247 LAPAROSCOPIC INTRAGASTRIC SUBMUCOSAL DISSECTION FOR EARLY GASTRIC CANCER: A VIDEO OF THE OXFORD APPROACH
Authors: Mastoridis S , Chana P , Sgromo B 
Published: September 2020

Abstract

Laparoscopic intragastric submucosal dissection (LISD) is a novel approach to the resection of early gastric cancers not amenable to conventional gastroscopic approaches. The technique permits favourable access to lesions situated high on the posterior wall or lesser curvature of the stomach, enables en-block resection of large areas of tissue, and can prevent the need for formal gastrectomy. Using intraoperative video capture, we demonstrate our approach to LISD, and describe our peri-operative and long-term outcomes.

Methods
Six cases were identified as suitable for LISD by multidisciplinary team panel following EUS assessment and employing locally developed inclusion criteria. As demonstrated by video tutorial, a 3-port laparoscopic approach to the stomach was undertaken and gastrotomies performed to enable port insertion into the stomach. Following establishment of stable pneumogastrium, the area of interest was circumferentially marked with cautery and submucosal colloid injection performed to provide a cushion in the plane of dissection. Resection was completed using cautery hook, and intracorporeal suture closure of gastrotomies performed. Measures were taken to ensure correct orientation of resected specimens prior to fixation.

Results
Four male and two female patients (median age 74.5 years) sequentially underwent LISD, with complete curative excision confirmed histologically in 5 cases. In one case, a positive deep margin necessitated completion total gastrectomy, later confirmed to be T0 resection. No immediate or late complications, including haemorrhage, perforation or stenosis, occurred in these cases.

Conclusion
In this, the largest United Kingdom case series, LISD is shown to be a safe and effective intervention for the treatment of early gastric cancers in selected patients having undergone appropriate mapping endoscopy and deemed not to be amenable for endoscopic mucosal resection. Its application can serve as route to avoid formal gastrectomy and the associated morbidity.

Video
https://www.dropbox.com/s/nqlp7b9v64z56z8/Low.mp4?dl=0 This video demonstrates a novel approach to the resection of early gastric cancers not amenable to conventional gastroscopic approaches. Laparoscopic intragastric submucosal dissection (LISD) involves 3-port laparoscopy and intragastric port passage via gastrotomies. Stable pneumogastrium is performed and the field circumferentially marked by cautery. Submucosal colloid injection aids dissection. Tumour resection is completed by cautery and specimens removed via ports. Of 6 cases performed in Oxford, complete curative excision was confirmed histologically in 5, with 1 necessitating completion gastrectomy later confirmed to be T0 resection. No immediate or late complications were encountered. LISD is a safe and effective intervention which permits favourable access to lesions situated high on the posterior wall or lesser curvature of the stomach, enables en-block resection of large areas, and can prevent the need for gastrectomy.