New method of endoscopic full-thickness resection: a pilot study of non-exposed endoscopic wall-inversion surgery in an ex vivo porcine model

Abstract

The indications for endoscopic full-thickness resection (EFTR) are limited because transmural communication during the entire procedure, causing tumor dissemination into the abdominal space, is inevitable. We invented a new method of EFTR without transmural communication, and explored its feasibility in an ex vivo porcine model. Three explanted porcine stomachs were used. First, markings around a model lesion were made with a flexible endoscope, and 0.9% normal saline with indigocarmine was injected into the submucosa around the markings. Second, a circumferential sero-muscular incision was made from the outside with an electrocautery knife, guided by the color of the submucosal injection and intragastric navigation with the endoscope. Third, the muscle layer was linearly sutured with the lesion inverted into the inside. Finally, a circumferential muco-submucosal incision was made with an electrocautery knife employed with the endoscope. The method was performed for 3 lesions (1 anterior wall, 1 lesser curve, and 1 posterior wall of the gastric body), and all lesions were successfully resected in en-bloc fashion. The mean size of the resected specimen was 4.5 cm in diameter. Neither perforation nor apparent air leakage was seen during or after the resection. Non-exposed endoscopic wall-inversion surgery (NEWS) is thought to be effective as a minimally invasive, and minimal-size endoluminal surgery for gastric submucosal tumors with or without ulceration, or even node-negative early gastric cancer that is difficult to resect by endoscopic submucosal dissection.

Novel surgical approach based on the sentinel node concept in patients with early gastric cancer

“…In order to prevent tumor dissemination induced by surgical procedures, modified LECS has recently been focused on as a promising non‐exposed approach 31. Non‐exposed endoscopic wall‐inversion surgery (NEWS) and the combination of laparoscopic and endoscopic approaches to neoplasia with a non‐exposure technique (CLEAN‐NET) are some representatives of modified LECS 32, 33, 34…”

A new stage of sentinel node navigation surgery in early gastric cancer

“…Although laparoscopic and endoscopic cooperative surgery has the merit of minimizing the surgical margin, it induces the exposure of the gastric lesion to the peritoneal cavity, which might lead to iatrogenic implantation and dissemination of cancer cells. More recently, other new techniques such as the combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) [49] and nonexposed endoscopic wall-inversion surgery (NEWS) [50,51] have been developed (Fig. 5).…”

Commentary on Laparoscopic-Endoscopic Cooperative Surgery for Duodenal Lesions

“…LECS, in which intraoperative endoscopy is combined with a manual ESD technique, has enabled the performance of reliable and adequate resection of duodenal tumors. Various LECS approaches have been reported including creative methods such as LECS reported by Irino et al [5] and NEWS [8] and CLEAN-NET [9]. These procedures do not perforate the duodenal wall and therefore avoid the dispersion of tumor cells.…”