Indications
– Gastric Mass
– Patients with previous abdominal surgery
– Location of mass near GE junction or pylorus (resection will cause stricture)
Contraindications
– Adenocarcinoma
– Mass that is into the muscular wall of the stomach
– Mass that will not lift with submucosal injection
1) Identifying and marking the mass: Being be locating the mass/lesion that will be removed. Ensure that it can be resected with some sort of pre-operative imaging (CT, MRI, EUS). Once you have identified a resectable lesion, you need to mark the resectable area. This is because once the submucosal lift is done you will lose the visual ques that are used to identify the lesion. Thus, using a through the scope “TT” knife on coagulation, place bovie markers roughly 5mm apart and what ever distance from the lesion you choose to resect, usually 5-10mm.
2) Preform submucosal lite distal to proximal: Now you can use any type of endoscopic injection device, usually a 21 or 25 gauge needle. The, lift is one most important parts of the case, if you get this right the procedure is fairly straight forward. If the mucosa does not lift off of the mucosa, there should be a high level of concern this mass has invaded into the underlying muscle and the procedure should be aborted. I like to inject roughly 10cc of saline mixed with a small amount of methylene blue. The methylene blue stains the underlying submucosal layer and aids in dissection. When you begin your injection start at the area that is furthest away and work back proximal. You will have the marking from step 1 to guide you.
3) Create a mucosotomy proximal to distal. Use the marks from step one as your guide. You will connect these marking, cutting only through the mucosal layer. If you see the circular muscle you have gone far enough.
4) Dissect out the mass using dissection cap saying in the submucosal plane. Now use the dissecting cap to help create tension. Then use the TT knife to cut through the submucosal layer. You may come across some large vessels, use a grasper with cautery to cauterize these vessels before they bleed.
5) Mass fully resected, remove the mass. The best way to do this is usually with a Roth Net. Once the mass is out, it can be pinned to assist the pathologists with orientation.
6) +/- Closure of the mucosotomy. If this procedure was done in the stomach the mucosotomy does not need to be closed as the serosa layer is present. Sometimes these resections can be extremely large and the mucosotomy is impossible to close. However, in the esophagus it is recommend to try to close the mucosotomy as there is no serosal layer. If there is a post-operative hole in the stomach, this can usually be controlled with operative closure or drains. However, a hole in the esophagus can be catastrophic leading quickly to mediastinitis, sepsis and death.
| Pre Operative Diagnosis – Mass of the gastric wall, in setting of previous multiple abdominal surgeries Post Operative Diagnosis – Mass of the gastric wall, in setting of previous multiple abdominal surgeries Procedure Preformed – Endoscopic Submucosal Dissection with Endoscopic Resection of Gastric Mass Surgeon: Christopher DuCoin, MD First Assistant: Kais Rona, MD Anesthesia: GETA Findings – Mass in the wall of the stomach Specimen: Gastric Mass Complications: None Condition: Awake, Alert and Orientated, will be evaluated in PACU and admitted to hospital bed. Indications: Pt is a 57 yo male who was found to have a mass in the wall of his stomach. This mass has been biopsied and has under gone EUS with FNA, and there is no conclusive diagnosis. The patient has undergone multiple abdominal procedures and is not a good surgical candidate. For this reason we have recommended that he undergo Endoscopic Submucosal Dissection and Resection. Risks and benefits explained and the patient is willing to undergo Endoscopic Surgery. Procedure: The patient was seen in the Pre-Operative holding area where history and physical were examined along with consent forms. The patient was then moved to the operating room and secured on the OR table with a lap belt. A timeout was called acknowledging patient, procedure, and anatomical surgical sites. GETA was provided by the anesthesia team. A bite block was placed and a flexible front viewing endoscope was placed transorally, through the mouth and esophagus into the stomach. We were able to identify the gastric mass that is located roughly 5 cm proximal to the pyloris on the greater curve of the stomach. We then removed the scope and placed the dissection cap on the scope and reinserted the endoscope. We then marked out a margin around the lesion using the ‘TT’ (triangular tip) knife roughly 0.5 cm around the mass. Once this was marked we used a through the scope injection needle (25 gauge) to create our submucosal lift. The Lesion elevated nicely. The TT knife was then used to make a mucosotomy, and we created our submucosal lift with the dissection cap. We repeatedly injected the submucosal area with the injection lift and used the TT knife to dissect in the submucosal plan. We were able to dissect out the entire mass in this manner. With the mass fully resected and only a stalk attached to the mucosa, we used a through the scope snare to fully resect the mass. With the mass resected it was placed into a Roth bag and extracted, it will be sent to pathology for permanent. As there was no full thickness injury, and the stomach has a serosal lining, there is no need to close this defect. The stomach was deflated and the endoscope removed. The patient was seen gently waking from anesthesia, transferred from the OR bed to the stretcher, will be evaluated in PACU and admitted to a hospital bed. The family has been updated. |