• GI surgery
• endoscopic surgery
• gastrointestinal stromal tumor
• hybrid surgery

• Roux-en-Y reconstruction
• gastric cancer
• laparoscopy-assisted distal gastrectomy
• self-pulling and latter transection
• totally laparoscopic distal gastrectomy

• Science-Health Joint Medical Scientific Research Project of Chongqing

• gastrointestinal stromal tumors in esophagogastric junction
• laparoscopic surgery
• logistic regression
• nomogram
• resection of cardiac structure

• Guangdong Provincial Hospital of Traditional Chinese Medicine

• SMT
• esophagogastric junction
• single-incision LIGS

Various surgical procedures have been described for gastrointestinal stromal tumors (GISTs) at the esophagogastric junction (EGJ) close to the Z-line. However, surgery for EGJ-GIST involving Z-line has been rarely reported.

To introduce a novel technique called conformal resection (CR) for open resection of EGJ-GIST involving Z-line.

In this retrospective study, 43 patients having GISTs involving Z-line were included. The perioperative outcomes of patients receiving CR (n = 18) was compared with that of proximal gastrectomy (PG) (n = 25).

CR was successfully performed in all the patients with negative microscopic margins. The mean operative time, time to first passage of flatus, and postoperative hospital stay was significantly shorter in the CR group (P < 0.05), while the intraoperative blood loss was similar in the two groups. The postoperative gastroesophageal reflux as diagnosed by esophageal 24-h pH monitoring and quality of life at 3 mo were significantly in favor of CR compared to PG (both P < 0.001). The 5-year disease-free survival between the two groups was similar (P = 0.163). The cut- off value for the determination of CR or PG was 7.0 mm above the Z-line (83.33% sensitivity, 84.00% specificity, 83.72% accuracy).

CR is safe and feasible for EGJ-GIST located within 7.0 mm above the Z-line.

• Esophagogastric junction stromal tumor
• Surgery
• Anti-reflux
• 36-Item short-form health survey
• Disease-free survival

• Esophagogastric Junction/surgery
• Gastrectomy/adverse effects
• Gastrointestinal Stromal Tumors/surgery
• Humans
• Laparoscopy
• Quality of Life
• Retrospective Studies
• Stomach Neoplasms/surgery
• Treatment Outcome

Gastrointestinal stromal tumors are the most frequent mesenchymal tumors of the gastrointestinal tract. Complete resection of GISTs is the only chance of cure for patients. When these tumors are located near the esophagogastric junction, the surgical risk can cause deformity or stenosis in the gastric inlet, leading to higher complications and diminishing their quality of life. In such cases, a more sophisticated and tailored approach should be used.

We present the case of a 42-year-old female; she presented to our office with a 3-year history of nausea, vomiting and abdominal distension. Two GISTs were located near the EGJ, and with a combined approach we achieved complete resection. On follow-ups, the patient is doing well.

When diagnosis is confirmed, surgical resection must be the first choice for GISTs as complete surgical excision is the only permanent cure. The rise of endoscopic surgery has become a valuable tool and a critical element in surgery. Hybrid techniques that combine laparoscopic and endoscopic approaches can improve the patient's outcomes and provide better results.

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The rise of endoscopic surgery has become a valuable tool and a critical element in surgery.

• Gastrointestinal stromal tumors (GISTs) gastric tumors laparoscopy endoscopy

A novel resection method, namely, laparoscopic local resection through subserosal dissection with endoscopic air-insuff lation (LRSDEA) was used for submucosal tumors located near the esophagogastric junction (SMT-EGJ) to avoid major gastric resection.

A total of 9 cases underwent LRSDEA. We sequentially performed: laparoscopic dissections around EGJ, subserosal dissections around SMTs using laparoscopic electrocautery and ultrasonic shears, and finally, enucleation of SMTs. During these procedures, intraoperative endoscopic tumor localization, as well as endoscopic air-insufflation allowed for safe resection. These procedures are shown in the supplementary video clip. The clinicopathological characteristics and surgical results were analyzed.

All laparoscopic procedures were successfully performed without requiring a major gastrectomy. The mean operation time was 126.1 minutes, and estimated blood loss was 12.0 ml. There were no postoperative complications. Pathological diagnoses were 6 leiomyomas, 2 gastrointestinal stromal tumors, and 1 gastric duplication.

LRSDEA is an effective and safe treatment option for SMT-EGJ, as major resection of the stomach is avoided.

• GIST
• Laparoscopic transgastric resection
• Obesity surgery
• Sleeve gastrectomy

• Endoscopic assistance
• Esophagogastric junction
• Gastric submucosal tumor
• Laparoscopic wedge resection

• Adult
• Aged
• Endoscopy, Gastrointestinal
• Esophagogastric Junction/surgery
• Feasibility Studies
• Female
• Gastric Mucosa/pathology
• Gastric Mucosa/surgery
• Gastrointestinal Stromal Tumors/surgery
• Humans
• Laparoscopy
• Male
• Middle Aged
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Treatment Outcome

The aim of this study is to evaluate the results of a single and common approach for transgastric submucosal excision of small- to medium-sized gastrointestinal stromal tumours (GIST) having different locations in upper two-third of the stomach by pure minimally invasive approach.

A retrospective study from February 2012 to January 2015 on 11 patients was conducted including both male and female. Their age ranged from 40 to 65 years. All were subjected to laparoscopic transgastric submucosal excision of GIST in upper two-third of the stomach with 1 cm margin having different locations in stomach. Excised tumours were subjected to histopathological study. These patients were followed for 12 months assessing operative time, post-operative complications, conversion rates, morbidity, hospital stay and recurrence rate.

Duration of surgery was 150.6 ± 20.4 min. Mean hospital stay was 8 (range: 7–10) days. There were no post-operative complications. There were no conversions to open procedure. There were no recurrences. Morbidity was comparable to any other laparoscopic procedures.

We conclude that a single and common approach of transgastric submucosal excision of small- to medium-sized stromal tumours with 1 cm margin having different locations in upper two-third of stomach, by pure minimally invasive approach, has a better outcome and brings a uniformity in laparoscopic management of GIST.

• Gastric submucosal tumor
• endoluminal surgery
• esophagogastric junction (EGJ)
• intragastric surgery
• laparoendoscopic surgery
• transgastric surgery

• Bariatric surgery
• GIST
• Leiomyoma
• Morbid obesity
• Sleeve gastrectomy
• Submucosal tumor

AIM: To assess the efficacy and safety of intracorporeal esophagojejunostomy in patients undergoing laparoscopic total gastrectomy (LTG) for gastric cancer.

METHODS: A retrospective review of 81 consecutive patients who underwent LTG with the same surgical team between November 2007 and July 2014 was performed. Four types of intracorporeal esophagojejunostomy using staplers or hand-sewn suturing were performed after LTG. Data on clinicopatholgoical characteristics, occurrence of complications, postoperative recovery, anastomotic time, and operation time among the surgical groups were obtained through medical records.

RESULTS: The average operation time was 288.7 min, the average anastomotic time was 54.3 min, and the average estimated blood loss was 82.7 mL. There were no cases of conversion to open surgery. The first flatus was observed around 3.7 d, while the liquid diet was started, on average, from 4.9 d. The average postoperative hospital stay was 10.1 d. Postoperative complications occurred in 14 patients, nearly 17.3%. However, there were no cases of postoperative death.

CONCLUSION: LTG performed with intracorporeal esophagojejunostomy using laparoscopic staplers or hand-sewn suturing is feasible and safe. The surgical results were acceptable from the perspective of minimal invasiveness.

• Gastric cancer
• Total gastrectomy
• Esophagojejunostomy
• Laparoscopy
• Hand-sewn

• Aged
• Blood Loss, Surgical
• China
• Esophagostomy/adverse effects
• Esophagostomy/methods
• Female
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Humans
• Jejunostomy/adverse effects
• Jejunostomy/methods
• Laparoscopy/adverse effects
• Male
• Medical Records
• Middle Aged
• Operative Time
• Postoperative Complications/etiology
• Recovery of Function
• Retrospective Studies
• Stomach Neoplasms/surgery
• Surgical Stapling
• Suture Techniques
• Time Factors
• Treatment Outcome

Totally laparoscopic distal gastrectomy (TLDG) using intracorporeal anastomosis has gradually developed due to advancements in laparoscopic surgical instruments. However, totally laparoscopic total gastrectomy (TLTG) with intracorporeal esophagojejunostomy (IE) is still uncommon because of technical difficulties. Herein, we evaluated various types of IE after TLTG in terms of the technical aspects. We compared the short-term operative outcomes between TLTG with IE and laparoscopy-assisted total gastrectomy (LATG) with extracorporeal esophagojejunostomy (EE).

Between March 2006 and December 2014, a total of 213 patients with gastric cancer underwent TLTG and LATG. Overall, 92 patients underwent TLTG with IE, and 121 patients underwent LATG with EE. Generally, there are two methods of IE: mechanical staplers (circular or linear staplers) and hand-sewn sutures. Surgical efficiencies and outcomes were compared between two groups. We also described various types of IE using a subgroup analysis.

The mean operation times were similar in the two groups, as was the number of retrieved lymph nodes. However, the mean estimated blood loss of TLTG was statistically lower than LATG. There were no significant differences in time to first flatus, the time to restart oral intake, the length of the hospital stay after operation, and postoperative complications. Four types of IE have been applied after TLTG, including 42 cases of hand-sewn IE. The overall mean operation time and the mean anastomotic time in TLTG were 279.5 ± 38.4 min and 52.6 ± 18.9 min respectively. There was no case of conversion to open procedure. Postoperative complication occurred in 16 patients (17.4 %) and no postoperative mortality occurred.

IE is a feasible procedure and can be safely performed for TLTG with the proper laparoscopic expertise. It is technically feasible to perform hand-sewn IE after TLTG, which can reduce the cost of the laparoscopic procedure.

• Laparoscopic gastrectomy, Intracorporeal anastomosis, Hand-sewn
• Stomach neoplasms

• Endoscopy
• Gastric submucosal tumor
• Intragastric approach
• Minilaparoscopy
• Pig
• Single-incision surgery

Immunoglobulin G4 (IgG4)-associated disease is a recently recognized disease entity that is characterized by elevated serum IgG4 concentrations, abundant IgG4 lymphoplasmacytic infiltration, and dramatic steroid responses. IgG4-associated cholangitis is one manifestation of IgG4-associated disease. However, it is clinically challenging to make a preoperative differentiation between this rare disease and cholangiocarcinoma, especially for those with serum concentrations of IgG4 in the normal range. This article reports on a 57-year-old man with jaundice and upper abdominal discomfort. Imaging examination showed biliary stricture that closely resembled cholangiocarcinoma, and the patient’s serum IgG4 concentration was normal. The patient underwent a laparoscopic choledochectomy with Roux-en-Y hepaticojejunostomy using an intracorporeal hand-sewn technique. He recovered quickly without any complications. We also present our experience in laparoscopic intracorporeal hand-sewn hepaticojejunostomy.

• Biopsy
• Diagnosis, Differential
• Esophageal Diseases/diagnosis
• Esophageal Diseases/pathology
• Esophageal Diseases/surgery
• Esophageal Neoplasms/diagnosis
• Esophageal Neoplasms/pathology
• Esophageal Neoplasms/surgery
• Esophagogastric Junction/pathology
• Esophagogastric Junction/surgery
• Esophagoscopy
• Humans
• Laparoscopy

AIM: To systematically review the surgical outcomes of totally laparoscopic gastrectomy (TLG) vs open gastrectomy (OG) for gastric cancer.

METHODS: A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was conducted. All original studies comparing TLG with OG were included for critical appraisal. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: One RCT and 13 observational studies involving 1532 patients were included (721 TLG and 811 OG). TLG was associated with longer operation time [weighted mean difference (WMD) = 58.04 min, 95%CI: 37.77-78.32, P < 0.001], less blood loss [WMD = -167.57 min, 95%CI: -208.79-(-126.34), P < 0.001], shorter hospital stay [WMD = -3.75 d, 95%CI: -4.88-(-2.63), P < 0.001] and fewer postoperative complications (RR = 0.71, 95%CI: 0.58-0.86, P < 0.001). The number of harvested lymph nodes, surgical margin, mortality and cancer recurrence rate were similar between the two groups.

CONCLUSION: TLG may be a technically safe, feasible and favorable approach in terms of better cosmesis, less blood loss and faster recovery compared with OG.

• Gastric cancer
• Gastrectomy
• Intracorporeal anastomosis
• Laparoscopy
• Meta-analysis
• Survival

• Blood Loss, Surgical/prevention & control
• Chi-Square Distribution
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Gastrectomy/mortality
• Humans
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Laparoscopy/mortality
• Neoplasm Recurrence, Local
• Odds Ratio
• Postoperative Complications/etiology
• Risk Assessment
• Risk Factors
• Stomach Neoplasms/mortality
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Time Factors
• Treatment Outcome

Gastric cancer in remnant stomach is a rare tumor but with poor prognosis. Compared with conventional open surgery, laparoscopic gastrectomy has potential benefits for these patients due to advantages resulting from its minimally invasive approach. Herein, we report on three patients with gastric cancer in remnant stomach who underwent laparoscopic total gastrectomy with intracorporeal esophagojejunostomy successfully. The operative time was 280, 250 and 225 minutes, the estimated blood loss was 100, 80 and 50 ml and the length of postoperative hospital stay was seven, eight and nine days respectively. Our experience has suggested that laparoscopic total gastrectomy with intracorporeal esophagojejunostomy can be a safe, feasible and promising option for patients with gastric cancer in remnant stomach.

• Distal gastrectomy
• Gastric cancer
• Intracorporeal anastomosis
• Laparoscopy
• Meta-analysis

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.

METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).

RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.

CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.

• Laparoscopic surgery
• Splenic preservation
• Distal pancreatectomy
• Pancreatic tumor
• Pancreas

• Adult
• Aged
• Blood Loss, Surgical
• China
• Feasibility Studies
• Female
• Humans
• Laparoscopy/adverse effects
• Length of Stay
• Ligation
• Male
• Middle Aged
• Neoplasm Staging
• Operative Time
• Organ Sparing Treatments/adverse effects
• Pancreatectomy/adverse effects
• Pancreatectomy/methods
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery
• Postoperative Complications/etiology
• Retrospective Studies
• Splenic Artery/surgery
• Splenic Vein/surgery
• Time Factors
• Treatment Outcome

Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, the long-term oncological outcomes of LDG have rarely been reported. This study aimed to investigate the survival outcomes of LDG, and evaluate the early surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG).

Clinical outcomes of 240 consecutive patients with gastric cancer who underwent LDG at our institution between October 2004 and April 2013 were analyzed. Early surgical outcomes of LADG and TLDG were compared and operative experiences were evaluated.

Of the 240 patients, 93 underwent LADG and 147 underwent TLDG. There were 109 T1, 36 T2, 31 T3, and 64 T4a lesions. The median follow-up period was 31.5 months (range: 4–106 months). Tumor recurrence was observed in 40 patients and peritoneal recurrence was observed most commonly. The 5-year disease-free survival (DFS) and overall survival (OS) rates according to tumor stage were 90.3% and 93.1% in stage I, 72.7% and 67.6% in stage II, and 34.8% and 41.5% in stage III, respectively. No significant differences in early surgical outcomes were noted such as operation time, blood loss and postoperative recovery between LADG and TLDG (P >0.05).

LDG for gastric cancer had acceptable long-term oncologic outcomes. The early surgical outcomes of the two commonly used LDG methods were similar.

• clinical study
• gastric cancer
• laparoscopy
• survival