OGC P44 Endoscopy-guided Laparoscopic Trans-gastric Resection (ELTGR) of bleeding gastric submucosal lesion, adjacent to the gastro-oesophageal junction
Authors: Wu Diana , Khan Jan Sher , Kouli Tasnim , Oglesby Stuart , Patil Pradeep , Zino Samir 
Published: December 2022

Abstract

Background
Leiomyomas are rare, benign submucosal tumours originating from smooth muscle cells. Ulcerated lesions could present with Upper Gastrointestinal(UGI) bleeding. Treatment of these lesion could be challenging especially if they are close to the Oesophagogastric Junction(OGJ).
In this abstract, we present a novel surgical technique for resection of symptomatic gastric submucosal lesion located near the gastro-oesophageal junction on the lesser curve of the stomach. The Endoscopy guided laparoscopic trans-gastric resection technique is minimally invasive and avoids partial or total gastrectomy.

Methods
We present a case of 74-year-old male with a body mass index of 32.3 requiring resection of a bleeding gastric submucosal lesion. The patient presented with melaena, and an upper GI endoscopy diagnosed a single 30mm sub mucosal tumour immediately distal to the gastro-oesophageal junction. Stable clinical condition allowed complete preoperative work out including staging CT that showed small lesion at OGJ with no evidence of metastasis. UGI MDT discussion advised surgery without Endoscopic Ultrasound as it was a bleeding lesion. The patient was consulted on the management options and decided on surgical resection for prevention of re-bleeding. Surgical options discussed included local resection, partial and or total gastrectomy. Endoscopy was performed under general anaesthetic at the time of surgery and the tumour was found to be on the upper part of lesser curvature, thus not suitable for wedge or sleeve gastrectomy. A decision was made to try the trans-gastric approach.

Results
The endoscope was left in the stomach to demonstrate and protect the gastro-oesophageal junction. A gastrotomy was made longitudinally on the anterior surface of the stomach. Careful assessment of the lesion suggested that it could be resected using the trans-gastric approach. The endoscope was used to protect the junction and an endoscopic stapler (Echelon flex 60mm, Gold) was used to resect the tumour. A nasogastric drainage tube (NGT) was placed under vision and the gastrostomy was closed with the Echelon flex stapler 60 mm gold and blue .
The NGT left for 72 hours with restricted and controlled fluid intake started the day after surgery and gradually increased to soft diet over three days. Patient was discharged on day 4. Follow up on day 7; WBC 10, CRP 19 and patient was very satisfied that he is at home and eating now normal diet. Using this minimally invasive approach we achieved macroscopic complete resection of the tumour whilst avoiding a total gastrectomy. Pathology report concluded features are of a smooth muscle tumour favouring a benign leiomyoma that is fully excised.
Repeat scope after 3 month showed good healing and no recurrence or stricture and patient remains asymptomatic.

Conclusions
In this abstract we present endoscopic guided laparoscopic trans gastric resection (ELTGR) approach as a novel technique to avoid laparoscopic or open proximal gastrectomy or total gastrectomy in patients with tumours adjacent to the gastro-oesophageal junction and on the lesser curve that do not require radical oncological resection.