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Page 2 of 8 Toma et al. Mini-invasive Surg 2018;2:21 I http://dx.doi.org/10.20517/2574-1225.2018.24

INTRODUCTION
Recent advances in gastrointestinal endoscopic technology and diagnostic skills have led to increased oc-
currence of asymptomatic non-ampullary duodenal epithelial neoplasms (NADENs) in daily clinical prac-
[1-3]
tice . Either endoscopic mucosal resection (EMR) or submucosal dissection (ESD) has occasionally been
indicated in the treatment of NADENs, but the procedure remains technically challenging, given that ex-
pertise in both meticulous dissection and subsequent repair is required in the narrow lumen of the duode-
[2-5]
num . In addition, the prevention of bleeding and perforation during and after the procedure is pivotal,
[4-6]
given that the incidence of these serious complications is relatively frequent in ESD for NADENs .
Laparoscopic and endoscopic cooperative surgery (LECS) was initially invented for the purpose of less in-
[7]
vasive surgery for gastric non-epithelial neoplasms but later employed to overcome the limitation of ESD
[8]
for early gastric cancer (e.g., non-exposed wall inversion surgery (NEWS ), a combination of laparoscopic
[9]
and endoscopic approaches to neoplasia using non-exposure techniques (CLEAN-NET ). Similarly, recent
reports demonstrated that LECS offers a promising procedure of choice to facilitate less invasive surgery
in the treatment of NADENs [10-15] , but the clinical evidence verifying its efficacy remains limited. In this
report, we sought to investigate our initial experience of LECS for NADENs and further reveal its clinical
significance. Our LECS procedure including ESD and subsequent laparoscopic and endoscopic repair may
extend the indication of ESD and improve its safety in the treatment of NADENs.

METHODS
Five consecutive patients with the diagnosis of NADENs between April 2015 and January 2016 were includ-
ed in this study. All of the patients were referred to the department of surgery by the gastroenterologists.
LECS for NADENs was indicated for these patients following routine preoperative examination including
esophagogastroduodenoscopy with concomitant biopsy, endoscopic ultrasonography (EUS), upper GI series
and computed tomography (CT). Gastroenterologists and surgeons had deliberate discussion to determine
the surgery indication for all of patients. In the discussion, special attention was given to the distance be-
tween NADENs and Vater papilla obtained from upper GI series images in view of both the prevention of
the injury to Vater papilla and the security of the resection margin at least 10 mm away from Vater papilla.
Epithelial neoplasms confined in the mucosa at the risk of malignancy were eligible for treatment. In prin-
ciple, NADENs located in the duodenal wall side of the pancreas head were preoperatively contraindicated
for LECS, given that laparoscopic suture repair following ESD was considered to be rather demanding.
All of the patients consequently provided written informed consent prior to surgery. Clinical records were
reviewed retrospectively. Clinical outcomes included operation time, blood loss, intra- and postoperative
complications, and length of postoperative hospital stay. Postoperative complications were graded accord-
[16]
ing to the Clavien-Dindo Classification (C-D: Grade ). All patients were followed up in the outpatient
clinic after the discharge. The follow-up examination included the endoscopy during the first postoperative
year. In cases with malignancy in the final diagnosis, CT was also periodically performed in the outpatient
clinic.

LECS procedure for NADENs
The surgery of LECS for NADENs was performed by a single surgeon (HT) with the certification of Japan
Society for Endoscopic Surgery. The patient was placed in a supine position with both legs apart under
general anesthesia. A total of five ports were inserted in the abdomen, as described in Figure 1, and the
pneumoperitoneum was created and maintained at approximately 8 to 10 mmHg. The operative field was
visualized by 3-dimensional imaging systems equipped with a 10 mm flexible scope (Olympus, Tokyo, Ja-
pan) through the infraumbilical port. The infrapyloric region was reached by the dissection of the greater
omentum in the vicinity of the transverse colon with an ultrasonically activated scalpel. Following the ad-
equate mobilization of the duodenum, the upper jejunum around 10-20 cm away from Treiz ligament was