7. Laparoscopy-assisted endoscopic full-thickness resection

This technique was reported by Abe et al. in [28]. The same procedure as LECS technique is applied; however, the endoscopist plays an important role in resecting the tumor. The endoscopic team starts full-thickness resection around the tumor, and after two-thirds of the resection is performed, the laparoscopic team finishes the full-thickness resection with laparoscopic devices.

### 7.1. LECS for duodenal tumors

4. "A full-layer specimen is lifted by four stay sutures. This process allows a wider cancer-free

5. "A full-layer resection using a mechanical stapler is performed and the resected tumor is removed from abdominal cavity side." These figures are excerpted from Inoue's report.

margin around a full-thickness lesion."

36 Gastric Cancer - An Update

There are some limitations with LECS for removal of duodenal tumors. First, anatomical elements such as the pyloric ring, Vater's papilla and the third to fourth portion make it difficult to perform. Second, there are a few reports of lymph node metastasis from submucosal invading duodenal cancers or carcinoids, so partial resection is controversial. Small submucosal tumors, duodenal adenomas, or intramucosal carcinomas at duodenal bulb or the opposite side of the papilla are indications for LECS. The basic concept of gastric LECS also applies to duodenum LECS [4, 29]. The difficulty in mobilizing organs and closing the defected walls needs to be advanced.

#### 7.2. LECS for colorectal tumors

LECS for colorectal tumors is not often used. We rarely experience GISTs in the colorectum, and in many cases the laparoscopist must achieve adequate mobilization which may be difficult in colorectal-LECS. Some researchers have reported the laparoscopy-assisted endoscopic resection (LAER) for colorectal tumors [30–32], and as the combined laparoscopic endoscopic resection (CLER). Fukunaga et al. reported LECS for laterally spreading colorectal tumors, which are difficult to resect by the ESD technique because of submucosal fibrosis or multiple surrounding diverticula [33] (Figures 18 and 19). He suggested several concerns about his technique: limitation for tumors located on the mesenteric side, strictures after surgery, and contamination of the abdominal cavity by bowel contents. He proposed several adjustments in his report. Indications for colorectal LECS are the same as for colorectal ESD. Tumors that would be difficult to resect endoscopically are good indications for both. Figures 18 and 19 are excerpted from Fukunaga's report.

Figure 18. A laparoscopic coagulating system is used to dissect the full thickness of the colon wall along the submucosal line created by endoscopic dissection.

gastric cancer. On the other hand, some researchers reported the utility of sentinel node biopsy in patients with gastric cancer [34–36]. Although gastric lymphatic drainage is often complicated, by using the dual tracer method with radiolabeled tin colloid and blue dye, Kitagawa reported that the sentinel node detection rate was 97.5% (387 of 397) and the accuracy of nodal evaluation for metastasis was 99% (383 of 387) in cT1 and tumors <4 cm [36]. These facts implicate that by combining LECS technique and sentinel node biopsy, LECS with lymph node dissection might become possible in the future (Figure 20). More research and clinical trials

Figure 20. By combining LECS technique and sentinel node biopsy, LECS with lymph node dissection might become

Laparoscopic Endoscopic Cooperative Surgery: Current Status and Perspective

http://dx.doi.org/10.5772/intechopen.76983

39

[1] Qiu WQ et al. Minimally invasive treatment of laparoscopic and endoscopic cooperative surgery for patients with gastric gastrointestinal stromal tumors. Journal of Digestive

about LECS and biopsy to sentinel lymph node for early gastric cancer are expected.

Address all correspondence to: lunlun8shunsuke@gmail.com

Department of Surgery, Juntendo Shizuoka Hospital, Shizuoka, Japan

Author details

possible in the future.

Shunsuke Sakuraba

References

Diseases. 2013;14:469-473

Figure 19. The incision line was closed using laparoscopic stapline devices. The Figures 18 and 19 are excerpted from Fukunaga's report.

#### 7.3. LECS plus biopsy to sentinel lymph node for early gastric cancer

The application LECS has progressed from resection of gastric submucosal tumors to early stage gastric cancer. The current therapeutic adaptation is for removal of low-risk lymph node metastases. Further, there still remains the possibility of lymph node metastasis in treating

Figure 20. By combining LECS technique and sentinel node biopsy, LECS with lymph node dissection might become possible in the future.

gastric cancer. On the other hand, some researchers reported the utility of sentinel node biopsy in patients with gastric cancer [34–36]. Although gastric lymphatic drainage is often complicated, by using the dual tracer method with radiolabeled tin colloid and blue dye, Kitagawa reported that the sentinel node detection rate was 97.5% (387 of 397) and the accuracy of nodal evaluation for metastasis was 99% (383 of 387) in cT1 and tumors <4 cm [36]. These facts implicate that by combining LECS technique and sentinel node biopsy, LECS with lymph node dissection might become possible in the future (Figure 20). More research and clinical trials about LECS and biopsy to sentinel lymph node for early gastric cancer are expected.
