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Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
SH Kong
Lecture
4 years ago
2262 views
123 likes
2 comments
22:10
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
Pure NOTES: Transvaginal tubal sterilization with flexible endoscope
Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. The patient is 32 years old with a history of one previous vaginal delivery and one previous cesarean delivery. Her BMI is 20. The procedure was fully explained to the patient and written consent was obtained.
J Mejías, H Almau, P Rosales, R de la Fuente, N García, C Bravo
Surgical intervention
8 years ago
472 views
13 likes
0 comments
07:05
Pure NOTES: Transvaginal tubal sterilization with flexible endoscope
Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. The patient is 32 years old with a history of one previous vaginal delivery and one previous cesarean delivery. Her BMI is 20. The procedure was fully explained to the patient and written consent was obtained.
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
S Perretta, M Diana, B Dallemagne, R Cahill, J Marescaux
Surgical intervention
9 years ago
131 views
3 likes
0 comments
02:28
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.