rates, although subgroup analysis revealed decreased survival rates in patients with T1 tumors showing infiltration of the submucosa, compared with patients whose tumor infiltration was restricted to the mucosal layer [1] [3] [5] [6] [8].

When deciding on the appropriate treatment option for the cancer patient, it must be remembered that the peak incidence of nearly all epithelial tumors of the gastrointestinal tract is in the elderly age group. The risk of tumor recurrence after local (potentially endoscopic) resection has to be weighed against the usually higher risk of an open surgical procedure with radical tumor removal.

Besides epithelial tumors, mesenchymal tumors such as gastrointestinal stromal tumors also require complete local resection.

Lymphadenectomy is not obligatory in these patients because lymph node metastases are exceptionally rare. A method combining the advantages of complete local resection with the less invasive access afforded by intraluminal endoscopy would therefore seem to be beneficial [2]. We report here the first true full-thickness gastric resection procedures using exclusively endoluminal access [9].

Procedure

Stapling devices have been used extensively in surgical resections and anastomoses for many years. The SurgAssist system (Power Medical Interventions Deutschland GmbH, Hamburg, Germany) is a recently developed stapler application system which is commercially available. It combines a flexible, 13-mm-diameter shaft for intraluminal application with a conventional stapler magazine (55 mm in length) and allows an electronically controlled remote release (Figure [1], [2]). The linear stapling device and the gastroscope can be introduced simultaneously through the esophagus into the stomach. (The introduction of the rigid tip of the stapling device can be facilitated by using a temporarily placed overtube.) The lower part of the corpus and the antrum can be reached by the stapler. The gastric wall can be pulled by a grasper from the endoscope into the opened branches of the linear stapler (Figure [3]). The number of magazines required depends on the size of the target lesion. The resection specimen is removed through the esophagus using the endoscope. The feasibility of this approach was successfully tested experimentally in a pig model as well as in three human preparations [10]. We present here the first clinical applications of this technique.

Case Reports

Patient 1

An 82-year-old woman was referred because of incomplete endoscopic resection (R1) of a malignant gastric polyp (pT1[m]) G2 LO V0) in the lower gastric corpus. Endoscopic ultrasound revealed that there were no lymph node metastases. An area of the corpus, 4 cm × 4 cm in size, was resected using three 55-mm-long linear magazines (Figure [4]). Ultrasound examination immediately after the procedure did not show any free fluid or air in the abdominal cavity. Histopathological examination of the specimen showed the residual noninvasive adenomatous tissue in the mucosa with tumor-free margins. The minimum distance of tumor from the resection margin was 1.2 cm, and the final tumor stage was therefore classified as pT1(m) G2 L0 V0 R0.

The postinterventional follow-up period was uneventful, with the exception of mild dysphagia for the first day after the procedure. Gastroscopy on day 4 showed intact suture lines in the stomach (Figure [5]).

Patient 2

A 64-year-old man was referred for mucosal resection of a carcinoid polyp in the corpus ventriculi. Endoscopic ultrasound revealed a tumor, 1.2 cm in diameter, infiltrating the submucosa, but no lymph node metastases. The endoluminal gastric resection was performed with two 55-mm linear magazines. One metal clip was applied because of bleeding from the suture. Histopathological examination of the resected specimen showed a mixed exocrine-endocrine carcinoma (Figure [6]). The minimum distance from the tumor to the resection margin was 0.8 cm, and the tumor stage was therefore pT1(sm) L0 V0 R0. The follow-up period was uneventful, and the patient was discharged 2 days after the procedure.

Discussion

This is the first report describing totally endoluminal full-thickness resections of the stomach. The presented clinical cases suggest that this method may complement the endoscopic mucosal resection techniques that we are already using. Although the currently available SurgAssist stapler device enables full-thickness resection, there should be further development to improve endoluminal navigation and the degree of precision. This could also lead to expansion of the range of possible future indications. In addition, an even smaller diameter would be advantageous for endoscopic use and transesophageal introduction of stapler devices. Lastly, special stapler magazines could be developed which are only mounted with outer brackets because the stapler suture along the resected tissue is dispensable.

The results presented above justify the initiation of clinical investigations of endoscopic full-thickness resection of the stomach. Because a possible bleeding site can be detected intraluminally, the treatment would follow the principles of conventional endoscopic management, with clip application or injection therapy. Another critical point is the need to preserve the integrity of adjacent organ structures. This could be verified by simultaneous transabdominal ultrasound. For the future, we see gastrointestinal stromal tumors and T1 carcinomas of the stomach in patients with severe co-morbidity as possible indications for full-thickness endoscopic resection, and regard the results in the two patients presented here as promising.

References

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• 9 Ikeda K, Fritscher-Ravens A, Mosse S, Swain P. Endoscopic full-thickness partial gastric wedge resection (FTR) with suture closure of defect.  Endoscopy. 2004;  36 Suppl 1 A15
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G. F. B. A. Kähler, M. D.

Sektion Endoskopie und Sonographie

Chirurgische Universitätsklinik Mannheim · Theodor-Kutzer-Ufer 1 - 3 · 68167 Mannheim · Germany

Fax: +49-383-3385 ·

Email: georg.kaehler@chir.ma.uni-heidelberg.de

References

• 1 Abe N, Watanabe T, Sugiyama M. et al . Endoscopic treatment or surgery for undifferentiated early gastric cancer?.  Am J Surg. 2004;  188 181-184
  CrossrefPubMedSearch in Google Scholar
• 2 Harms J, Schneider A, Roesch T, Böttcher K. Minimal invasive, endogastrale endoskopisch assistierte Resektion eines Gastrointestinalen Stromatumors des Ösophagogastralen Übergangs: erster Erfahrungsbericht.  Chir Gastroenterol. 2003;  19 391-395
  CrossrefPubMedSearch in Google Scholar
• 3 Kashimura H, Ajioka Y, Watanabe H. et al . Risk factors for nodal micrometastasis of submucosal gastric carcinoma: assessment of indications for endoscopic treatment.  Gastric Cancer. 1999;  2 33-39
  CrossrefPubMedSearch in Google Scholar
• 4 Ludwig K, Wilhelm L, Scharlau U. et al . Laparoscopic-endoscopic rendezvous resection of gastric tumors.  Surg Endosc. 2002;  16 1561-1565
  CrossrefPubMedSearch in Google Scholar
• 5 Mitsunaga A, Konishi H, Nakamura S. et al . Evaluation of endoscopic mucosal resection for early gastric cancer in aged patients.  Gut. 2004;  53 (Suppl VI) A15
  PubMedSearch in Google Scholar
• 6 Nakagoe T, Tanaka K, Yasutake T. et al . Long-term outcomes of intragastric endoscopic mucosal resection using a modified Buess technique for early gastric cancer.  Dig Surg. 2003;  20 141-147
  CrossrefPubMedSearch in Google Scholar
• 7 Rosch T, Sarbia M, Schumacher B. et al . Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series.  Endoscopy. 2004;  36 788-801
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Tanabe S, Koizumi W, Mitomi H. et al . Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer.  Gastrointest Endosc. 2002;  56 708-713
  CrossrefPubMedSearch in Google Scholar
• 9 Ikeda K, Fritscher-Ravens A, Mosse S, Swain P. Endoscopic full-thickness partial gastric wedge resection (FTR) with suture closure of defect.  Endoscopy. 2004;  36 Suppl 1 A15
  PubMedSearch in Google Scholar
• 10 Kaehler G FBA, Langner C, Suchan K L. et al . Endoscopic full thickness resection of the stomach: an experimental approach.  Surg Endosc. 2005;  in press
  PubMedSearch in Google Scholar

G. F. B. A. Kähler, M. D.

Sektion Endoskopie und Sonographie

Chirurgische Universitätsklinik Mannheim · Theodor-Kutzer-Ufer 1 - 3 · 68167 Mannheim · Germany

Fax: +49-383-3385 ·

Email: georg.kaehler@chir.ma.uni-heidelberg.de