A Hybrid Laparoscopic-Endoscopic Approach Enabling Endoscopic Submucosal Dissection for Early Gastric Cancer in a...

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancer; however, severe anatomical distortion caused by a large hiatal hernia can render the procedure technically infeasible. We report a case in which laparoscopic reduction enabled successful ESD in a 1-stage hybrid procedure.

An older woman with a large type III hiatal hernia was diagnosed with early gastric cancer in the antrum, with most of the stomach herniated into the thoracic cavity. ESD was attempted but proved technically infeasible because of poor endoscopic maneuverability due to the intrathoracic displacement of the stomach. A 1-stage hybrid approach was therefore planned for treatment. With the patient under general anesthesia, laparoscopic reduction and posterior crural closure were performed to restore the normal hiatal anatomy. ESD was then performed under more stabilized conditions that allowed en bloc resection, while intraoperative endoscopy simultaneously enabled assessment of luminal narrowing at the esophagogastric junction. The anterior wall of the upper gastric body was fixed to the abdominal wall to prevent recurrence of the hernia. The patient's postoperative course was uneventful. Histopathological examination of the resected specimen confirmed the curative resection of an intramucosal adenocarcinoma (pT1a, ly0, v0, HM0, VM0). No recurrence was observed during 3 years of follow-up.

A hybrid laparoscopic-endoscopic approach can enable ESD in otherwise technically infeasible cases by restoring anatomical configuration and stabilizing endoscopic maneuverability. This strategy may provide a safe and minimally invasive 1-stage treatment option.