Post written by Deepak Madhu, MD, MRCP, DM, from NTT Medical Center Tokyo, Tokyo, Japan.

An 83-year-old man with severe comorbidities underwent endoscopic submucosal dissection for early gastric cancer. Histologic analysis of the resected specimen showed that vertical margins were positive, and the tumor had deep submucosal invasion.

In light of severe comorbidities, a multidisciplinary decision was taken to choose the least invasive option for completion of local resection of the tumor. Nonexposed endoscopic wall inversion surgery (NEWS) was selected as the preferred option.

The margins of the lesion were marked endoscopically. Laparoscopic suturing was then performed along the margins on the serosal side. This produced an inversion of the gastric wall into the lumen of the stomach.

Next, we completed resection of the lesion endoscopically. A schematic diagram illustrating the key steps in the procedure is given (Fig. 4).

Conventional endoscopic full-thickness resection and classical laparoscopic endoscopic cooperative surgery techniques may be associated with risk of peritoneal contamination. With the NEWS technique, laparoscopic suturing prior to endoscopic resection (Fig. 4) overcomes this problem. It also allows the endoscopist to maintain adequate gaseous distension during endoscopic full-thickness resection.

The NEWS technique can be a therapeutic option for selected patients with gastric epithelial tumors. Although the initial reports of the NEWS technique indicated requirement of the use of a spacer and laparoscopic seromuscular dissection prior to inversion of the stomach wall into the lumen, we demonstrate that both these steps can be potentially bypassed.

Further studies should evaluate the role of this technique in the management of selected cases of gastric epithelial tumors. 

Schematic diagram describing the procedure. A, Laparoscopic suturing. B, Endoscopic dissection of the inverted portion of the gastric wall. C, Defect after resection.

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