Laparoscopic and endoscopic cooperative surgery for full-thickness resection and sentinel node dissection for early gastric cancer

TO THE EDITOR

We read with great interest the retrospective study by Inokuchi

[1],which evaluated the feasibility and efficacy of gastric endoscopic submucosal dissection (ESD) in patients aged ≥ 80 years.The study was based on 172 sessions of gastric ESD in 124 patients,with a final diagnosis of gastric cancer (GC) in 175 Lesions.The patients were studied retrospectively to evaluate short-term outcomes (procedurerelated mortality,complications,curative dissection and rates of

dissection) and survival.In the study,there was a high

dissection rate (97.1%) and a curative dissection rate of 77.1%.Complications occurred in 8 patients (4.7%).There were 6 cases (3.4%) of postoperative bleeding,2 (1.1%) of intraoperative perforation,and 1 (0.6%) of aspiration pneumonitis after ESD.There were no procedurerelated deaths[1].The significant risk factors that increased the rates of bleeding were tumor location in the lower third of the stomach,lesions ＞ 40 mm,presence of a depressive component,and ulcerative features.The main risk factor for perforation was the site in the upper third of the stomach[1].To evaluate long-term outcomes,the patients were divided into two groups: curative group (

= 87) and non-curative (without additional surgery) ESD group (

= 33).The overall survival rate was strongly predicted by the Charlson Comorbidity Index (CCI).Patients with CCI ≥ 2 had a poor prognosis,regardless of curability.The conclusion of the study underlines that ESD is feasible even in elderly patients aged ＞ 80 years,without an increase in complications.

They even suggested that she should carry weights in her pockets, or have them tied to her ankles; but this idea was given up, as the princess found it so uncomfortable

It is clear why,over the years,the ESD technique has become the gold standard for submucosal tumors with negligible risk of lymph node metastasis (LNM),namely its minimal invasiveness and ability to improve quality of life.We agree with the importance of ESD,but this technique is limited in stage T1 cancers that have a low risk of developing LNM.

The laparoscopic endoscopic cooperative surgery (LECS) approach was melt,for the treatment of gastric submucosal tumors (SMTs),from fusion of ESD and surgery to endoscopic identification of the resection line and laparoscopic resection of gastric wall[2-4].LECS begins with the endoscopic pre-cut around the tumor and section of the gastric wall.Then,with a laparoscopic approach,the tumor is excised and the gastric wall defect is reconstructed with a mechanical stapler.The advantage is that there are no limitations on tumor location[5].LECS was used initially for the SMTs without ulceration[6].Subsequently,the indication was expanded to also include lesions with ulcerative features and GC with very low risk of LNM[7,8].The limitation of classical LECS includes the possibility of tumor and gastric content contamination into the peritoneal cavity because of the opening of the gastric wall during the procedure,increasing the risk of peritoneal tumor seeding.Therefore,some modified LECS procedures have been developed,such as inverted LECS[7],non-exposed endoscopic wall-inversion surgery (NEWS)[9-11],a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique[12],and closed LECS[13].

The NEWS technique allows full thickness resection avoiding contamination of the intra-abdominal region with intragastric material.This procedure does not require intentional perforation,avoiding the risk of tumor seeding.Saline solution is injected endoscopically into the submucosa to mark the lesion margins.In the next step,the section of the outer layers of the wall and their suture are performed laparoscopically in such a way as to invert the early GC (EGC) towards the inside of the stomach.The last step is represented by the removal of the specimen by the ESD approach and closure of the defect with clips or nets.NEWS has the advantage of avoiding peritoneal contamination and cancer cell seeding.The limitations are represented by the long duration due to the combination with ESD and endoscopic closure of the mucosal defect.It is also difficult to perform for lesions of the esophagogastric junction and pylorus.The main disadvantage of this technique is the size of the tumor.Since the lesion must be extracted orally,this approach is limited for gastric SMTs greater than 3 cm[5].The indication for NEWS is gastric SMTs and lymph node-negative EGC,where there is some technical contraindication to ESD.

I never could hold a pencil the right way. I never could color in the lines. Every ime I would try, my hand would cramp2 up and the letters would come out sloppy3, the lines too dark, and the marker would get all over my hands. Nobody wanted to switch papers with me to grade them because they couldn t read them. Keith could, but he moved away.

Currently,the main indications for modified LECS are EGCs not amenable to endoscopic treatment by endoscopic mucosal resection (EMR)/ESD,again with negligible risk of LNM.The suspicion of LNM requires a gastrectomy with lymphadenectomy[15].

His sons and daughters, who had been very uneasy at his long absence, rushed to meet him, eager to know the result of his journey, which, seeing him mounted upon a splendid horse and wrapped in a rich mantle35, they supposed to be favourable36

The combination of the NEWS technique with sentinel node (SN) navigation surgery for the treatment of EGCs was reported by Goto

[10,16].A previous prospective multicenter study had already validated SN navigation surgery for GC[17].The combined use of modified LECS and SN navigation surgery in the case of EGC allows for oncologically adequate resections with minimally invasive approaches,and can represent a valid alternative in elderly patients.Currently,this combination technique can be applied to EGC in which SN (surgical nodal basin) dissection can be performed with intra-operative evaluation by the one-step nucleic acid amplification assay[8].

The Japanese National Health Insurance Plan recently approved the LECS procedure for GC for insurance coverage.Postoperative gastrectomy syndrome and post-procedure physical weakness are negligible with LECS.

LECS was recently performed in an elderly patient who refused radical surgery as a palliative treatment[14].

All the authors declare no conflicts of interest.

Vanella S designed the study;Godas M,Pereira AM,and Apicella I conducted the study;Crafa F and Pereira JC revised the letter.

Italy

The princess had heard the trumpets44 and the proclamations, and knew quite well that her ring was at the bottom of it all. She, too, had fallen in love with the prince in the brief glimpse she had had of him, and trembled with fear lest someone else’s finger might be as small as her own. When, therefore, the messenger from the palace rode up to the gate, she was nearly beside herself with delight. Hoping all the time for such a summons, she had dressed herself with great care, putting on the garment of moonlight, whose skirt was scattered45 over with emeralds. But when they began calling to her to come down, she hastily covered herself with her donkey-skin and announced she was ready to present herself before his Highness. She was taken straight into the hail, where the prince was awaiting her, but at the sight of the donkey-skin his heart sank. Had he been mistaken after all ?

Moreover,as suggested by the authors,this new cooperative technique can be applied even to EGC,which has features that significantly increase the risk of bleeding and/or perforation.Careful selection of indications and careful post-operative follow-up is required.No cases of disseminated GC recurrence have been described after LECS[7,15,18,19].Randomized clinical trials on long-term oncological outcomes are needed to better clarify the future indications of ESD and modified LECS with SN navigation surgery.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

: Serafino Vanella 0000-0002-6599-8225;Maria Godas 0000-0002-3777-5788;Ana Pereira 0000-0002-1374-1372;Francesco Crafa 0000-0002-2038-625X.

Now the reason for this was the tiny doll, without whose help little Vasilissa could never have managed to do all the work that was laid upon her. Each night, when everyone else was sound asleep, she would get up from her bed, take the doll into a closet, and locking the door, give it something to eat and drink, and say: There, my little doll, take it. Eat a little, drink a little, and listen to my grief. I live in my father s house, but my spiteful stepmother wishes to drive me out of the white world. Tell me! How shall I act, and what shall I do?

Liu JH

A

Liu JH

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