Intragastric surgery may be performed for the local resection of small submucosal tumors such as leiomyomas, as well as for control of bleeding in areas out of reach of a standard upper endoscope (or when upper endoscopy has failed). Intragastric surgery can also be used to create a communication between a pancreatic pseudocyst and the stomach (laparoscopic intragastric cyst-gastrostomy). The indications for each of these procedures are quite different.
Leiomyoma, Lipoma, and Other Small Gastric Tumors
The indication for an intragastric approach to a submucosal tumor generally requires that the tumor be sufficiently small that a “shelling out” will not risk the chance of incomplete resection and tumor recurrence. Thus, this approach should only be used for lipomas or leiomyomas, and not GI stromal tumors. Generally leiomyomas are 1 cm or less in diameter and possess smooth muscle cells that are not c-Kit positive by fine-needle aspirate.
Early gastric cancers have generally been approached with endoscopic mucosal resection (EMR) using a flexible endoscope. However, intragasstric surgery may be used if experience with EMR is limited but the lesion would otherwise be amenable to a local approach (confined to the mucosa by endoscopic ultrasonography [EUS], and <1.0 cm in diameter).
Pancreatic Pseudocyst Drainage
Another indication for intragastric surgery is for drainage of a pancreatic pseudocyst. Although most pancreatic pseudocysts are asymptomatic and/or resolve spontaneously, large cysts may persist and cause symptoms of postprandial pain or gastric outlet obstruction. When a computed tomography (CT) scan shows a mature pseudocyst clearly adherent to the posterior gastric wall, laparoscopic intragastric cystogastrostomy may be indicated.
Most intragastric bleeding lesions (except gastric varices) can be controlled with endoscopic injection of epinephrin. Occasionally a lesion develops that cannot be adequately controlled with a flexible endoscope, especially those near the gastroesophageal (GE) junction, such as a Mallory-Weiss tear or a Dieulafoy lesion. These lesions may be approached with intragastric surgery for direct suture ligation of the bleeding site.
General anesthesia is a requirement. Intravenous antibiotics are administered.
For most intragastric surgery, the position used for laparoscopic fundoplication is the best. The patient is supine with the legs abducted on leg boards and the patient is placed in a steep reverse Trendelenburg position. The surgeon stands between the patient’s legs (Figure 1).
Before trocars are placed, an upper GI endoscopy is usually performed to confirm the location of the lesion and to distend the stomach for placement of the intragastric ports after laparoscopic access has been completed.