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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Single-incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum Masaki Ohi,1 Hiromi Yasuda,2 Yoshito Ishino,2 Masaki Katsurahara,3 Susumu Saigusa,2 Kyosuke Tanaka,3 Koji Tanaka,2 Yasuhiko Mohri,2 Yasuhiro Inoue,2 Keiichi Uchida2 & Masato Kusunoki1 1 Department of Innovative Surgery, Mie University Graduate School of Medicine, Tsu, Japan 2 Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan 3 Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
Keywords Duodenal submucosal tumor; laparoscopic-endoscopic cooperative surgery; single-incision laparoscopic surgery Correspondence Masaki Ohi, Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan. Tel: +81 59 232 1111 (ext. 5645) Fax: +81 59 232 6968 Email: [email protected] Received: 19 January 2013; revised 18 May 2013; accepted 29 July 2013
Abstract We report a case involving a minimally invasive single-incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59-year-old man presented with a 35-mm lesion located in the second portion of the duodenum. A local resection was performed via single-incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single-incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.
DOI:10.1111/ases.12059
Introduction Duodenal gastrointestinal stromal tumors (GIST) are not common, but they account for approximately 30% of primary duodenal tumors (1). The standard surgical approach for GIST is local excision with negative margins (2), but laparoscopic wedge resection has recently been reported as a minimally invasive alternative. Surgeons may be reluctant, however, to perform laparoscopic surgery for duodenal GIST because local duodenal resection can be technically difficult, especially if the involved portion of the duodenum is retroperitoneal or in close proximity to Vater’s papilla. Furthermore, there is a risk of postoperative duodenal stenosis. Because of these difficulties, pancreaticoduodenectomy is frequently required to resect these tumors successfully. Laparoscopic and endoscopic cooperative surgery (LECS) is a novel surgical method that consists of an endoscopic approach from within the gastrointestinal
tract and a laparoscopic approach. LECS enables tumor resection with adequate surgical margins while being minimally invasive (3). In recent years, SILS has been developed to further reduce surgical trauma (4). Although there have been a few cases of gastric submucosal tumors resected by SILS (5,6), there have been no reports, to our knowledge, of duodenal submucosal tumor resection by SILS combined with a LECS technique. Herein, we report a case of a single-incision LECS to treat GIST arising from the duodenum.
Case Presentation In the course of a comprehensive medical checkup, a 59-year-old man was diagnosed by upper endoscopy with a duodenal lesion. One year later, follow-up endoscopy showed the lesion had increased in size. The patient was referred to our hospital.
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
307
Single-incision LECS for GIST
M Ohi et al.
Figure 1 Upper gastrointestinal series before and after the operation. The upper gastrointestinal series showed a protrusion into the lumen with a mild narrowing (left panel). The postoperative upper gastrointestinal series showed normal passage through the second portion of the duodenum (right panel).
Figure 2 Endoscopic studies of the upper digestive tract revealed a 3.5-cm submucosal tumor located in the second portion of duodenum near the inferior duodenal angle.
We conducted an upper gastrointestinal series, which showed protrusion of the tumor into the lumen (Figure 1, left panel). Endoscopy of the upper digestive tract revealed a 3.5-cm submucosal tumor with a shallow ulcer located in the second portion of the duodenum near the inferior duodenal angle (Figure 2). Biopsies were performed, and histopathology demonstrated a GIST with low-grade malignancy (MIB-1 index: 5.8%). There was no evidence of invasion of the surrounding organs or of distant metastases according to CT. Based on the location, the size (3.5 cm) of the tumor, and lowgrade malignancy, single-incision LECS was undertaken. We decided upon this approach after careful consideration regarding the feasibility and oncological safety of
308
single-incision LECS as compared to the conventional laparoscopic approach. The procedure was approved by the Institutional Review Board (Mie University Graduate School of Medicine, Tsu, Japan), and informed consent was obtained from the patient. Under general and epidural anesthesia, the patient was placed in the supine position with the lower limbs abducted and supported by a levitator. The abdomen was entered via a 35-mm umbilical incision using Hasson’s technique, and a Lap Protector (Hakko Medical, Nagano, Japan) with EZ access (Hakko Medical) was folded around the wound. A 5-mm umbilical port that was 150-mm in length (Endopath Xcel Trocar; Ethicon EndoSurgery, Cincinnati, USA) was placed through the EZ access as were two parallel 5-mm working ports (Hakko Medical), both with shorter lengths to avoid dueling interference (Figure 3, left panel). Pneumoperitoneum was established by CO2 insufflation to an abdominal pressure of 8 mmHg. A 5-mm 45° videolaparoscope (Stryker 1228 full high-definition video system; Stryker Endoscopy, San Jose, USA) was used for visualization (Figure 4, left panel). The jejunum near the ligament of Treitz was then clamped with a pair of bulldog clamp forceps. After the duodenum was mobilized from the retroperitoneum by a Kocher maneuver, peroral endoscopy was performed. The mucosa and submucosa were circumferentially dissected around the tumor by using endoscopic submucosal dissection techniques. After the serosa was reached, full-thickness laparoscopic dissection was performed around one-third of the duodenal wall’s circumference with an ultrasonically activated device (HARMONIC Scalpel; Ethicon Endo-Surgery). Next, the tumor with free margins was retracted away from the duodenal lumen, and the final dissection and duodenal closure was achieved with a laparoscopic stapling device
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-incision LECS for GIST
M Ohi et al.
Figure 3 The setting and transumbilical sites of the trocars placed through an EZ access are shown (left panel). The umbilical incision, shown at 12 months after surgery (right panel).
Figure 4 Intraoperatively, the lesion was found to protrude mainly into the lumen, with a small extraluminal component (left panel). The tumor was then exteriorized to the abdominal cavity and dissected with an endoscopic linear stapling device (middle panel). The illustration for the operation is shown (right panel).
(Echelon 60; Ethicon Endo-Surgery) (Figure 4, middle panel). The resected specimen was collected in a retrieval bag (ENDOPOUCH; Ethicon Endo-Surgery) and was removed from the abdominal cavity through the umbilical incision with the Lap Protector. Finally, we confirmed laparoscopically and endoscopically that there was no bleeding, narrowing, or leakage at the resection site. Total operative time was 186 min. Intraoperative blood loss was less than 10 mL. Histopathological examination revealed a low-risk GIST. The surgical margins were negative of tumor involvement. There were no postoperative complications, including no stenosis (Figure 1, right panel), and the patient was discharged on postoperative day 5. At the 12-month follow-up, there was no evidence of tumor recurrence. The incision had healed satisfactorily (Figure 3, right panel).
Discussion The standard procedure for GIST is a local excision with negative margins and without lymphadenectomy (2). For gastric GIST, laparoscopic resection has become the procedure of choice for tumors less than 5 cm in diameter
(7). Conversely, local excision of the rarer duodenal GIST is more challenging because of the risk of causing deformity or stenosis, especially in cases with lesions occupying a significant portion of the duodenal circumference. Recently, some reports have described techniques for successful local duodenal resection using the LECS approach (8,9). In these case reports, the defect in the duodenal wall was closed by a laparoscopic, hand-sewn suture technique to avoid narrowing or stricture of the duodenum. In our case, the tumor was completely resected without excessive removal of normal tissue with a LECS method, and reconstruction was achieved by utilization of a laparoscopic stapling device on the duodenal wall, without deformity or stenosis of the lumen postoperatively. To perform this closure, the incision line (A → B) was straightened by grasping each end of the incision, and the tumor was brought out of the lumen, with traction applied to both sides of the incision. We emphasize that the direction of the incision line (A → B) should be parallel to the direction of cartridge fork of the linear stapler (C → D) (Figure 4, right panel). Flexible laparoscopic linear staplers may be useful to control the direction of the incision line.
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
309
Single-incision LECS for GIST
M Ohi et al.
The technical steps needed to avoid complications, such as contamination and dissemination of the tumor, can make the transluminal approach challenging (10). Based on these concerns, surgeons must be scrupulous in employing wound protection, excising the tumor from the gastrointestinal tract without manipulation, and using a retrieval bag to isolate the tumor immediately. It should be noted that a surgeon can easily convert a single-incision procedure into another procedure if the tumor location or limitation of the working space make it difficult to close the wall with an automatic suture device and to ensure oncological safety. In conclusion, single-incision LECS for duodenal GIST appears to be feasible in our preliminary experience when performed by experienced laparoscopic surgeons. This minimally invasive surgical procedure may become an attractive option in the treatment of GIST arising at locations where there are technical hurdles for laparoscopic local resection, such as the duodenum.
Acknowledgment
2.
3.
4.
5.
6.
7.
8.
The authors have no conflicts of interest or financial ties to disclose. 9.
References 1. Miettinen M, Kopczynski J, Makhlouf HR et al. Gastrointestinal stromal tumors, intramural leiomyomas, and
310
10.
leiomyosarcomas in the duodenum: A clinicopathologic, immunohistochemical, and molecular genetic study of 167 cases. Am J Surg Pathol 2003; 27: 625–641. Joensuu H, Fletcher C, Dimitrijevic S et al. Management of malignant gastrointestinal stromal tumours. Lancet Oncol 2002; 3: 655–664. Hiki N, Yamamoto Y, Fukunaga T et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008; 22: 1729–1735. Curcillo Ii PG, King SA, Podolsky ER et al. Single port access (SPA) minimal access surgery through a single incision. Surg Technol Int 2009; 18: 19–25. Sasaki A, Koeda K, Nakajima J et al. Single-incision laparoscopic gastric resection for submucosal tumors: Report of three cases. Surg Today 2011; 41: 133–136. Takahashi T, Takeuchi H, Kawakubo H et al. Single-incision laparoscopic surgery for partial gastrectomy in patients with a gastric submucosal tumor. Am Surg 2012; 78: 447–450. Nishida T, Hirota S, Yanagisawa A et al. GIST Guideline Subcommittee. Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version. Int J Clin Oncol 2008; 13: 16–30. Abe N, Takeuchi H, Shibuya M et al. Successful treatment of duodenal carcinoid tumor by laparoscopy-assisted endoscopic full-thickness resection with lymphadenectomy. Asian J Endosc Surg 2012; 5: 81–85. Sakon M, Takata M, Seki H et al. A novel combined laparoscopic-endoscopic cooperative approach for duodenal lesions. J Laparoendosc Adv Surg Tech A 2010; 20: 555–558. Ibrahim IM, Silvestri F, Zingler B. Laparoscopic resection of posterior gastric leiomyoma. Surg Endosc 1997; 11: 277–279.
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Single-incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum Masaki Ohi,1 Hiromi Yasuda,2 Yoshito Ishino,2 Masaki Katsurahara,3 Susumu Saigusa,2 Kyosuke Tanaka,3 Koji Tanaka,2 Yasuhiko Mohri,2 Yasuhiro Inoue,2 Keiichi Uchida2 & Masato Kusunoki1 1 Department of Innovative Surgery, Mie University Graduate School of Medicine, Tsu, Japan 2 Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan 3 Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
Keywords Duodenal submucosal tumor; laparoscopic-endoscopic cooperative surgery; single-incision laparoscopic surgery Correspondence Masaki Ohi, Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan. Tel: +81 59 232 1111 (ext. 5645) Fax: +81 59 232 6968 Email: [email protected] Received: 19 January 2013; revised 18 May 2013; accepted 29 July 2013
Abstract We report a case involving a minimally invasive single-incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59-year-old man presented with a 35-mm lesion located in the second portion of the duodenum. A local resection was performed via single-incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single-incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.
DOI:10.1111/ases.12059
Introduction Duodenal gastrointestinal stromal tumors (GIST) are not common, but they account for approximately 30% of primary duodenal tumors (1). The standard surgical approach for GIST is local excision with negative margins (2), but laparoscopic wedge resection has recently been reported as a minimally invasive alternative. Surgeons may be reluctant, however, to perform laparoscopic surgery for duodenal GIST because local duodenal resection can be technically difficult, especially if the involved portion of the duodenum is retroperitoneal or in close proximity to Vater’s papilla. Furthermore, there is a risk of postoperative duodenal stenosis. Because of these difficulties, pancreaticoduodenectomy is frequently required to resect these tumors successfully. Laparoscopic and endoscopic cooperative surgery (LECS) is a novel surgical method that consists of an endoscopic approach from within the gastrointestinal
tract and a laparoscopic approach. LECS enables tumor resection with adequate surgical margins while being minimally invasive (3). In recent years, SILS has been developed to further reduce surgical trauma (4). Although there have been a few cases of gastric submucosal tumors resected by SILS (5,6), there have been no reports, to our knowledge, of duodenal submucosal tumor resection by SILS combined with a LECS technique. Herein, we report a case of a single-incision LECS to treat GIST arising from the duodenum.
Case Presentation In the course of a comprehensive medical checkup, a 59-year-old man was diagnosed by upper endoscopy with a duodenal lesion. One year later, follow-up endoscopy showed the lesion had increased in size. The patient was referred to our hospital.
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
307
Single-incision LECS for GIST
M Ohi et al.
Figure 1 Upper gastrointestinal series before and after the operation. The upper gastrointestinal series showed a protrusion into the lumen with a mild narrowing (left panel). The postoperative upper gastrointestinal series showed normal passage through the second portion of the duodenum (right panel).
Figure 2 Endoscopic studies of the upper digestive tract revealed a 3.5-cm submucosal tumor located in the second portion of duodenum near the inferior duodenal angle.
We conducted an upper gastrointestinal series, which showed protrusion of the tumor into the lumen (Figure 1, left panel). Endoscopy of the upper digestive tract revealed a 3.5-cm submucosal tumor with a shallow ulcer located in the second portion of the duodenum near the inferior duodenal angle (Figure 2). Biopsies were performed, and histopathology demonstrated a GIST with low-grade malignancy (MIB-1 index: 5.8%). There was no evidence of invasion of the surrounding organs or of distant metastases according to CT. Based on the location, the size (3.5 cm) of the tumor, and lowgrade malignancy, single-incision LECS was undertaken. We decided upon this approach after careful consideration regarding the feasibility and oncological safety of
308
single-incision LECS as compared to the conventional laparoscopic approach. The procedure was approved by the Institutional Review Board (Mie University Graduate School of Medicine, Tsu, Japan), and informed consent was obtained from the patient. Under general and epidural anesthesia, the patient was placed in the supine position with the lower limbs abducted and supported by a levitator. The abdomen was entered via a 35-mm umbilical incision using Hasson’s technique, and a Lap Protector (Hakko Medical, Nagano, Japan) with EZ access (Hakko Medical) was folded around the wound. A 5-mm umbilical port that was 150-mm in length (Endopath Xcel Trocar; Ethicon EndoSurgery, Cincinnati, USA) was placed through the EZ access as were two parallel 5-mm working ports (Hakko Medical), both with shorter lengths to avoid dueling interference (Figure 3, left panel). Pneumoperitoneum was established by CO2 insufflation to an abdominal pressure of 8 mmHg. A 5-mm 45° videolaparoscope (Stryker 1228 full high-definition video system; Stryker Endoscopy, San Jose, USA) was used for visualization (Figure 4, left panel). The jejunum near the ligament of Treitz was then clamped with a pair of bulldog clamp forceps. After the duodenum was mobilized from the retroperitoneum by a Kocher maneuver, peroral endoscopy was performed. The mucosa and submucosa were circumferentially dissected around the tumor by using endoscopic submucosal dissection techniques. After the serosa was reached, full-thickness laparoscopic dissection was performed around one-third of the duodenal wall’s circumference with an ultrasonically activated device (HARMONIC Scalpel; Ethicon Endo-Surgery). Next, the tumor with free margins was retracted away from the duodenal lumen, and the final dissection and duodenal closure was achieved with a laparoscopic stapling device
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-incision LECS for GIST
M Ohi et al.
Figure 3 The setting and transumbilical sites of the trocars placed through an EZ access are shown (left panel). The umbilical incision, shown at 12 months after surgery (right panel).
Figure 4 Intraoperatively, the lesion was found to protrude mainly into the lumen, with a small extraluminal component (left panel). The tumor was then exteriorized to the abdominal cavity and dissected with an endoscopic linear stapling device (middle panel). The illustration for the operation is shown (right panel).
(Echelon 60; Ethicon Endo-Surgery) (Figure 4, middle panel). The resected specimen was collected in a retrieval bag (ENDOPOUCH; Ethicon Endo-Surgery) and was removed from the abdominal cavity through the umbilical incision with the Lap Protector. Finally, we confirmed laparoscopically and endoscopically that there was no bleeding, narrowing, or leakage at the resection site. Total operative time was 186 min. Intraoperative blood loss was less than 10 mL. Histopathological examination revealed a low-risk GIST. The surgical margins were negative of tumor involvement. There were no postoperative complications, including no stenosis (Figure 1, right panel), and the patient was discharged on postoperative day 5. At the 12-month follow-up, there was no evidence of tumor recurrence. The incision had healed satisfactorily (Figure 3, right panel).
Discussion The standard procedure for GIST is a local excision with negative margins and without lymphadenectomy (2). For gastric GIST, laparoscopic resection has become the procedure of choice for tumors less than 5 cm in diameter
(7). Conversely, local excision of the rarer duodenal GIST is more challenging because of the risk of causing deformity or stenosis, especially in cases with lesions occupying a significant portion of the duodenal circumference. Recently, some reports have described techniques for successful local duodenal resection using the LECS approach (8,9). In these case reports, the defect in the duodenal wall was closed by a laparoscopic, hand-sewn suture technique to avoid narrowing or stricture of the duodenum. In our case, the tumor was completely resected without excessive removal of normal tissue with a LECS method, and reconstruction was achieved by utilization of a laparoscopic stapling device on the duodenal wall, without deformity or stenosis of the lumen postoperatively. To perform this closure, the incision line (A → B) was straightened by grasping each end of the incision, and the tumor was brought out of the lumen, with traction applied to both sides of the incision. We emphasize that the direction of the incision line (A → B) should be parallel to the direction of cartridge fork of the linear stapler (C → D) (Figure 4, right panel). Flexible laparoscopic linear staplers may be useful to control the direction of the incision line.
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
309
Single-incision LECS for GIST
M Ohi et al.
The technical steps needed to avoid complications, such as contamination and dissemination of the tumor, can make the transluminal approach challenging (10). Based on these concerns, surgeons must be scrupulous in employing wound protection, excising the tumor from the gastrointestinal tract without manipulation, and using a retrieval bag to isolate the tumor immediately. It should be noted that a surgeon can easily convert a single-incision procedure into another procedure if the tumor location or limitation of the working space make it difficult to close the wall with an automatic suture device and to ensure oncological safety. In conclusion, single-incision LECS for duodenal GIST appears to be feasible in our preliminary experience when performed by experienced laparoscopic surgeons. This minimally invasive surgical procedure may become an attractive option in the treatment of GIST arising at locations where there are technical hurdles for laparoscopic local resection, such as the duodenum.
Acknowledgment
2.
3.
4.
5.
6.
7.
8.
The authors have no conflicts of interest or financial ties to disclose. 9.
References 1. Miettinen M, Kopczynski J, Makhlouf HR et al. Gastrointestinal stromal tumors, intramural leiomyomas, and
310
10.
leiomyosarcomas in the duodenum: A clinicopathologic, immunohistochemical, and molecular genetic study of 167 cases. Am J Surg Pathol 2003; 27: 625–641. Joensuu H, Fletcher C, Dimitrijevic S et al. Management of malignant gastrointestinal stromal tumours. Lancet Oncol 2002; 3: 655–664. Hiki N, Yamamoto Y, Fukunaga T et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008; 22: 1729–1735. Curcillo Ii PG, King SA, Podolsky ER et al. Single port access (SPA) minimal access surgery through a single incision. Surg Technol Int 2009; 18: 19–25. Sasaki A, Koeda K, Nakajima J et al. Single-incision laparoscopic gastric resection for submucosal tumors: Report of three cases. Surg Today 2011; 41: 133–136. Takahashi T, Takeuchi H, Kawakubo H et al. Single-incision laparoscopic surgery for partial gastrectomy in patients with a gastric submucosal tumor. Am Surg 2012; 78: 447–450. Nishida T, Hirota S, Yanagisawa A et al. GIST Guideline Subcommittee. Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version. Int J Clin Oncol 2008; 13: 16–30. Abe N, Takeuchi H, Shibuya M et al. Successful treatment of duodenal carcinoid tumor by laparoscopy-assisted endoscopic full-thickness resection with lymphadenectomy. Asian J Endosc Surg 2012; 5: 81–85. Sakon M, Takata M, Seki H et al. A novel combined laparoscopic-endoscopic cooperative approach for duodenal lesions. J Laparoendosc Adv Surg Tech A 2010; 20: 555–558. Ibrahim IM, Silvestri F, Zingler B. Laparoscopic resection of posterior gastric leiomyoma. Surg Endosc 1997; 11: 277–279.
Asian J Endosc Surg 6 (2013) 307–310 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
