Laparo-endogastric surgery

# Guidance
Current evidence on the safety and efficacy of laparo-endogastric surgery does not appear adequate to support the use of this procedure without special arrangements for consent and for audit or research. Clinicians wishing to undertake laparo-endogastric surgery should inform the clinical governance leads in their Trusts. They should ensure that patients offered it understand the uncertainty about the procedure's safety and efficacy and should provide them with clear written information. Use of the Institute's information for the public is recommended. Clinicians should ensure that appropriate arrangements are in place for audit or research. Publication of safety and efficacy outcomes will be useful in reducing the current uncertainty. NICE is not undertaking further investigation at present.
The procedure should only be performed by specialists in laparoscopic surgery who have observed at least one patient undergoing the procedure.# The procedure

# Indications
Laparo-endogastric surgery is also known as laparoscopic endoluminal surgery, endo-organ gastric surgery and laparoendoscopic gastric surgery. It is used to treat lesions located in the fundus of the stomach, the gastroesophageal junction, and near the pylorus. These include gastric polyps, gastric wall tumours (lymphomas, leiomyomas, leiomyosarcomas, carcinoids), gastric cancer, Dieulafoy's lesion (arterial malformation) and intractable gastroduodenal ulcers. Lesions on the greater and lesser curvatures are relatively inaccessible.
Large or advanced gastric cancers are rarely suitable for laparo-endogastric surgery.
Traditional approaches to gastric surgery are resection operations through a laparotomy incision or laparoscopy.

# Outline of the procedure
Laparo-endogastric surgery is a minimally invasive approach to surgery for gastric wall lesions, and attempts to avoid resection of the full thickness of the stomach wall. With the patient under general anaesthetic, the surgeon passes an endoscope through the oesophagus into the stomach. A laparoscope is inserted through a small incision in the upper abdominal wall, passed into the stomach, and surgery is performed from inside the stomach.

# Efficacy
Evidence was from small, uncontrolled case series. The efficacy of the procedure compared with conventional open laparotomy or laparoscopic partial gastrectomy remains uncertain. For more details refer to the sources of evidence section.
Specialist Advisors considered laparo-endogastric surgery to be a very new procedure carried out in very few specialist units worldwide. The technique is not widely disseminated, and there are few opportunities for training. One Specialist Advisor questioned the procedure's efficiency in excising small malignant lesions completely.

# Safety
Few complications were reported in the studies. As the case series are so small, it is not possible to reliably estimate the frequency of complications. For more details refer to the sources of evidence section.
Specialist Advisors noted that possible complications include leaking at the site of repair to the stomach following surgery and subsequent infection or bleeding, but these were uncommon.

# Other comments
The Interventional Procedures Advisory Committee noted that the inadequate visualisation of tumours might lead to staging errors, and identified tumour spillage as a potential risk.
The Advisory Committee also noted that the technique is likely to have limited application in the foreseeable future.
Andrew DillonChief ExecutiveDecember 2003# Further information

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedure overview of laparo-endogastric surgery', November 2002.

# Information for patients
NICE has produced information on this procedure for patients and carers ('Understanding NICE guidance'). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# Changes since publication
As part of NICE's work programme, the current guidance was considered for review but did not meet the review criteria as set out in the IP process guide. This guidance therefore remains current.
January 2012: minor maintenance.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2003. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
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