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OBJECTIVES: The current literature describes a variety of techniques detailed under the name of combined endoscopic-laparoscopic surgery (CELS) procedures. This systematic review of literature assessed the outcomes of colonoscopic-assisted laparoscopic-wedge resection (CAL-WR) in particular to evaluate its feasibility to remove colonic lesions that do not qualify for endoscopic resection. MATERIALS AND METHODS: Electronic databases (PubMed, Embase, and Cochrane) were searched for studies evaluating CAL-WR for the treatment of colonic lesions. Studies with missing full text, language other than English, systematic reviews, and studies with fewer than ten patients were excluded. The quality of the studies was assessed using the Newcastle-Ottawa Scale. RESULTS: Out of 68 results, duplicate studies (n = 27) as well as studies that did not meet the inclusion criteria (n = 32) were removed. Nine studies were included, encompassing 326 patients who underwent a CAL-WR of the colon. The technical success rate varied from 93 to 100%, with an R0 resection rate of 91-100%. Morbidity ranged from 6% to 20%. The quality of the included studies was rated as low to moderate and contained heterogeneous terminology, methodology, and outcome measures. CONCLUSIONS: There is insufficient high-quality data and substantial variation in outcome measures to draw firm conclusions regarding the value of CAL-WR. Although CAL-WR is a promising local resection technique for endoscopically unremovable neoplasms of the colon, further investigation of this technique in well-designed prospective, multicenter studies with predefined outcome measures is required.Trial registration: A protocol for this systematic review was registered in PROSPERO with the number CRD42023407966.

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AIM: The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR. METHOD: A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period. RESULTS: Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001). CONCLUSION: Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.

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BACKGROUND: The sole presence of deep submucosal invasion is shown to be associated with a limited risk of lymph node metastasis. This justifies a local excision of suspected deep submucosal invasive colon carcinomas (T1 CCs) as a first step treatment strategy. Recently Colonoscopy-Assisted Laparoscopic Wedge Resection (CAL-WR) has been shown to be able to resect pT1 CRCs with a high R0 resection rate, but the long term outcomes are lacking. The aim of this study is to evaluate the safety, effectiveness and long-term oncological outcomes of CAL-WR as primary treatment for patients with suspected superficial and also deeply-invasive T1 CCs. METHODS: In this prospective multicenter clinical trial, patients with a macroscopic and/or histologically suspected T1 CCs will receive CAL-WR as primary treatment in order to prevent unnecessary major surgery for low-risk T1 CCs. To make a CAL-WR technically feasible, the tumor may not include > 50% of the circumference and has to be localized at least 25 cm proximal from the anus. Also, there should be sufficient distance to the ileocecal valve to place a linear stapler. Before inclusion, all eligible patients will be assessed by an expert panel to confirm suspicion of T1 CC, estimate invasion depth and subsequent advise which local resection techniques are possible for removal of the lesion. The primary outcome of this study is the proportion of patients with pT1 CC that is curatively treated with CAL-WR only and in whom thus organ-preservation could be achieved. Secondary outcomes are 1) CAL-WR's technical success and R0 resection rate for T1 CC, 2) procedure-related morbidity and mortality, 3) 5-year overall and disease free survival, 4) 3-year metastasis free survival, 5) procedure-related costs and 6) impact on quality of life. A sample size of 143 patients was calculated. DISCUSSION: CAL-WR is a full-thickness local resection technique that could also be effective in removing pT1 colon cancer. With the lack of current endoscopic local resection techniques for > 15 mm pT1 CCs with deep submucosal invasion, CAL-WR could fill the gap between endoscopy and major oncologic surgery. The present study is the first to provide insight in the long-term oncological outcomes of CAL-WR. TRIAL REGISTRATION: CCMO register (ToetsingOnline), NL81497.075.22, protocol version 2.3 (October 2022).

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INTRODUCTION: Gastrointestinal stromal tumors (GIST) are infrequent, and clinical presentation varies between asymptomatic and diffuse symptoms such as abdominal pain and dyspepsia. Surgical approach depends on location and size of the tumor. There are some reports of the specific surgical approach for GIST located at the gastroesophageal junction. This is a case report of a patient with a GIST located specifically at the gastroesophageal junction and the surgical approach selected for the treatment. PRESENTATION OF THE CASE: A 70-year-old patient who developed an episode of upper gastrointestinal bleeding with hemorrhagic shock accompanied by elevated troponins that required transfusion therapy and whose endoscopic evaluation showed a subcardial ulcerated lesion of 16 × 5 mm, located 2 cm below the z-line. The lesion was biopsied and was negative for malignancy. A combined surgical approach for resection by combined laparoscopy and submucosal resection by upper gastrointestinal endoscopy was performed by the interventional gastroenterology service and surgical oncology service. DISCUSSION: Specific management of GISTs depends on the location of the tumor, even though, complete surgical resection remains the gold standard treatment. Minimally invasive techniques can be used to assess these tumors leading to shorter hospital stays and lesser risk of complications. Laparoendoscopic cooperative surgery is a promising approach for managing lesions near the gastroesophageal junction. CONCLUSION: GISTs located near the gastroesophageal junction require a complex approach. The laparaendoscopic approach seems to be a feasible approach for GIST in the gastroesophageal junction.

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Background: Depending on the location of gastric subepithelial tumors (SETs), surgical access is difficult with a risk of postoperative complications. This study aimed to evaluate the clinicopathological characteristics of small-sized gastric SETs and their surgical outcomes depending on location and provide considering factors for their treatment plans. Methods: This single-center, retrospective study reviewed patients who underwent surgical resection for gastric SETs (size < 5 cm). SETs were divided into benign SETs and gastrointestinal stromal tumors (GISTs) for comparison. The clinicopathological characteristics of SETs in the cardia were compared to those in the other regions. Results: Overall, 191 patients with gastric SETs (135 GISTs, 70.7%; and 56 benign SETs, 29.3%) were included. In multivariate analysis, age > 65 years (odds ratio (OR), 3.183; 95% confidence interval (CI), 1.310−7.735; p = 0.011), and non-cardiac SETs (OR, 2.472; 95% CI, 1.110−5.507; p = 0.030) were associated with a significant risk of malignancy. Compared to SETs in other locations, cardiac SETs showed more complications (3 versus 0; p = 0.000), and open conversion rates (2 versus 0; p = 0.003). However, the proportion of GISTs of SETs in the cardia is not negligible (52.9%). Conclusions: Considering the malignancy risk of SETs, active surgical resection should be considered in old age and/or location in the non-cardiac area. However, in young patients, SETs located in the gastric cardia have a considerably benign nature and are associated with poor short-term surgical outcomes. An individualized surgical approach for asymptomatic small SETs according to the gastric location is warranted.

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Third space robotic and endoscopic cooperative surgery (TS-RECS) is a novel minimally invasive surgery for resecting gastric submucosal tumours (GSMTs), which could accomplish the completely oncological curability and maximal functional preservation. This study investigated the clinical outcomes and gastrointestinal function after TS-RECS versus laparoscopic wedge resection (LWR) for GSMTs. This was a single-centre retrospective study that included 130 patients with GSMTs who underwent LWR or TS-RECS from 2013 to 2019. To overcome selection biases, we performed propensity score matching (1:1) using seven covariates that could impact the group assignment and outcomes. Then, the clinical outcomes and gastrointestinal function in the LWR and TS-RECS groups were compared in a matched cohort. Among the 130 enrolled patients, 96 patients underwent LWR, and 34 underwent TS-RECS and were matched into 30 patients for each group. There was no significant difference in the operation time between the two groups (P = 0.543). However, the TS-RECS group had significantly less blood loss (20,5-100 vs 95,10-310 ml, P < 0.0001) and better postoperative recovery in terms of time to oral intake (2,2-4 vs 3,2-6 days, P < 0.0001) and postoperative hospital stay (5,4-10 vs 8.5,5-16 days, P < 0.0001) than the LWR group. The severity and frequency scores of postoperative gastrointestinal symptoms in the TS-RECS group were significantly lower than those in the LWR group. The median follow-up period was 24 months (10-60 months) in the LWR group and 18 months (10-27 months) in the TS-RECS group, and there was in total a single recurrence in the LWR group. TS-RECS appears to be a technically safe and effective surgery with preservation of gastrointestinal function for resection of GSMT resection.

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It is essential for the surgery of gastric submucosal tumors to resect the tumor with a negative margin and minimize the incision of the normal stomach wall. We developed a novel procedure for patients with gastric submucosal tumors using a laparoscopic ultrasound probe as a guide to determine the resection line. Since 2014, we have performed the laparoscopic ultrasound-guided wedge resection of the stomach in seven patients. The tumor was localized, and the property of the tumor was clearly identified using a laparoscopic ultrasound probe. As a result, the ideal incision line was determined without intraoperative endoscopy. The stomach wall was perforated along the marking on the planned incision line and the whole layer is subsequently incised along with the tumor. The surgical margins were negative, and there were no obvious injuries of the pseudocapsule, microscopically, in any case. It is possible that the laparoscopic ultrasound-guided wedge resection of the stomach contributes to a simplification of the surgery of gastric submucosal tumors resulting in reduced medical cost while maintaining curability and functional preservation.

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INTRODUCTION AND IMPORTANCE: Surgical resection is the only curative treatment for gastrointestinal stromal tumor (GIST). Laparoscopic approach for large (>5 cm) and giant (>10 cm) gastric GIST remains under controversy. What's more, whether laparoscopic surgery could be performed after preoperative imatinib treatment of giant gastric GIST is still unknown. CASE PRESENTATION: We report a 68-year-old man with a giant (almost 30 cm) locally advanced gastric GIST which required resection of contiguous organs initially. After received 12 months imatinib therapy, the tumor became resectable and he finally achieved a complete laparoscopic wedge resection. Pathological evaluation of the resected specimen revealed a near pathological complete response was obtained. The imatinib treatment was ongoing after surgical resection and there was no radiological or clinical evidence of disease recurrence until to October 2021. CLINICAL DISCUSSION: Laparoscopic approach is safe and effective for gastric GIST. Even for lesions greater for 5 cm. However, there are few reports for the application of laparoscopic wedge resection for gastric GIST larger than 10 cm. Preoperative use of imatinib can decrease the tumor size, so that may increase the chance of laparoscopic approach. CONCLUSION: Preoperative imatinib therapy was effective for reducing the gastric GIST, which may increase the chance of minimally invasive approach and organ preservation. Patients with locally advanced GIST could benefit from the multidisciplinary approach.

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BACKGROUND AND AIMS: Gastric schwannoma (GS) is not well clinically recognized and surgical resection (SR) remains the mainstay of treatment. Recently, endoscopic resection (ER) appears to be a safe and effective alternative. However, its comparative outcomes with SR is lacking. Our aim was to first compare clinical outcomes and costs between ER and SR in the management of GSs. METHODS: A total of 46 consecutive patients with GSs who underwent ER (n = 16) or SR (n = 30) in our large tertiary center between July 2007 and Oct 2018 were included. Clinicopathologic features, clinical outcomes, medical costs and follow-up were retrospectively reviewed and compared between two groups. RESULTS: Baseline characteristics are comparable except for a smaller tumor size in ER group (22.9 vs 41.0 mm, p = 0.002). Complete resection was achieved in 87.5% of patients with ER and 100% of patients with SR (p = 0.116). The ER group had a significant shorter operative time (91.6 vs 128.2 min), less blood loss (16.9 vs 62.7 mL) and lower operation cost (21,054.4 vs 30,843.4 RMB) than SR group (all p < 0.05). There was no significant difference in adverse events (12.5% vs 10%, p = 0.812) and length of postoperative hospital stay (8.3 vs 8.2 days, p = 0.945). During a long-term follow-up of mean 37.4 months (range 6-140 months), no residue, recurrence or metastasis was observed in both groups. CONCLUSIONS: Compared with SR, ER has the similar safety and efficacy in the management of GSs, but contributes to a shorter operation time and lower medical costs. ER may be considered as the first-line treatment, especially for patients with GSs smaller than 30 mm.

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BACKGROUND: Gastric schwannoma is a rarely seen gastric tumor accounting for only 0.2% of all gastric tumors. It is difficult to distinguish a gastric schwannoma from other gastric tumors preoperatively.Case presentation: A 30-year-old man with no significant medical history or physical examination findings presented with a 1-month history of right upper abdominal discomfort. The preoperative diagnosis was a gastrointestinal stromal tumor, but the postoperative pathologic and immunohistochemical examinations confirmed a gastric schwannoma. The patient underwent laparoscopic wedge resection of the stomach without additional postoperative treatment, and his postoperative recovery was uneventful. No recurrence or metastasis was found at the 2-year follow-up examination. CONCLUSION: Although gastric schwannomas are usually not malignant, they are difficult to distinguish from other malignant stromal tumors preoperatively. Surgical resection should be recommended when a schwannoma is malignant or considered to be at risk of becoming malignant.

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BACKGROUND: Gastric gastrointestinal stromal tumours (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of laparoscopic resection of smaller gastric GIST has been established, the feasibility and long-term efficacy of these techniques are unclear in larger lesions. This study is done to assess the feasibility of the laparoscopic resection of gastric GISTs and their long-term outcomes. METHODS: Patients who underwent laparoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics, operative findings, morbidity and histopathologic characteristics of the tumour. Patient and tumour characteristics were analysed to identify risk factors for tumour recurrence. RESULTS: There were 42 patients with a mean age of 56.7 years and had a mean tumour size was 4.5 ± 2.7 cm. Laparoscopic wedge resection was the most common procedure done. There were no major perioperative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 48 months, 36/39 (92.3%) patients were disease free and 3/39 (7.6%) had progressive disease. Univariate analysis showed that there was a statistically significant association of disease progression with tumour size, high mitotic index, tumour ulceration and tumour necrosis. The presence of >10 mitotic figures/50 high-power field was an independent predictor of disease progression. CONCLUSION: Our study establishes laparoscopic resection is feasible and safe in treating gastric GISTs for tumours >5 cm size. The long-term disease-free survival in our study shows acceptable oncological results in comparison to historical open resections.

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BACKGROUND: To avoid excessive sacrifice of the tissue surrounding the submucosal tumor in gastric wedge resection with a stapling device, we perform a "combined laparoscopic and endoscopic approach for neoplasia with a nonexposure technique" (CLEAN-NET). Herein the operative technique of CLEAN-NET is described and its short-term outcomes in 50 patients are evaluated. PATIENTS AND METHODS: Between December 2015 and July 2017 CLEAN-NET was performed in 50 patients with gastric submucosal tumors. During the operation, the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. When seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. The mucosa is then transected with a stapling device to execute full-thickness resection of the specimen. Finally, the seromuscular defect is repaired by hand-sewn suture. The hospital records of the 50 patients were reviewed to assess the outcomes. The margin width was compared with those measured in another group with 19 patients, who underwent conventional wedge resection with a stapling device. RESULTS: The operation was completed as CLEAN-NET and the tumor was resected en-bloc without rupture in all patients. The average operation time ranged from 50 to 220 min with an average of 105.4 min. The post-operative course was uneventful. Microscopically the surgical margin was tumor-negative (R0 resection) in all cases. The margin width in the CLEAN-NET group was smaller than that in the wedge resection group (5.4 mm ± 2.5 vs. 33.1 mm ± 14.7). CONCLUSIONS: CLEAN-NET can be performed safely with an acceptable operation time. CLEAN-NET can be a useful option in the laparoscopic surgical treatment of gastric submucosal tumors, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided.

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BACKGROUND: Laparoscopic wedge resection (LWR) is used to treat gastric submucosal tumors (SMTs). However, LWR can injure the cardia if tumors are near the esophagogastric junction (EGJ), resulting in gastric stenosis. This study's purpose was to summarize our experience with endoscope-assisted LWR for gastric SMTs within 3 cm of the EGJ and to verify the procedure's feasibility and safety. METHODS: Data from 91 consecutive patients with gastric SMTs within 3 cm of the EGJ who underwent endoscope-assisted LWR at our hospital from 2007 to 2017 were obtained from a prospectively maintained database. The clinicopathological results, perioperative data, and long-term follow-up data were analyzed. RESULTS: All patients successfully underwent endoscope-assisted LWR. The mean distance from tumor to EGJ was 2.43 ± 0.80 cm. Eighty-two patients underwent laparoscopic exogastric wedge resection (LEWR) and nine underwent laparoscopic transgastric wedge resection (LTWR). Mean operative time was 112.4 ± 48.8 min; mean blood loss was 36.8 ± 53.5 ml. Mean time to first flatus was 2.04 ± 0.68 days. Mean time to liquid intake was 2.53 ± 0.85 days. Mean postoperative hospital stay was 4.97 ± 1.80 days. Three patients (3.3%) had postoperative complications, all Clavien-Dindo grade I. The mean maximum tumor diameter was 3.00 ± 1.96 cm (range 0.5-10). LTWR was used more often than LEWR for SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ. The mean follow-up time was 36.86 ± 29.73 months (range 3-126). There was no stenosis of EGJ or tumor recurrence. Sixteen patients (17.6%) complained of upper gastrointestinal symptoms during the follow-up, which were all relieved by usage of acid suppressive medications. CONCLUSIONS: Endoscope-assisted LWR is safe, feasible, and effective for gastric SMTs near the EGJ. LTWR is preferable to LEWR for gastric SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ.

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BACKGROUND: Current endoscopic full-thickness resection (EFTR) methods produce transmural communication and expose the tumor to the peritoneum. An EFTR method with a simple suturing technique that does not expose the gastric mucosa to the peritoneum (non-exposure simple suturing, NESS) was recently developed. To date, there have been no prospective studies that compare EFTR with laparoscopic wedge resection in human or animal. The aim of this study was to compare outcomes between NESS-EFTR and laparoscopic wedge resection (LWR) using the linear staplers in a randomized animal study. METHODS: NESS-EFTR includes steps of laparoscopic seromuscular suturing, EFTR of the inverted stomach wall, and endoscopic mucosal suturing with endoloops and clips. Sixteen pigs underwent NESS-EFTR (n = 8) or LWR (n = 8). The resected locations were the cardia, fundus, upper body anterior and greater curvature, antrum lesser and greater curvature side. The pigs were killed 3 weeks after surgery. Rates of successful complete resection (en-bloc resection with clear margins), successful closure, and complications were evaluated. RESULTS: The complete resection rates in the NESS-EFTR and LWR groups were 100 and 75%, respectively (P = 0.467). All wounds were successfully closed in both groups. Resected tissues were significantly larger in the LWR group (mean ± SD: 8.0 ± 0.8 cm vs. 4.4 ± 0.5 cm, P < 0.001). Procedure time was significantly shorter in the LWR group (31.7 ± 10.0 min vs. 118.1 ± 23.4 min, P < 0.001). Early deaths due to complications only occurred in the LWR group (a leakage at cardia and a stenosis at the antrum lesser curvature side). CONCLUSIONS: Incomplete resection and complications were occurred in only LWR group. NESS-EFTR was feasible and safe in animal.

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INTRODUCTION: The safety and oncologic outcome of laparoscopic gastric GIST resection is well established especially for lesions <5cm in diameter. The optimal management of GIST tumors near the GE junction remains unclear. METHODS: We present a case-report of a 4.7cm GIST tumor near the GE junction managed by endoscopically-assisted laparoscopic wedge resection (EAWR). We present a review of the literature highlighting the various combined laparo-endoscopic techniques available. RESULTS: We used the non-touch lesion-lifting method to laparoscopically resect the GIST tumor under endoscopic guidance. There were no complications and the patient was discharged on postoperative day 3. CONCLUSIONS: Endoscopically-assisted laparoscopic wedge resections are feasible and safe for GIST tumors near the GE junction.

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INTRODUCTION: Endoscopic submucosal dissection (ESD) has been used for the treatment of gastric submucosal tumors (SMTs). This study aims to compare clinical outcomes of ESD versus laparoscopic wedge resection (LWR) for gastric SMTs. METHODS: This is a retrospective cohort study. Patients with SMTs who underwent ESD or LWR were enrolled in this study at a university-affiliated hospital from January 2010 to October 2015. Preoperative endoscopic ultrasound and computed tomography were performed to determine origin of layer and growth pattern. Clinical outcomes including baseline demographics, tumor size, operation time, blood loss, hospital stay, cost, pathology and postoperative complications were compared. RESULTS: From January 2010 to October 2015, 68 patients with SMTs received ESD and 47 patients with SMTs received LWR. There was no difference in age, gender, body mass index, origin of layer and proportion with symptoms between ESD group and LWR group. However, tumor size was significantly larger in the LWR group (37.1 mm) than in the ESD group (25.8 mm, P = 0.041). For patients with tumors smaller than 20 mm, ESD was associated with shorter mean operation time (89.7 ± 23.5 vs 117.6 ± 23.7 min, P = 0.043), less blood loss (4.9 ± 1.7 vs 72.3 ± 23.3 ml, P < 0.001), shorter length of hospital stay (3.6 ± 1.9 vs 6.9 ± 3.7 days, P = 0.024) and lower cost (2471 ± 573 vs 4498 ± 1257 dollars, P = 0.031) when compared with LWR. For patients with tumors between 20 mm and 50 mm, ESD was associated with shorter mean operation time (99.3 ± 27.8 vs 125.2 ± 31.5 min, P = 0.039), less blood loss (10.1 ± 5.3 vs 87.6 ± 31.3 ml, P < 0.001), shorter length of hospital stay (4.0 ± 1.7 vs 7.3 ± 4.5 days, P = 0.027) and lower cost (2783 ± 601 vs 4798 ± 1343 dollars, P = 0.033) when compared with LWR. There were no significant differences in terms of rates of en bloc resection, complete resection and complication and histological diagnosis regardless of tumor size. CONCLUSIONS: ESD can achieve similar oncological outcomes when compared with surgery for treatment of gastric SMT smaller than 50 mm.

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Herein, we report a case of a gastrointestinal stromal tumor (GIST) at the esophagogastric junction (EGJ) that was successfully treated by a laparoscopic wedge resection (LWR) after dissection of the seromuscular layer around the tumor to prevent postoperative deformities and stenosis of the EGJ. Subsequently, the abdominal esophagus was wrapped by the gastric fornix according to Dor's method in order to prevent reflux esophagitis after surgery.A 71-year-old female patient was admitted with a diagnosis of a GIST (23 × 20 × 20 mm) at the EGJ. We performed the abovementioned operation.Gastroduodenal endoscopic examination revealed no deformity or stenosis of the EGJ at 6 months after the operation. The patient has not experienced any reflux symptoms. Tumor recurrence was not noted 26 months after the operation.This procedure is useful in preventing the deformity and stenosis of the EGJ as well as postoperative reflux esophagitis.

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AIM: To investigate the predictive factors of lymph node metastasis (LNM) in poorly differentiated early gastric cancer (EGC), and enlarge the possibility of using laparoscopic wedge resection (LWR). METHODS: We retrospectively analyzed 85 patients with poorly differentiated EGC who underwent surgical resection between January 1992 and December 2010. The association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (OR) with 95%CI were calculated. We further examined the relationship between the positive number of the three significant predictive factors and the LNM rate. RESULTS: In the univariate analysis, tumor size (P = 0.011), depth of invasion (P = 0.007) and lymphatic vessel involvement (P < 0.001) were significantly associated with a higher rate of LNM. In the multivariate model, tumor size (OR = 7.125, 95%CI: 1.251-38.218, P = 0.041), depth of invasion (OR = 16.624, 95%CI: 1.571-82.134, P = 0.036) and lymphatic vessel involvement (OR = 39.112, 95%CI: 1.745-123.671, P = 0.011) were found to be independently risk clinicopathological factors for LNM. Of the 85 patients diagnosed with poorly differentiated EGC, 12 (14.1%) had LNM. The LNM rates were 5.7%, 42.9% and 57.1%, respectively in cases with one, two and three of the risk factors respectively in poorly differentiated EGC. There was no LNM in 29 patients without the three risk clinicopathological factors. CONCLUSION: LWR alone may be sufficient treatment for intramucosal poorly differentiated EGC if the tumor is less than or equal to 2.0 cm in size, and when lymphatic vessel involvement is absent at postoperative histological examination.

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A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

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A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

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