Endoscopic Resection for Early Gastric Carcinoma (EGC)

Modalities

1. Endoscopic Mucosal Resection (EMR)

• Technique: Saline injection into the submucosal layer lifts the lesion, which is then encircled with a snare or suction cap and excised with electrocautery.
• Methods: Cap-assisted (lesion sucked into transparent cap then snared), ligation-assisted (band creates pseudopolyp then excised), or injection-assisted.
• Perforation rate: Low; bleeding ~15% (usually controllable endoscopically).
• Key limitation: Piecemeal resection is common for larger lesions, which raises recurrence risk. En bloc resection is preferred.

2. Endoscopic Submucosal Dissection (ESD)

• Technique: Electrocautery marks the lesion borders; epinephrine + indigo carmine is injected submucosally to hydrodissect; an insulation-tipped (IT) knife dissects a submucosal plane deep to the tumor for complete en bloc removal; bleeding controlled with electrocautery throughout.
• Key advantage: Enables en bloc resection of larger tumors and those with limited submucosal invasion, regardless of tumor size, location, or ulceration status.
• En bloc resection rate: 92.7-98.0% across large series; a meta-analysis confirms ESD superior to EMR for en bloc rates.
• More technically demanding than EMR, with a higher risk of perforation.
• Predominantly performed in East Asian centers; adoption in Western centers remains limited due to the steep learning curve.

Indications

Standard (Absolute) Criteria

Expanded (Extended) Criteria

1. > 2 cm, differentiated type, intramucosal, without ulceration
2. ≤ 3 cm, differentiated type, intramucosal, with ulceration (UL+)
3. ≤ 2 cm, undifferentiated type, intramucosal, without ulceration
4. ≤ 3 cm, differentiated type, SM1 invasion (< 500 µm into submucosa)

Pre-procedural Assessment

• Endoscopic ultrasound (EUS): Critical for T staging - the first/second hypoechoic layers = mucosa; third hyperechoic = submucosa; fourth hypoechoic = muscularis propria. EUS distinguishes T1a (mucosal) from T1b (submucosal) disease.
• Magnifying NBI: The MESDA-G algorithm (Magnifying Endoscopy Simple Diagnostic Algorithm for EGC) guides optical diagnosis.
• Paris classification: Classifies superficial lesion morphology (0-I polypoid; 0-IIa/b/c flat; 0-III excavated).
• CT staging: To exclude lymph node involvement and distant metastasis before planning endoscopic vs surgical approach.

Post-resection Pathological Assessment and Decision-Making

• Completeness: Lateral and vertical margins
• Depth of invasion: Mucosal (M) vs. submucosal (SM1 < 500 µm; SM2 ≥ 500 µm)
• Histological type: Differentiated vs. undifferentiated
• Lymphovascular invasion: ly(+) or ly(-)
• Ulceration: Present or absent

Management by Resection Result

Outcomes vs. Surgery

• Higher rates of incomplete resection and local recurrence compared with conventional surgery
• No significant difference in 5-year overall survival when selection criteria are appropriately applied
• (Sabiston Textbook of Surgery)

Complications

Technical Innovations (2025-2026)

• Traction-assisted ESD: A 2026 meta-analysis (Zhang et al., Surg Endosc, PMID 41731140) confirms traction devices improve ESD efficacy and safety (faster dissection, reduced perforation).
• Pocket-creation method (PCM): A 2025 meta-analysis (Song et al., Saudi Med J, PMID 40335108) found PCM reduces procedure time and improves en bloc resection rates vs. conventional ESD.

Summary

Management of a 4 cm Perforation of the First Part of the Duodenum (D1)

1. Immediate Resuscitation (Pre-operative)

• IV access, aggressive fluid resuscitation (crystalloids) to correct hypovolaemia and sepsis.
• Broad-spectrum IV antibiotics (e.g. co-amoxiclav or cephalosporin + metronidazole) promptly; add antifungal cover only in frail, immunosuppressed, or previously hospitalised patients.
• Nasogastric (NG) tube: stomach decompression, reduces further peritoneal soilage.
• Urinary catheter for monitoring urine output.
• Blood tests: FBC, U&E, LFTs, amylase, coagulation, crossmatch, ABG.
• IV proton pump inhibitor (PPI) infusion.
• CT abdomen (with IV contrast): confirms pneumoperitoneum, extent of peritoneal soilage, and any associated pathology. Most sensitive for diagnosing perforation and retroperitoneal involvement.
• Optimise but do not delay surgery unduly - resuscitation and surgical treatment must proceed in parallel.

2. Decision: Operative vs Non-operative

3. Operative Approach

Access

Initial Steps

• Peritoneal washout with 5-10 litres of warm saline; send peritoneal fluid for culture and sensitivity including fungal studies.
• Biopsy the ulcer edge only if there is any suspicion of malignancy (routine biopsy is not necessary).
• Assess: size, exact location in D1, tissue quality, proximity to pylorus and ampulla, degree of local inflammation.
• A Kocher manoeuvre (mobilising the duodenum off the retroperitoneum) facilitates exposure and tension-free repair.

4. Repair Options for the Large (4 cm) Perforation

A. Primary Closure + Omental Buttress (Patch)

• If tissue quality permits, close the defect with interrupted or running slowly absorbable sutures (one or two layers) without significantly narrowing the duodenal lumen. Up to 50% luminal narrowing is generally acceptable. For longitudinal lacerations, close transversely (Heineke-Mikulicz principle) to avoid stricture.
• Cover/buttress the primary closure with a well-vascularised omental flap, circumferentially sutured around the repair site with multiple interrupted sutures. Ensure the inferior end is well anchored to prevent tension on the patch.
• If no viable omentum, the falciform ligament (divided close to the abdominal wall and mobilised to the liver) is an alternative.
• Test repair integrity by injecting air/methylene blue through the NG tube while the site is submerged under irrigation fluid.

B. Omental Plug Technique (Modified Graham)

• If primary closure will cause unacceptable narrowing or the tissue is too friable to hold sutures, place double-armed sutures "inside out" through the duodenal wall surrounding the perforation, and pull a tongue of well-vascularised omentum directly into the defect as a plug. Tie sutures snugly to secure, without causing ischaemia.

C. Jejunal Serosal Patch (Thal Patch)

• A loop of healthy proximal jejunum is brought up (antecolic or retrocolic) adjacent to the perforation and sutured to the perforation margins with full-thickness bites to seromuscular bites of the jejunum.
• Better suited for defects not amenable to omental repair; however, carries a significant failure rate for very large defects or severe local inflammation.

D. Roux-en-Y Duodenojejunostomy

• For large, chronic perforations in a stable, low-risk patient, the debrided duodenal opening is anastomosed to a Roux limb in a tension-free two-layer side-to-side handsewn anastomosis. This provides durable closure and wide duodenal decompression.

5. The Triple-Tube Technique (High-Risk Adjunct)

1. Gastrostomy tube - decompresses the stomach and reduces acid/content load on the repair.
2. Retrograde duodenostomy tube - a jejunostomy tube passed retrogradely through the jejunum into the duodenum, providing controlled duodenal decompression and a controlled fistula if the repair leaks.
3. Antegrade feeding jejunostomy - enables early enteral nutrition.

6. Pyloric Exclusion

• The pylorus is closed with a heavy absorbable suture (which will recanalize in 3-6 weeks), diverting gastric contents away from the repair.
• A dependent loop gastrojejunostomy is fashioned to restore gastric outflow.
• This protects the repair by reducing luminal pressure and acid exposure during healing.

7. Definitive Ulcer Surgery

• Truncal vagotomy + gastrojejunostomy (with or without temporary pyloric closure) after repair.
• Truncal vagotomy + antrectomy (Billroth II): Only if the perforated duodenum can be safely resected with the antrum and a secure duodenal stump created. If ampullar involvement is a risk, protect with a biliary Fogarty catheter passed via the cystic duct. Never attempt resection if a tenuous duodenal stump or ampullary injury is likely.

8. Drains and Closure

• Place at least one (preferably two) closed-suction peritoneal drains near the repair site - repair site leakage is not uncommon with large perforations.
• NG tube remains in situ postoperatively for decompression and for contrast studies if leak is suspected.
• Abdominal closure per standard technique.

9. Post-operative Management

• IV PPI (high-dose) continued until oral intake established; then switch to oral PPI.
• Continue IV antibiotics per culture sensitivity results.
• H. pylori testing (CLO test on intraoperative biopsy or serology) and eradication therapy on resuming oral intake - most important step in preventing recurrence.
• NG tube removed once bowel function returns; enteral nutrition via jejunostomy tube if triple-tube technique used.
• Contrast study through NG tube or water-soluble swallow at 5-7 days to confirm repair integrity before oral diet.
• DVT prophylaxis; early mobilisation.
• Drain output monitored - if bile/intestinal fluid suggests fistula, the controlled retrograde duodenostomy tube provides a safe conduit.

Summary Table