Laparoscopic resection of gastric GIST and benign gastric tumours: evolution of a new technique

Single-incision transgastric resection for gastric gastrointestinal stromal tumors in anatomically challenging locations

Surgical resection is the mainstay treatment for resectable gastrointestinal stromal tumors (GISTs). However, resection in anatomically challenging locations, such as near the gastroesophageal junction, lesser curve and fundus, remain technically challenging. We herein report the outcomes of the largest series of patients who underwent single-incision transgastric resection of an intraluminal gastric GIST. Our reduced-port resection technique for intraluminal GISTs in these anatomically challenging locations involves a single incision in the left hypochondrium, deepened to access the gastric lumen, with the surgery completed in a transgastric manner. A total of 22 patients received surgery with this technique at the National University Hospital in Singapore from November 2012 to September 2020. The median operative time was 101 (range 50-253) min, with no conversions to open surgery, median lesion size 3.6 (range 1.8-8.2) cm and median postoperative length of stay 5 (range 1-13) days. There was no 30-day mortality and no recurrence during the follow-up period. Our laparoscopic approach for reduced-port transgastric excision of intraluminal GISTs allows for adequate surgical clearance, convenient extraction and secure gastrostomy closure with low morbidity.

FULL-THICKNESS ENDOSCOPIC GASTRIC RESECTION USING A STAPLER AND GASTROSTOMY: A FEASIBILITY STUDY

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the most frequently performed bariatric procedure in Turkey. The goal of weight reduction surgery is not only to decrease excess weight, but also to improve obesity related comorbidities and quality of life (QoL).

AIM

To evaluate the impact of LSG on patient quality of life, weight loss, and comorbidities associated with morbid obesity according to the updated BAROS criteria.

METHODS

Eleven hundred thirty-eight adult patients were undergone to LSG by our bariatric surgery team between January 2013 and January 2016. A questionnaire (The Bariatric Analysis and Reporting Outcome System - BAROS) was published on social media. The data on postoperative complications were collected from hospital database.

RESULTS

Number of respondants was 562 (49.4%). Six of 1138 patients(0.5%) had leakage. All patients who had leakage were respondants. The overall complication rate was 7.7%. After a mean period of 7.4±5.3 months(1-30), mean excess weight loss was 71.3±27.1% (10.2-155.4). The respondants reported 772 comorbidities. Of these, 162 (30%) were improved, and 420 (54.4%) were resolved. The mean scores for QoL were significantly increased after LSG (range, p<0.05 to <0.001). Of the 562 patients, 26 (4.6%) were classified as failures; 86 (15.3%) fair; 196 (34.9%) good; 144 (25.6%) very good, and 110 (19.6%) excellent results according to the updated BAROS scoring system.

CONCLUSION

LSG is a highly effective bariatric procedure in the manner of weight control, improvement in comorbidities and increasing of QoL in short- and mid-term.

Novel NOTES Techniques and Experimental Devices for Endoscopic Full-thickness Resection (EFTR)

Natural orifice transluminal endoscopic surgery (NOTES), in which a flexible endoscope is used to perform operations that have traditionally required laparoscopic surgery, has garnered attention as a minimally invasive surgery that does not leave a surgical wound on the body. Among the various forms of NOTES, endoscopic full-thickness resection (EFTR) is an ultraminimally invasive endoscopic surgery that allows for radical resection, which is an extension of endoscopic submucosal dissection and involves full-thickness excision of a tumor of the gastrointestinal tract wall. With further development of the equipment, including full-thickness suture instruments, nonexposed EFTR could be a feasible surgical procedure.

Total inverse transgastric resection with transoral specimen removal

BACKGROUND

Laparoscopic local excision is accepted for gastrointestinal stromal tumors (GIST) and benign lesions of the stomach. Yet, tumors at the gastroesophageal junction, on the posterior wall, or in the distal antrum are difficult to approach. Such tumors often must be exposed via gastrotomy or using a rendezvous maneuver. Our method of total intragastric laparoscopic resection using 'pneumogastrum', rigid laparoscope, and conventional laparoscopic instruments is described in an intuitive video.

METHODS

Two cases of total inverse transgastric resection involved resection of a submucosal GIST, one at the front wall of the cardia and the other on the posterior wall of the antrum. The third case required excision of a large prepyloric cystic lesion leading to a gastric outlet stenosis. After insertion of three trocars under laparoscopic control, a further trocar was introduced into the stomach and 'pneumogastrum' was established. Two additional 5-mm trocars were intragastrally placed. Intragastric endoscopy with a rigid optic provided an excellent view. The tumor was exposed resected with a linear stapler. The specimen was inserted into an Endo Pouch™ which was sutured to an orally inserted gastric tube. The Endo Pouch™ was gently pulled transorally. After removal of the intragastric trocars, the entrance points were laparoscopically closed.

RESULTS

From the first and second cases, we retrieved GIST tumors. In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful.

CONCLUSIONS

Gastric GIST should be resected laparoscopically if negative margins are safely achieved regardless of its size. Tumors at the frontwall and exophytic backwall GIST are addressed by laparoscopic wedge resection. Tumors at the gastrojejunal junction, in the prepyloric region, and fundus as well as submucous GIST of the gastric backwall are best approached by intragastric laparoscopic resection. Transoral specimen retrieval is an interesting option in smaller tumors.

Laparoscopic Surgery In The Treatment of Gastrointestinal Stromal Tumors

BACKGROUND AND AIMS

Gastrointestinal stromal tumors are rare neoplasms of the gastrointestinal tract. These lesions are characterized by different levels of malignancy. Only radical surgery offers a chance of curing the disease. The aim of this study is to present the results of gastrointestinal stromal tumor treatment with minimally invasive surgery.

MATERIAL AND METHODS

The study group included 27 patients operated laparoscopically on for gastrointestinal stromal tumor with laparoscopic surgery between September 2009 and December 2013. The most common location of the tumor was the stomach (21 patients, 77.8%) and the small intestine (4 patients, 14.8%). We analyzed early surgery results, the number and character of complications, lengths of hospital stays, histological types of the removed tumors, and long-term results of treatment.

RESULTS

There was no need for conversion to open surgery in any patient from the study group. Post-surgery complications occurred in 2 patients (7.4%). The median duration of the hospital stay was 4.5 days; none of the patients had to be readmitted to the hospital in the first 30 days after the procedure. In 26 out of 27 patients, microscopic examination confirmed the radicality of the surgical procedure (R0 resection). The mean size of the removed lesions was 4.1 cm. Using the Joensuu malignancy classification model, it was established that in 6 (22.2%) patients gastrointestinal stromal tumor was characterized by a very low level of malignancy, in 11 patients (40.7%) a low level, in 4 (14.9%) a medium level, and in 6 (22.2%) a high level. The average duration of follow-up was 13 months. During the observation period, there was no recurrence of the disease.

CONCLUSION

Minimally invasive surgery in the treatment of gastrointestinal stromal tumors is possible and allows for satisfactory results both in terms of the postoperative course and the oncological quality of the procedure.

Establishment of the hybrid endoscopic full-thickness resection of gastric gastrointestinal stromal tumors

A prospective observational study was conducted to establish the procedure of hybrid endoscopic full-thickness resection (EFTR) using an existing flexible endoscope. The present study included 16 patients who underwent hybrid EFTR between September 2009 and February 2013 for gastric gastrointestinal stromal tumor (GIST). The patients were selected using the following inclusion criteria for histological findings: Mitotic counts <5/high-power field and immunohistochemical stains positive for KIT or cluster of differentiation 34 (CD34). The mean patient age was 68.2 years (range, 44-81 years); the male-to-female ratio was 6:10; lesion sites at upper (U), middle (M) and lower regions (L) of the stomach were 9/6/1; and the average tumor diameter was 28.3 mm. The mean surgical time was 271 min and the surgical time became progressively faster with each successive surgery. There were 12 and four patients with mitotic counts of <5 and 5-10, respectively, which was significantly different (P=0.01). Immunohistochemical stains showed that tumors from 13 and 10 patients (81.2 and 62.5%, respectively) were positive for KIT and CD34, respectively (P=0.328). All resected surgical margins were negative. According to Fletcher's risk classification, there were five, eight and three patients at an 'extremely low', 'low', and 'intermediate' risk (31.2, 50 and 18.8%, respectively) (P=0.003). The mean postoperative hospital duration was 12.3 days (range, 10-15 days). In conclusion, an ultra-minimally invasive surgery-hybrid EFTR is a safe and established surgical endoscopy procedure.

Endoscopic full-thickness resection and laparoscopic surgery for treatment of gastric stromal tumors

AIM

To assess the effectiveness of endoscopic full-thickness resection (EFR) and laparoscopic surgery in the treatment of gastric stromal tumors arising from the muscularis propria.

METHODS

Out of 62 gastric stromal tumors arising from the muscularis propria, each > 1.5 cm in diameter, 32 were removed by EFR, and 30 were removed by laparoscopic surgery. The tumor expression of CD34, CD117, Dog-1, S-100, and SMA was assessed immunohistochemically. The operative time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rate were compared between the two groups. Continuous data were compared using independent samples t-tests, and categorical data were compared using χ (2) tests.

RESULTS

The 32 gastric stromal tumors treated by EFR and the 30 treated by laparoscopic surgery showed similar operative time [20-155 min (mean, 78.5 ± 30.1 min) vs 50-120 min (mean, 80.9 ± 46.7 min), P > 0.05], complete resection rate (100% vs 93.3%, P > 0.05), and length of hospital stay [4-10 d (mean, 5.9 ± 1.4 d) vs 4-19 d (mean, 8.9 ± 3.2 d), P >0.05]. None of the patients treated by EFR experienced complications, whereas two patients treated by laparoscopy required a conversion to laparotomy, and one patient had postoperative gastroparesis. No recurrences were observed in either group. Immunohistochemical staining showed that of the 62 gastric stromal tumors diagnosed by gastroscopy and endoscopic ultrasound, six were leiomyomas (SMA-positive), one was a schwannoglioma (S-100 positive), and the remaining 55 were stromal tumors.

CONCLUSION

Some gastric stromal tumors arising from the muscularis propria can be completely removed by EFR. EFR could likely replace surgical or laparoscopic procedures for the removal of gastric stromal tumors.

Laparoscopic versus open gastric resections for gastric gastrointestinal stromal tumors: a meta-analysis

PURPOSE

We conducted a meta-analysis to compare surgical and oncologic outcomes of patients with gastric gastrointestinal stromal tumors (GISTs) undergoing laparoscopic resection surgery (LAP) and open resection surgery (OPEN).

METHODS

PubMed, Ovid, Web of Science, Cochrane, CNKI, and Chinese Biomedical Database were searched. Statistical analysis was carried out by RevMan 5.0 software. The quality of evidence was assessed by the Newcastle-Ottawa scale. A decision tree analysis model was constructed to evaluate the treatment strategy.

RESULTS

Seventeen studies involving 776 participants were included for the meta-analysis. The meta-analysis results showed that, compared with OPEN, LAP indicates potentially favorable outcomes in terms of intraoperative blood loss [weighted mean difference (WMD), -60.67; 95% confidence interval (95% CI), -116.66 to -4.69], time to first flatus (WMD, -1.19; 95% CI, -1.65 to -0.73), time to oral intake (WMD, -1.26; 95% CI, -1.89 to -0.63), and hospital stay (WMD, -2.62; 95% CI, -3.25 to -1.99). There were no differences in terms of the operative time, overall complication, and recurrence. Decision analysis showed that LAP was the strategy with a higher overall success (93%) compared with OPEN (88%).

CONCLUSIONS

This meta-analysis showed that LAP for gastric GISTs was associated with less blood loss, earlier return of bowel function, earlier resumption of diet, and shorter length of hospital stay when compared with OPEN; however, LAP and OPEN had similar operative time, overall complication, and recurrence. The LAP might be superior to OPEN for the patients with GIST <5 cm. Methodologically, high-quality comparative studies are needed for further evaluation.

A systematic review and meta-analysis comparing laparoscopic versus open gastric resections for gastrointestinal stromal tumors of the stomach

BACKGROUND

This study is a systematic review and meta-analysis that compares the short- and long-term outcomes of laparoscopic gastric resection (LR) versus open gastric resection (OR) for gastric gastrointestinal stromal tumors (GISTs).

METHODS

Comparative studies reporting the outcomes of LR and OR for GIST were reviewed.

RESULTS

A total of 11 nonrandomized studies reviewed 765 patients: 381 LR and 384 OR. A higher proportion of high-risk tumors and gastrectomies were in the OR compared with LR (odds ratio, 3.348; 95 % CI, 1.248-8.983; p = .016) and (odds ratio, .169; 95 % CI, .090-.315; p < .001), respectively. Intraoperative blood loss was significantly lower in the LR group [weighted mean difference (WMD), -86.508 ml; 95 % CI, -141.184 to -31.831 ml; p < .002]. The LR group was associated with a significantly lower risk of minor complications (odds ratio, .517; 95 % CI, .277-.965; p = .038), a decreased postoperative hospital stay (WMD, -3.421 days; 95 % CI, -4.737 to -2.104 days; p < .001), a shorter time to first flatus (WMD, -1.395 days; 95 % CI, -1.655 to -1.135 days; p < .001), and shorter time for resumption of oral intake (WMD, -1.887 days; 95 % CI, -2.785 to -.989 days; p < .001). There was no statistically significant difference between the two groups with regard to operation time (WMD, 5.731 min; 95 % CI, -15.354-26.815 min; p = .594), rate of major complications (odds ratio, .631; 95 % CI, .202-1.969; p = .428), margin positivity (odds ratio, .501; 95 % CI, .157-1.603; p = .244), local recurrence rate (odds ratio, .629; 95 % CI, .208-1.903; p = .412), recurrence-free survival (RFS) (odds ratio, 1.28; 95 % CI, .705-2.325; p = .417), and overall survival (OS) (odds ratio, 1.879; 95 % CI, .591-5.979; p = .285).

CONCLUSIONS

LR results in superior short-term postoperative outcomes without compromising oncological safety and long-term oncological outcomes compared with OR.

Endoscopic full-thickness resection of gastric stromal tumor arising from the muscularis propria

BACKGROUND

Gastric stromal tumors are the most common type of tumor originating from mesenchymal tissue. The traditional method for the treatment of gastric stromal tumor is surgical operation or therapeutic laparoscopy. More recently, endoscopic micro-traumatic surgery has become possible for gastric stromal tumors, with any perforation caused by endoscopic therapy mended endoscopically. We assessed the effectiveness of endoscopic full-thickness resection (EFR) in the treatment of gastric stromal tumors arising from the muscularis propria.

METHODS

Of the 42 gastric stromal tumors, each > 2.0 cm in diameter, arising from the muscularis propria, 22 were removed by EFR and 20 by laparoscopic surgery. Tumor expression of CD34, CD117, Dog-1, S-100, and smooth muscle actin (SMA) was assessed immunohistochemically. Operating time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rates were compared between the two groups. Continuous data were compared by using independent samples t-tests and categorical data by using χ(2) tests.

RESULTS

Comparisons of the 22 gastric stromal tumors treated with EFR and the 20 treated with laparoscopic surgery showed similar operation times (60 - 155 minutes (mean, (90 ± 17) minutes) vs. 50 - 210 minutes (mean, (95 ± 21) minutes), P > 0.05), complete resection rates (100% vs. 95%, P > 0.05), and length of hospital stay (4 - 10 days (mean, (6.0 - 1.8) days) vs. 4 - 12 days (mean, (7.3 - 1.7) days), P > 0.05). None of the patients treated with EFR experienced complications, whereas one patient treated with laparoscopy required a conversion to laparotomy and one experienced postoperative gastroparesis. No recurrences were observed in either group. Immunohistochemical staining showed that of the 42 gastric stromal tumors diagnosed by gastroscopy and endoscopic ultrasound, six were leiomyomas (SMA-positive) and the remaining 36 were stromal tumors.

CONCLUSIONS

Gastric stromal tumors arising from the muscularis propria can be completely removed by EFR. EFR may replace surgical or laparoscopic procedures for the removal of gastric stromal tumors.

Surgical treatment of gastric gastrointestinal stromal tumor

Gastrointestinal stromal tumor is the most common mesenchymal tumor in the gastrointestinal tract and is most frequently developed in the stomach in the form of submucosal tumor. The incidence of gastric gastrointestinal stromal tumor is estimated to be as high as 25% of the population when all small and asymptomatic tumors are included. Because gastric gastrointestinal stromal tumor is not completely distinguished from other submucosal tumors, a surgical excisional biopsy is recommended for tumors >2 cm. The surgical principles of gastrointestinal stromal tumor are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles. Laparoscopic surgery has been indicated for gastrointestinal stromal tumors <5 cm, and the indication for laparoscopic surgery is expanded to larger tumors if the above mentioned surgical principles can be maintained. A simple exogastric resection and various transgastric resection techniques are used for gastrointestinal stromal tumors in favorable locations (the fundus, body, greater curvature side). For a lesion at the gastroesophageal junction in the posterior wall of the stomach, enucleation techniques have been tried preserve the organ's function. Those methods have a theoretical risk of seeding a ruptured tumor, but this risk has not been evaluated by well-designed clinical trials. While some clinical trials are still on-going, neoadjuvant imatinib is suggested when marginally unresectable or multiorgan resection is anticipated to reduce the extent of surgery and the chance of incomplete resection, rupture or bleeding.

Predictors of unsuccessful laparoscopic resection of gastric submucosal neoplasms

BACKGROUND

While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome.

METHODS

From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months.

RESULTS

Patients were 62 ± 14 years and 56 % male. Mean tumor size was 5.5 ± 4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p < 0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p < 0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1-1.3; p = 0.13).

CONCLUSIONS

Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.

Modern treatment of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GIST) are rare mesenchymal smooth muscle sarcomas that can arise anywhere within the gastrointestinal tract. Sporadic mutations within the tyrosine kinase receptors of the interstitial cells of Cajal have been identified as the key molecular step in GIST carcinogenesis. Although many patients are asymptomatic, the most common associated symptoms include: abdominal pain, dyspepsia, gastric outlet obstruction, and anorexia. Rarely, GIST can perforate causing life-threatening hemoperitoneum. Most are ultimately diagnosed on cross-sectional imaging studies (i.e., computed tomography and/or magnetic resonance imaging in combination with upper endoscopy. Endoscopic ultrasonographic localization of these tumors within the smooth muscle layer and acquisition of neoplastic spindle cells harboring mutations in the c-KIT gene is pathognomonic. Curative treatment requires a complete gross resection of the tumor. Both open and minimally invasive operations have been shown to reduce recurrence rates and improve long-term survival. While there is considerable debate over whether GIST can be benign neoplasms, we believe that all GIST have malignant potential, but vary in their propensity to recur after resection and metastasize to distant organ sites. Prognostic factors include location, size (i.e., > 5 cm), grade (> 5-10 mitoses per 50 high power fields and specific mutational events that are still being defined. Adjuvant therapy with tyrosine kinase inhibitors, such as imatinib mesylate, has been shown to reduce the risk of recurrence after one year of therapy. Treatment of locally-advanced or borderline resectable gastric GIST with neoadjuvant imatinib has been shown to induce regression in a minority of patients and stabilization in the majority of cases. This treatment strategy potentially reduces the need for more extensive surgical resections and increases the number of patients eligible for curative therapy. The modern surgical treatment of gastric GIST combines the novel use of targeted therapy and aggressive minimally invasive surgical procedures to provide effective treatment for this lethal, but rare gastrointestinal malignancy.

Laparoscopic versus open resection of gastric gastrointestinal stromal tumors

OBJECTIVES

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. There is some controversy as to the effectiveness and feasibility of laparoscopic versus open resection of these tumors. We hypothesized that laparoscopic resection of gastric GISTs would offer better perioperative outcomes compared with the traditional open approach.

METHODS

A retrospective review was conducted of all GISTs treated at a tertiary care urban teaching hospital between January 1999 and August 2008. The medical records were examined for demographic and clinicopathological features.

RESULTS

Forty-six gastric GISTs were identified (17 treated laparoscopically and 29 treated via laparotomy). The median age of patients in these groups were comparable at 62 and 60, respectively. Body mass index of these patients were also similar at 28.2 kg/m(2) for the laparoscopic and 29.9 kg/m(2) for the open group. The average size of tumor was slightly smaller in the laparoscopic group at 4.27 cm versus the open group at 6.39 cm (NS). The estimated blood loss for the laparoscopic group was lower at 94 mL versus 169 mL (P = 0.059). Operative times for the 2 surgical approaches were not significantly different at 135 minutes for laparoscopic and 157.4 minutes for open. Laparoscopic resection yielded a significantly shorter length of stay compared with open at 2.68 versus 6.25 days (P < 0.001).

CONCLUSIONS

Laparoscopic resection of gastric GISTs offers a decreased length of stay, a trend to decreased blood loss, and comparable oncologic outcomes indicating that a laparoscopic approach should be considered in all patients with gastric GISTs who do not have a contraindication to this approach.

Gastric surgery and notes

Rather than being an end point in and of itself, NOTES offers an approach that encompasses the potential use of a natural orifice in conjunction with flexible instruments as a less invasive and more cosmetically appealing method of performing certain surgical procedures. Gastric surgery through natural orifices is one of the cutting-edge procedures in the evolving field of NOTES. The potential indications for NOTES involve a wide spectrum of upper gastrointestinal diseases, including achalasia, reflux disease, submucosal tumors, cancer, and morbid obesity. Although NOTES is becoming more widely used, most studies still involve only small numbers of patients, and the design of larger series and comparative trials to evaluate the early indications and results of NOTES is needed.

Endoscopic therapy for gastric stromal tumors originating from the muscularis propria

AIM

To explore endoscopic therapy methods for gastric stromal tumors originating from the muscularis propria.

METHODS

For 69 cases diagnosed as gastric stromal tumors originating from the muscularis propria, three types of endoscopic therapy were selected, based on the size of the tumor. These methods included endoscopic ligation and resection (ELR), endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFR). The wound surface and the perforation of the gastric wall were closed with metal clips. Immunohistostaining for CD34, CD117, Dog-1, S-100 and smooth muscle actin (SMA) was performed on the resected tumors.

RESULTS

A total of 38 cases in which the tumor size was less than 1.2 cm were treated with ELR; three cases were complicated by perforation, and the perforations were closed with metal clips. Additionally, 18 cases in which the tumor size was more than 1.5 cm were treated with ESE, and no perforation occurred. Finally, 13 cases in which the tumor size was more than 2.0 cm were treated with EFR; all of the cases were complicated by artificial perforation, and all of the perforations were closed with metal clips. All of the 69 cases recovered with medical treatment, and none required surgical operation. Immunohistostaining demonstrated that among all of the 69 gastric stromal tumors diagnosed by gastroscopy, 12 cases were gastric leiomyomas (SMA-positive), and the other 57 cases were gastric stromal tumors.

CONCLUSION

Gastric stromal tumors originating from the muscularis propria can be treated successfully with endoscopic techniques, which could replace certain surgical operations and should be considered for further application.

Laparoscopic approaches to gastric gastrointestinal stromal tumors: an institutional review of 57 cases

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are uncommon gastric neoplasms, which are typically treated by surgical excision. During the past 10 years, our institution has gained experience in resecting these tumors by minimally invasive methods. The purpose of this study is to review our experience with laparoscopic resection, report our short-term outcomes, and offer our perspective on the technical nuances involved in handling these neoplasms.

METHODS

We retrospectively queried our prospectively maintained, institutional review board-approved database for all gastric GISTs resected from 2002 to 2012. We analyzed all cases that were resected via laparoscopy. Operative notes were reviewed for the technique employed. Data on tumor location, size, margin status, operative time, and blood loss were collected and analyzed.

RESULTS

During the 10-year study period, 104 gastric GISTs were resected. Laparoscopy was attempted in 58 cases with only one conversion to an open procedure. Tumors were separated based on anatomic zones. Forty-seven tumors (82%) were located on the body or fundus of the stomach (18 on the posterior wall and 29 on the anterior wall). Five GISTs (9%) were located at the gastroesophageal junction (GEJ). Five tumors (9%) were located at the antrum. The mean tumor size was 3.8 cm with a mean estimated blood loss of 40 ml. We achieved R0 resection in 100% of the cases. Most tumors (96%) were amenable to wedge resection. Tumors at the extremes of the stomach required variations of technique to achieve resection. Intraoperative endoscopy was selectively utilized.

CONCLUSIONS

As our experience with gastric GISTs has increased, laparoscopic resection has become our first-line treatment for most small- and moderate-sized tumors. By employing a structured approach to tumors along the entire stomach, laparoscopic resection of these tumors can be performed safely with adequate short-term results.

Safe laparoscopic resection of a gastric gastrointestinal stromal tumor close to the esophagogastric junction

Laparoscopic gastrectomy is commonly performed for gastrointestinal stromal tumors (GISTs). Partial gastrectomy is usually achieved with a wedge resection to preserve gastric function; however, performing a wedge resection to excise a large tumor located close to the esophagogastric junction (EGJ) can result in deformation of the stomach and/or the stenosis of the EGJ if the gastric wall resection is excessive. We describe our procedure, in which the whole layer of the gastric wall was cut, maintaining a sufficient margin and confirming the distance between the tumor and the EGJ, by endoscopy and laparoscopy. The defect in the gastric wall was closed using linear staplers by hanging up the stay sutures. Five patients with GIST close to EGJ underwent this procedure, followed by a good postoperative course. Thus, we consider our procedure to be safe and effective for gastric GISTs close to the EGJ.

Laparoscopically assisted resections of small bowel stromal tumors are safe and effective

OBJECTIVE

To compare the efficacy of laparoscopically assisted and open resections in treatment of small bowel stromal tumors (SBST).

METHODS

A retrospective study of 85 patients who underwent curative resections for SBST (38 by laparoscopically assisted procedures and 47 by open procedures) was performed.

RESULTS

There were no differences between open and laparoscopically assisted approaches in terms of patients' age, gender, presenting symptoms, histological risk or extent of resection (P > 0.05). The median tumor size for laparoscopically assisted resections was 4.0 cm (range 1.2-7.0 cm), which was the same as that for the open resections (range 2.0-10.0 cm). There were fewer complications in the laparoscopic group than those in the open resection group (7.9% vs 17.0%), but no significant difference was observed (P > 0.05). The 2-year survival of the two patient groups was almost the same (86.8% vs 89.4%). Laparoscopically assisted procedures required on average 22.5 min less of operating time (87.5 min vs 110.0 min, P = 0.006), 1.0 day less of bowel recovery time (3.0 days vs 4.0 days, P = 0.001) and 5.0 days less in hospital stay (8.0 days vs 13.0 days, P < 0.001).

CONCLUSION

Laparoscopically assisted resection of SBST is a safe alternative to open resection.

Surgical treatment of gastric and small bowel gastrointestinal stromal tumours

AIM

This study aimed to evaluate a set of gastrointestinal stromal tumours (GIST) of the stomach and the small bowel managed with a laparoscopic technique.

MATERIAL AND METHODS

The study covers a period from January 1, 2007 until June 1, 2010 during which 13 patients underwent the laparoscopic removal of stomach tumours and 2 patients underwent the removal of a small bowel GIST in the General Hospital in Pardubice. In all cases tumours were removed in a laparoscopic way, including the healthy border of the stomach tissue.

RESULTS

No death was observed in our study. Two patients suffered from wound infection (secondary healing), one of them requiring repeat surgery owing to the excessive narrowing of the distal part of the stomach. Dehiscence of laparoscopic sutures or other intra-abdominal complications were not observed. During monitoring all patients were free of signs of local recurrence, but tumour progression into the liver was observed in 1 patient. Gastrointestinal stromal tumours are very rare tumours but their incidence is increasing. At this time the consensus about the necessity of preoperative unambiguous differentiation between malignant or less malignant variants is not available. Strict differentiation is very difficult and the decision whether to choose a more radical surgical approach for more malignant variants is not clear-cut.

CONCLUSIONS

In cases of gastric and small bowel GISTs the local removal of a tumour with the healthy border of the stomach tissue may be chosen as an adequate approach. Our results support this local surgical approach.