468 Human Hybrid Endoscopic and Laparoscopic Management of Mass Lesions of the Foregut

Flexible Transgastric Endoscopic Liver Cyst Fenestration: A Feasibility Study in Human Dong Wang, Danlei Chen, Joseph W. Leung Gastroenterology, Changhai Hospital, Shanghai, China; General surgery, Changhai Hospital, Shanghai, China; Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, Sacramento, CA Abstract Background: There is no clinical report on the use of natural orifice transluminal endoscopic surgery (NOTES) for the management of patients with large liver cysts. Objective: To evaluate the feasibility and safety of NOTES for liver cyst fenestration in human using currently available technique. Methods: From February 2009 to June 2010, four cases of transgastric endoscopic liver cyst fenestration were performed, three with NOTES only and one was additional laparoscopic assistance. Results: Time taken to manipulate the flexible endoscope within the abdomen improved from 22 minutes in the 1st case to 5 minutes in the last case. It was easy to locate the liver cysts if they were in the left lobe or on the liver surface. Transgastric endoscopic liver cyst fenestration was successful in all patients. The use of an occlusion balloon helped with endoscopic clip closure of the gastrostomy incision. The mean operative time was 101.3 minutes (range 90-112min). There were no intra or post operative complications including infections. All patients recovered well after the surgery with minor postoperative throat pain. There was no abdominal pain in the three cases performed with NOTES only. Conclusion: It is technically feasible and safe to perform clinical transgastric endoscopic liver cyst fenestration. This encouraging experience helps with the future development of incisionless NOTES. 468 Human Hybrid Endoscopic and Laparoscopic Management of Mass Lesions of the Foregut Sagar Garud, S. S. Davis, Melinda M. Lewis, Shishir K. Maithel, David Kooby, Field Willingham Digestive Diseases, Emory University School of Medicine, Atlanta, GA; Pathology, Emory University School of Medicine, Atlanta, GA; Surgery, Emory University School of Medicine, Atlanta, GA Introduction: To date, most reports of NOTES procedures in humans have recapitulated laparoscopic procedures such as cholecystectomy which have an excellent safety profile and little long term implications for quality of life. We sought to determine if a subset of mass lesions of the foregut would be amenable to a hybrid laparoscopic and endoscopic approach with decreased operative morbidity and long term quality of life implications. Methods: Six patients with mass lesions of the foregut were were offered hybrid laparoscopic and endoscopic management. Two patients had mass lesions involving the gastroesophageal (GE) junction, two patients had gastrointestinal stromal tumors (GIST) involving the proximal stomach, one patient had an antral mass, and one patient had a duodenal duplication cyst. The lesions were deemed unresectable by the referring gastroenterologist as well as the tertiary care gastroenterologist and were referred for surgical management. Pre-operative EGD, EUS with or without FNA, and cross sectional imaging were obtained for all patients. All procedures were performed in the operating room under general anesthesia. Results: All six patients underwent a laparoscopic and endoscopic hybrid procedure (Table 1). Both lesions involving the GE junction were successfully resected using a combined approach and these patients were spared a total or subtotal gastrectomy. The two patients with GIST tumors were not successfully resected via the hybrid approach and they proceeded to laparoscopic resection. In one case the tumor was too large to be completely ensnared with a 5.5cm snare despite laparoscopic assistance. In the second case, there was involvement of the serosal surface and a full thickness laparoscopic wedge resection was performed. The antral mass was resected using a hybrid approach and this patient was spared an antrectomy. The final patient with a duodenal duplication cyst was successfully managed with a hybrid approach and this patient was spared a laparotomy, duodenotomy, cystectomy, and sphincteroplasty. There were no immediate complications. All six patients have remained asymptomatic without evidence of recurrence over 80 months of cumulative follow-up. Conclusion: This is the first report of successful hybrid laparoscopic and endoscopic management for a malignant tumor of the GE junction. The hybrid technique was safe and feasible in six human patients with foregut mass lesions which were not amenable to endoscopic management. Out of six cases, the technique was successful in sparing four patients a major surgical resection with long term quality of life implications. In highly selected cases, a hybrid approach may be superior to either standard surgical or endoscopic management. This report demonstrates the promise of NOTES not in recapitulating, but in improving on the current standard approach.