NOTES & Gastric Cancer Research Soonchunhyang University, Seoul, Korea

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NOTES & Gastric Cancer Research Soonchunhyang University, Seoul, Korea Hybrid NOTES - Simultaneous Endoscopic-Laparoscopic Surgery for Gastric Submucosal Tumor in Human - Joo Young Cho, Yong Jin Kim, Youn Sun Park Jin-Oh Kim, Won Young Cho, So Young Jin NOTES & Gastric Cancer Research Soonchunhyang University, Seoul, Korea

박 O O M/68 Chief complaint : Indigestion Present illness Lab : 타병원에서 하체부 대만의 점막하종양으로 정밀 검사 위해 전원됨. Lab CBC 8,300/uL-13.7g/dL-289K/uL AST/ALT 30/19 IU/L BUN/Cr 12.3/0.7 mg/dL

Chest PA with Lt. lat. Within normal limit

Homogenous hypoechoic lesion GFS & EUS 12 MHz 22.2 X 14.5 mm Distal body, GC-PW SMT Origin: pm layer Homogenous hypoechoic lesion

Materials Endoscopy Laparoscopy 1 High-Definition Endoscope (EPIK-I®, Pentax) Endoscopic knives : flex-knife ®, IT Knife-2®,Olympus : fork-knife® Hemostatic forcep Modified transparent cap Electrosurgical Unit (VIO300D®, ERBE) Laparoscopy Disposable Trocar LigaSureTM Verres needle EthiconTM

Methods IRB approved OP team : Endoscopist – stoods at anesthesiologist’s side : Laparoscopic Surgeon – Rt. Side of patient Procedures General anesthesia, Supine position Demarcation of Submucosal tumor area - ESD technique Puncture of Stomach wall - Endoknives Randezvous resection; endo-laparoscopic approach Laparoscopic closure of punctured stomach

Endo-Laparoscopic approach (I) Endoscopic approach : Margin incision Laparoscopic approach : Visualization of SMT lesion

Endo-Laparoscopic approach (II) Endoscopic approach : Full thickness incision Laparoscopic approach : Visualization of IT-2 knife & gastric wall incision site

Endo-Laparoscopic approach (III) Endoscopic approach : Insertion laparoscopic device through incision site Laparoscopic approach : Complete removal of SMT Laparoscopic approach : Gastric wall incision along Endoscopic incision site

Endo-Laparoscopic approach (IV) Endoscopic approach : Endoscopic view of Suture site Laparoscopic approach : Suturing

Pathology Complete resection H&E stain : Gastric stromal tumor ( Leiomyoma) Immunohistochemical stain : not reported

Discussion (I) Stomach puncture method Limitation ESD method Techically feasible and safe Limitation Endoscopic suturing devices; not available in Korea Laparoscopist dominant procedure

Discussion (II) Endoscopy-Laparoscopic approach Technically safe Reasonable operation times Adequate cutting lines independent of tumor location Alternative gastric wedge resection procedure with minimal transformation of the stomach. A step to advance Endoscopic Full-Thickness Resection(EFTR) of submucosal invasive EGC

NOTES 연구회 소화기내과 외 과 해부병리과 조주영 김진오 이준성 김완중 조원영 이태희 김현건 박윤선 김재준 허경열 김용진 조성우 최동호 해부병리과 진소영 진윤미