Laparoscopic intragastric resection of a gastrointestinal stromal tumor 0.5cm distal to the gastroesophageal junction performed with oral endoscopic assistance.
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http://www.ncbi.nlm.nih.gov/pubmed/21224608
DOI: http://dx.doi.org/10.17797/5v0bdou315
Editor Recruited By: Jeffrey Matthews, MD
The management of gastric submucosal tumors of mesenchymal origin, regardless of size, requires resection with negative pathologic margins. Laparoscopic and endoscopic cooperative surgery (LECS) provides a minimally invasive approach that allows for resection of intra-luminal GIST tumors with minimum surgical margins while avoiding excessive gastric wall distortion. This technique is especially effective for tumors located near the gastroesophageal junction or pylorus and obviates the need for major gastric resection and intestinal reconstruction, while still allowing for negative margins to be obtained.
The patient is placed supine on the operating table with both arms out secured to an arm board on either side. After induction of general anesthesia, a GIF-HQ190 upper endoscope is inserted and diagnostic endoscopy confirms a medium sized, sub-mucosal, non-circumferential mass on the posterior wall of the stomach 0.5cm distal to the GEJ. Methylene blue (5mL) is injected into the area at the base of the mass using an endoscopic injection device. The stomach is then desufflated to allow the surgeon to proceed with exploratory laparoscopy.
A 5mm peri-umbilical port is placed under direct vision and pneumoperitoneum established. Three additional blunt-type 5mm ports are placed in the right hemi-abdomen and one 12mm port in the left hemi-abdomen (See video for port site placement). A liver retractor is placed under direct vision through the right sided port closest to upper midline. The lesser curve of the stomach is exposed and the medial side of the esophagus mobilized in an attempt to visualize the tumor. Methylene blue dye is encountered and confirms the posterior location of the tumor at the GE junction within the stomach. The decision is made to proceed with intra-gastric stapling of the mass. A 1cm gastrotomy is created on the distal greater curvature using a harmonic energy device. Next, a balloon tip 12mm port is placed on the left side through the previously placed trocar site and then placed directly into the stomach via the gastrostomy. The balloon is inflated within the stomach and then affixed to that anterior abdominal wall. At this point, the gastroenterologist re-establishes gastric insufflation and a Rasper grasper is used to provide endoscopic traction and facilitate transgastric stapling of the mass.
The surgeon places an Endo-GIA linear stapler (Purple load; 45mm length) is placed through the intra-gastric trocar. With the tumor retracted, the surgeon proceeds with resection of the mass under direct visualization, to ensure no esophageal tissue is incorporated into the staple line. In total, 4 staple loads are used to safely remove the entire mass without compromising the esophagus. The specimen is endoscopically retrieved by placing it into a retrieval bag, extracted via the mouth, and sent to pathology for permanent section.
The esophageal mucosa is examined for integrity and hemostasis confirmed endoscopically. The gastrotomy is closed with a single fire of the Endo-GIA Purple loaded stapler. With endoscopic gastric insufflation, a leak test is performed and laparoscopy shows no evidence of gasric leakage either anteriorly or posteriorly. The endoscope is then removed, the upper abdomen is irrigated and laparoscopic ports sites removed under direct visualization without any bleeding. Port site skin closure done with 4-0 biosyn and dermabond.
The patient was extubated in the operating room without incident and sent to recovery in stable condition. Operative time: Approximately 80 minutes. Blood loss: 25 ml. Admitted for overnight observation. Diet was advanced as tolerated the next morning and the patient was discharged home on POD#1 tolerating a regular diet without dietary restrictions.
Final Pathology: 3.9cm x 2.6 x 1.6cm gastric gastrointestinal stromal tumor: spindle cell subtype, high grade (G2), mitotic rate 20/50, no necrosis, and negative margins.
1.Intra-gastric Gastrointestinal Stromal Tumors (GIST) 2-5cm in diameter (<8cm2 cross-sectional area) located on the posterior wall of upper stomach or close to the GE junction, amenable to removal via oral endoscopy 1
2.Experienced surgeon with advanced laparoscopic and interventional gastrointestinal endoscopist
1.Patients with cardiopulmonary disease unable to tolerate pneumoperitoneum;
2.Presence of gastric or esophageal varices;
3.Neoplasms involving the distal esophagus
4.GIST tumors >5cm diameter or >8cm2 cross-sectional area; tumor ulceration, or direct tumor exposure that carry risk of dissemination2
5.Inexperienced surgeon/endoscopist
6.Hostile abdomen with extensive adhesions
Endoscopic Equipment:
1.Flexible Upper Endoscope: Olympus GIF-HQ190 Scope E
2.Oral Overtube: Apollo Overtube���® (Apollo Endosurgery)
3.Endoscopic tissue grasper: Rasper grasper
4.Endoscopic tissue injector
5.Methylene blue dye
Laparoscopic Equipment:
1.Laparoscopic ports ���¢ 12mm balloon tip port x1; 5mm port x4
2.30o angled Laparoscope - Karl Storz
3.Atraumatic laparoscopic tissue grasper
4.Laparoscopic coagulating shears - Harmonic���® ultrasonic energy device
5.Endoscopic linear stapler ���¢ Endo-GIA Purple load, 45mm stapler - Covidien
Setup - specific tips for setup for the procedure and instruments
1.Patient supine on operating table with both arms out at the side. Operating surgeon stands on the patients right and assistant on the left. (Surgeon preference for general hiatal dissection - may place patient supine in split leg or lithotomy position, in order to stand between the legs). Instruments at the foot of the bed and scrub nurse standing on same side of the surgeon. Laparoscopic monitors on either side at head of table.
2.Gastroenterologist stands above patient���¢s head with anesthesia. Endoscopic tower placed on left side head of table. Endoscopic monitor at head of bed right to allow visualization by both the operating surgeon and endoscopist.
1.Presenting with dysphagia - a water-soluble contrast UGI study can demonstrate intrinsic lesions at the GEJ that may be causing luminal obstruction. If found, further work-up should be undertaken as described below
2.Suspected GIST ���¢ Computed Tomography (CT) - typically used as initial diagnostic study. It provides detailed information about the location of the tumor and can detect the presence of metastatic disease
3.All patients - diagnostic upper endoscopy to rule out other pathology and biopsies of suspicious lesions if found.
4.All patients - endoscopic ultrasound and fine-needle aspiration biopsy of the gastric mass should be obtained to confirm the pathologic diagnosis. Immunohistochemical analysis of tissue samples for the presence of c-KIT or CD34 is vital to confirm the diagnosis of GIST. EUS also allows for evaluation of lymphadenopathy and further FNA biopsies can be obtained during this time.
Typical appearance of GIST tumors:
UGI contrast study: intrinsic mass with smooth borders that may cause a filling defect or show luminal compression. If central ulceration of the mass is present, contrast may fill the area and can look like a ���¢bull���¢s eye���¢ lesion.
Upper Endoscopy: smooth, solid, subepithelial mass with regular borders typically seen in the upper and middle portions of or stomach. Central ulceration with or without bleeding can be seen.
Endoscopic ultrasound: will show a subepithelial, hypoechoic, solid mass continuous with the muscularis layer
1.Size and location may require additional intra-gastric ports to be placed.
2.Lesions that are not able to be removed via oral endoscope may require transgastric removal via the abdominal wall, necessitating enlargement of the one of the laparoscopic port sites to accoodate the specimen ensuring the specimen is removed intact.
3.Need for conversion to open for difficult anatomy
Laparoscopic and endoscopic cooperative surgery (LECS) provides a minimally invasive approach for the resection of intra-luminal GIST tumors with minimum surgical margins while avoiding excessive gastric wall distortion. This technique is especially effective for tumors located near the gastroesophageal junction or pylorus. It obviates the need for major gastric resection and intestinal reconstruction, as with previous open or laparoscopic resections, while still achieving an R0 resection.
Intra-operative:
Aspiration ���¢ assoc. with upper endoscopy. May be minimized by use of overtube
Esophageal mucosal injury or perforation - May be minimized by use of overtube
Narrowing of GEJ ���¢ adequate endoscopic visualization is imperative to ensure distal esophagus free from intended staple line
Possible need for conversion to laparotomy
Post-op Early:
Staple line bleeding
Port-site bleeding / infection
Post-op Late:
Gastric leak from compromised staple line
Dysphagia / GEJ stenosis / Decreased PO intake
Recurrence
Intra-operative:
Aspiration ���¢ assoc. with upper endoscopy. May be minimized by use of overtube
Esophageal mucosal injury or perforation - May be minimized by use of overtube
Narrowing of GEJ ���¢ adequate endoscopic visualization is imperative to ensure distal esophagus free from intended staple line
Possible need for conversion to laparotomy
Post-op Early:
Staple line bleeding
Port-site bleeding / infection
Post-op Late:
Gastric leak from compromised staple line
Dysphagia / GEJ stenosis / Decreased PO intake
Recurrence
Lydia M. Johns, CMI ���¢ medical illustrations
1.Tagaya N, Mikami H, Kubota K. Laparoscopic resection of gastrointestinal mesenchymal tumors located in the upper stomach. Surgical endoscopy. Oct 2004;18(10):1469-1474.
http://link.springer.com/article/10.1007%2Fs00464-004-8800-6
2.Hiki N, Yamamoto Y, Fukunaga T, et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surgical endoscopy. Jul 2008;22(7):1729-1735. http://link.springer.com/article/10.1007%2Fs00464-007-9696-8
3. Tagaya N, Mikami H, Kogure H, Kubota K, Hosoya Y, Nagai H. Laparoscopic intragastric stapled resection of gastric submucosal tumors located near the esophagogastric junction. Surg Endosc. 2002;16:177-179.
4. Tagaya N, Mikami H, Kubota K. Laparoscopic resection of gastrointestinal mesenchymal tumors located in the upper stomach. Surg Endosc. 2004;18:1469-1474.
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7. Na JU, Lee SI, Noh SM. The single incision laparoscopic intragastric wedge resection of gastric submucosal tumor. J Gastric Cancer. 2011;11:225-229.
8. Morales-Conde S, Alarc���³n I, Ortiz-Moyano C, Barranco A, Padillo FJ, Socas M. Intragastric endoscopic assisted single incision surgery for gastric leiomyoma of the esophagogastric junction. Case Rep Gastrointest Med. 2013;2013:391430.
9. Shim JH, Lee HH, Yoo HM, Jeon HM, Park CH, Kim JG, Song KY. Intragastric approach for submucosal tumors located near the Z-line: a hybrid laparoscopic and endoscopic technique. J Surg Oncol. 2011;104:312-315.
10. Hiki N, Yamamoto Y, Fukunaga T, Yamaguchi T, Nunobe S, Tokunaga M, Miki A, Ohyama S, Seto Y. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc. 2008;22:1729-1735.
11. Walsh RM, Ponsky J, Brody F, Matthews BD, Heniford BT. Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors. J Gastrointest Surg. 2003;7:386-392.
12. Uchikoshi F, Ito T, Nishida T, Kitagawa T, Endo S, Matsuda H. Laparoscopic intragastric resection of gastric stromal tumor located at the esophago-cardiac junction. Surg Laparosc Endosc Percutan Tech. 2004;14:1-4.
13. Li VK, Hung WK, Chung CK, Ying MW, Lam BY, Kan DM, Chan MC. Laparoscopic intragastric approach for stromal tumours located at the posterior gastric wall. Asian J Surg. 2008;31:6-10.
14. Sahm M, Pross M, Lippert H. Intraluminal resection of gastric tumors using intragastric trocar technique. Surg Laparosc Endosc Percutan Tech. 2011;21:e169-e172.
15. Dong HY, Wang YL, Jia XY, Li J, Li GD, Li YQ. Modified laparoscopic intragastric surgery and endoscopic full-thickness resection for gastric stromal tumor originating from the muscularis propria. Surg Endosc. 2014;28:1447-1453.
16. Vecchio R, Marchese S, Amore FF, La Corte F, Ferla F, Spataro L, Intagliata E. Laparoscopic-endoscopic rendez-vous resection of iuxta-cardial gastric GIST. G Chir. 2013;34:145-148.
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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
References: N/A
A 49-year-old female presented with a one-year history of right frontal headaches, not controlled despite OTC medication. Work up with head CT revealed an osteoma of the right frontal sinus. The patient experienced no improvement in headache severity and elected to have surgical intervention.
Methods: ENT Fusion Navigation system was used during the entire case. A ball-tip probe was used to fracture out the uncinate bone and a backbiter was used to remove the uncinate in its entirety. The natural ostium of the right maxillary sinus was then visualized. Again, the backbiter was used to remove tissue anterior to the natural ostium. A straight Tru-Cut was used to remove the ostium towards the posterior fontanelle. The right middle turbinate was resected in order to gain sufficient access for the resection of the osteoma. In order to remove the right middle turbinate, a turbinate scissors were used to make 3 cuts along the attachment of the middle turbinate and this was pulled down. A down biter was used to open up the maxillary sinus inferiorly. There was no tissue seen in the maxillary sinus. After this was done, an ethmoidectomy was performed by placing a J-curette behind the ethmoid bulla point anteriorly. This ethmoid bulla was removed along with several other anterior ethmoid cells. After this was done, a frontal sinus seeker was used to identify the right frontal osteoma. The patient did not have a right frontal sinus. Instead, an osteoma was in the area of what would have been the right frontal sinus or nasal frontal outflow tract. Image guidance was meticulously used to identify the osteoma. A 70-degree frontal drill was used and this osteoma was slowly drilled to remove as much as possible. Drilling was done from the posterior edge of the osteoma up to the skull base superiorly, to the lamina papyracea laterally and all bone that could be safely removed was removed. A right frontal propel stent was placed in the bony cavity created by the drill out and after this, the sinus was irrigated and suctioned.
Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient.
Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD.
Institution: Department of Otolaryngology – Head and Neck Surgery at the University of Arkansas for Medical Sciences.
Review Endoscopic Assisted Laparoscopic Transgastric Resection of GE Junction Gastrointestinal Stromal Tumor (GIST).