title: Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor.
abstract: OBJECTIVE
  Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients.
  
  
  METHODS
  Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect.
  
  
  RESULTS
  LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients.
  
  
  CONCLUSIONS
  LAEFR may be considered one of the so-called hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.
authors.affiliation: Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan. abenbtg@kyorin-u.ac.jp
authors.forename: Nobutsugu
authors.initials: N
authors.lastname: Abe
authors.forename: Hirohisa
authors.initials: H
authors.lastname: Takeuchi
authors.forename: Osamu
authors.initials: O
authors.lastname: Yanagida
authors.forename: Tadahiko
authors.initials: T
authors.lastname: Masaki
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Mori
authors.forename: Masanori
authors.initials: M
authors.lastname: Sugiyama
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Atomi
mesh_terms: D000368:Aged; D002828:Choristoma / Q000175:diagnosis / Q000601:surgery; D003951:Diagnostic Errors; D005260:Female; D046152:Gastrointestinal Stromal Tumors / Q000175:diagnosis / Q000601:surgery; D005773:Gastroscopy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008067:Lipoma / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009442:Neurilemmoma / Q000175:diagnosis / Q000601:surgery; D010179:Pancreas; D013272:Stomach Diseases / Q000175:diagnosis / Q000601:surgery; D013274:Stomach Neoplasms / Q000601:surgery*; D013536:Suture Techniques