Fig.1 Setupandportciteposition.Thesurgeon stoodonthepatient srightside,withthefirstassistantonthepatient sleftside,thelaparoscopist

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2 χ t P Fig. Setupandportciteposition.Thesurgeon stoodonthepatient srightside,withthefirstassistantonthepatient sleftside,thelaparoscopist intheexpandedlegs,andeithertheendoscopicoperatororassistantpositionedatthetopofthepatient shead.a cameraportwasinsertedintothe inferiorumbilicallesionusinganopentechnique. Fouradditionalports(three5-mm portsanda2- mm port)wereinsertedintotheleftupper,leftlower,rightupper,andrightlowerquadrants,respectively,under pneumoperitoneum of0 mmhg, withaview ofthelaparoscopicimage.

),thetu morlocationwasconfirmedbyintraluminalendo scopy(h260,olympus,tokyo,japan). Fig.

3 Fig.2 Confirmationofthetumorlocation.Folow ingclampingofthejejunum usingclampforceps (AESCULAP R,Tokyo,JAPAN)at0 20cm on theanalsideofthetreizligament(fig.),thetu morlocationwasconfirmedbyintraluminalendo scopy(h260,olympus,tokyo,japan). Fig.3 Markingaroundthetumorforendoscopic submucosalresection.thenewlydevelopedendoscopicsubmucosaldissection(esd)techniquewas used.first,the periphery ofthe tumor was markedusinganargonplasmacoagulationwitha forced20-w coagulationcurrent(psd-60;olympus,tokyo,japan),ascloseaspossibletothetumoredge.

Fig.4 Endoscopic submucosalresection around thetumor.afterinjectionofdilutedepinephrine (0.

knifeinsertedintothesubmucosal layer.then,threequartersofthemarkedwascut circumferentialyusingtheit knifeinthe00-w ENDO-CUT mode.

the tipoftheneedleknifewasapparentbeyondtheseromusclarlayerandartificialperforationwascarriedoutinthe00-w ENDO-CUT mode.

folowedthisprocedure,afurtherseromusclarlayerwasdissectedalongtheincision line using the Ligasure vascularsealing system. Fig.

Thetumor(nonresectedpart)andtheedgeoftheincisionlinewasthenlifted

4 Fig.4 Endoscopic submucosalresection around thetumor.afterinjectionofdilutedepinephrine (0.5%)intothesubmucosallayer,asmalinitialincisionwasmadewithastandardneedleknifein the00-w ENDO-CUT modewithefect3andthe tipoftheit knifeinsertedintothesubmucosal layer.then,threequartersofthemarkedwascut circumferentialyusingtheit knifeinthe00-w ENDO-CUT mode. Fig.5 Laparoscopic seromusclar dissection.the tipoftheneedleknifewasapparentbeyondtheseromusclarlayerandartificialperforationwascarriedoutinthe00-w ENDO-CUT mode.thetipof theultrasonicaly activated devicewasinserted intotheperforationhole,andseromusclardissectioncommenced.folowedthisprocedure,afurtherseromusclarlayerwasdissectedalongtheincision line using the Ligasure vascularsealing system. Fig.6 Laparoscopiclocalresection.Thetumor(nonresectedpart)andtheedgeoftheincisionlinewasthenlifted upusingforcepsbytheassistantandtheincisionlinewasclosedusinglaparoscopicstaplingdevices(endo-gia laparoscopicstapler,tycoautosuture,tokyo,japan)(fig.6a).theseproceduresdissectedthetumorandonly minimalextratissueareaofthestomachwal.thetumorwaslocatedneartheesophagogastricjunction(fig.6b) orpyloricring(fig.6c),theclosureofthedefectinthegastricwalwasperformedbylaparoscopichandsuturing techniquebecauselaparoscopicstaplingdevicesneedenoughspaceforsuturing.

5 Table Patientscharacteristics CONV(n= 7) LECS(n= 2) Pvalues Sex Age Bodymassindex Preoperativecomplication Diabetes Ischemicheartdisease Livercirrhosis Hypertention Symptom Epigastricpain Nausea Nosymptom Male/Female Average(y) Range(y) (kg/m2) 4/3 62± ± 3 3(8%) 0 6 4/8 58± ± ( 8%) 4(33%) Dataarepresentedasmeans±SE.Bodymassindex= Bodyweight/Height (kg/m 2 2 ),CONV = Con ventionalwedgeresection,lecs= LaparoscopyandEndoscopyCooperativeSurgery. Table2 Clinicopathologiccharacteristicsofsubmucosaltumor(SMT) CONV(n= 7) LECS(n= 2) Pvalues Locationoftumor esophagogastricjunction,anterior Upper,anterior Upper,posterior Middle,anterior Middle,posterior Lower,anterior Remnantstomach,posterior Mainlocationoftumor Extraandintra-gastrictype Intra-gasrictype Tumorsize(cm) Pathologicaldiagnosis GastrointestinalStromalTumor Schwannoma 3.2± (82%) 3(8%) 3.2± (83%) 2(7%) Dataarepresentedasmeans±SE,CONV = Conventionalwedgeresection,LECS= LaparoscopyandEndoscopyCooperativeSurgery.

6 Table3 Operativedata CONV(n= 7) LECS(n= 2) Pvalues Operationtime(min) Intraoperativebloodloss(mL) NumberofEndo-GIA used Conversiontoopensurgery Postoperativecomplications Gastricfulness Anastomoticleakage Anastomoticstenosis Anastomoticbleeding Timeuntilstartoforalintake(days) Postoperativehospitalstay(days) 0± 32 4± 4 3.2± 0.5.5± ± ± 35 6± 8 2.± 0.8.2± ± Dataarepresentedasmeans±SE,CONV = Conventionalwedgeresection,LECS= LaparoscopyandEndoscopyCooperativeSurgery.

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Table1 Subjectcharacteristics

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