Safe laparoscopic resection of a gastric gastrointestinal stromal tumor close to the esophagogastric junction. Surg Today. 2012;42:708-711. [PMID: 22270333 DOI: 10.1007/s00595-012-0121-0]

Endoscopic versus laparoscopic resection of gastrointestinal stromal tumors at the esophagogastric junction using propensity score matching analysis

The esophagogastric junction (EGJ) has a complex anatomy and critical physiological functions, making postoperative quality of life an important consideration in the surgical resection of gastrointestinal stromal tumors at this location (EGJ-GISTs). We conducted a propensity score-matched (1:1) analysis to compare the safety and efficacy of endoscopic resection (ER) and laparoscopic resection (LR) for patients with EGJ-GIST treated at the First Affiliated Hospital of Zhengzhou University, China, from December 2013 to November 2023. We reviewed 176 patients (ER 82; LR 94) with EGJ-GIST, of whom 85 patients with a tumor size of 2-5 cm met the matching criteria (ER 42; LR 43), yielding 20 pairs of patients. ER showed advantages over LR, with a shorter postoperative nil per os time (4.0 days (IQRs, 3.0-5.0) vs. 5.5 days (IQRs, 4.3-7.8), p = 0.005) and postoperative hospitalization time (6.0 days (IQRs, 5.0-6.8) vs. 8.5 days (IQRs, 6.0-11.8, p = 0.002). Long-term adverse events were significantly lower in the ER group (15% vs. 55%, p = 0.005). No recurrence or metastasis was observed in either group during a mean follow-up of 42.3 months. These findings suggest that for 2-5 cm EGJ-GISTs, ER is a safe and effective alternative, offering minimal invasiveness, faster recovery, fewer complications, and improved long-term quality of life.

Safety, efficacy, and selection strategy of laparoscopic local gastrectomy for gastrointestinal stromal tumors in the esophagogastric junction

Objective

To investigate the safety, efficacy, and selection strategy of laparoscopic local gastrectomy for stromal tumors in the esophagogastric junction.

Methods

Thirty-eight patients with mesenchymal tumors in the esophagogastric junction were retrospectively enrolled from April 2018 to July 2021 in which the upper edge of the tumor is less than 2 cm from the Z-line or has invaded the Z-line <1/2 circumference. Surgical outcomes, complications, recover, and postoperative gastroesophageal reflux of both groups were compared.

Results

27 patients underwent wedge resection, and 11 underwent resection by opening all of the layers of the stomach wall. Operative time (90.0 vs. 181.8 min, respectively, P = 0.001) was shorter for the WR group vs. RASW. Blood loss (20 vs. 50 ml, respectively, P = 0.012) was less for the WR group vs. RASW. Recovery of the RASW group was slower in terms of time to pass gas (2 vs. 3 days, P = 0.034), time to oral intake (2 vs. 4 days, P = 0.007), time to semi-liquid food intake (4 vs. 8 days, P = 0.003), and postoperative hospitalization (5 vs. 8 days, P = 0.001) vs. WR. In terms of short-term complications (≤30 days), no significant between-group differences were observed. Cardia stenosis did not occur in either group. In the WR group, one patient experienced mild reflux at 6 months and recovered 1 year after surgery. In the RASW group, one patient experienced severe gastroesophageal reflux at 6 months and 1 year after surgery, which was not entirely relieved by taking antacids. No other patients have gastroesophageal reflux.

Conclusion

Laparoscopic local gastrectomy is safe and feasible for mesenchymal tumors in the esophagogastric junction in which the upper edge of the tumor is less than 2 cm from the Z-line or has invaded the Z-line <1/2 circumference, and has achieved an excellent short-term effect. The choice of surgery is based on the relationship between the tumor and the position of the cardia.

Safety of laparoscopic local resection for gastrointestinal stromal tumors near the esophagogastric junction

PURPOSE

Laparoscopic local resection for gastrointestinal stromal tumors (GISTs) near the esophagogastric junction (EGJ) increases the risk of injuring the EGJ. We investigated the safety of laparoscopic local resection for GISTs near the EGJ according to the distance from the EGJ to the tumor edge.

METHODS

We retrospectively evaluated 40 patients who had undergone laparoscopic local resection for GISTs near the EGJ between January 2009 and December 2019. After excluding 1 patient who had undergone right colectomy at the same time, 39 patients were classified according to distance of the GIST from the EGJ in the Near group (0-2.0 cm; n = 16) and the Far group (2.1-5.0 cm; n = 23).

RESULTS

We found no marked differences in the operation time, blood loss, length of postoperative hospital stay, or postoperative complication rate in the two groups. Anastomotic leakage occurred with a tumor located on the EGJ. Three tumors recurred in the Near group, and all of them were located on the EGJ.

CONCLUSION

Except for GISTs located on the EGJ, laparoscopic local resection for GISTs near the EGJ can be performed safely with few postoperative complications and a low risk of recurrence.

Laparoscopic vs. open surgery for gastrointestinal stromal tumors of esophagogastric junction: A multicenter, retrospective cohort analysis with propensity score weighting

Objective

Laparoscopic resection is increasingly performed for gastrointestinal stromal tumors (GISTs). However, the laparoscopic approach for GISTs located in the esophagogastric junction (EGJ-GIST) is surgically challenging. This study compares the efficacy of laparoscopic surgery and the open procedure for EGJ-GIST through the propensity score weighting (PSW) method.

Methods

Between April 2006 and April 2018, 1,824 surgical patients were diagnosed with primary gastric GIST at four medical centers in South China. Of these patients, 228 were identified as EGJ-GISTs and retrospectively reviewed clinicopathological characteristics, operative information, and long-term outcomes. PSW was used to create the balanced cohorts.

Results

PSW was carried out in laparoscopic and open-surgery cohorts according to year of surgery, sex, age, body mass index (BMI), tumor size, mitotic rates and recurrence risk. After PSW, 438 patients consisting of 213 laparoscopic (L group) and 225 open surgery (O group) patients were enrolled. After PSW, the following measures in the L group were superior to those in the O group: median operative time [interquartile range (IQR)]: 100.0 (64.5−141.5)vs. 149.0 (104.0−197.5) min, P<0.001; median blood loss (IQR): 30.0 (10.0−50.0)vs. 50.0 (20.0−100.0) mL, P=0.002; median time to liquid intake (IQR): 3.0 (2.0−4.0)vs. 4.0 (3.0−5.0) d, P<0.001; median hospital stay (IQR): 6.0 (4.0−8.0)vs. 7.0 (5.0−12.0) d, P<0.001; and postoperative complications (10.3%vs. 22.7%, P=0.001). The median follow-up was 55 (range, 2−153) months in the entire cohort. No significant differences were detected in either relapse-free survival (RFS) [hazard ratio (HR): 0.372, 95% confidence interval (95% CI): 0.072−1.910, P=0.236) or overall survival (OS) (HR: 0.400, 95% CI: 0.119−1.343, P=0.138) between the two groups.

Conclusions

Laparoscopic surgery for EGJ-GIST is associated with the advantages of shorter operative time, reduced blood loss, shorter time to liquid intake, and shorter length of stay, all without compromising postoperative outcomes and long-term survival.

Laparoscopic resection for gastrointestinal stromal tumors in esophagogastric junction (EGJ): how to protect the EGJ

BACKGROUND

Laparoscopic surgery for gastric gastrointestinal stromal tumors (GISTs) is now widely performed. However, laparoscopic resection of GIST in the esophagogastric junction (EGJ) is technically difficult and rarely reported. Herein, we introduce four fashions of laparoscopic resection for EGJ-GIST.

METHODS

A retrospective review of 42 consecutive patients with EGJ-GIST who underwent attempted laparoscopic surgery was conducted. EGJ-GIST was defined as GIST with an upper border of less than 5 cm from the esophagogastric line. Four fashions of laparoscopic resection were performed: fashion A, laparoscopic wedge resection using linear stapler; fashion B, laparoscopic complete resection by opening the stomach wall and closing with suture or linear stapler; fashion C, laparoscopic mucosa-preserving resection; and fashion D, laparoscopic proximal gastrectomy with pyloroplasty and gastric plication. Clinicopathologic characteristics, operative course, and short-term and long-term outcomes were analyzed.

RESULTS

All procedures were completed successfully without operative complications. In 24 of 42 (57.1%) patients, tumors were located in the fundus or greater curvature. Out of those, 70.8% (17/24) received fashion A and 29.2% (7/24) received fashion B. Tumors in 16 of 42 (38.1%) patients were located in the lesser curvature. Of those, 81.3% (13/16) underwent fashion B and 18.7% (3/16) underwent fashion D. One tumor in the anterior stomach wall and one in the posterior wall received fashion C. The mean operative time was 103.8 ± 22.1 min and the mean estimated blood loss was 22.4 ± 13.5 ml. The mean time to flatus was 40.3 ± 12.9 h and the time to fluid intake was 43.2 ± 14.3 h. The mean hospital stay was 4.8 ± 2.1 days.

CONCLUSIONS

Laparoscopic surgery for EGJ-GIST is safe and feasible. The selection of various laparoscopic resection fashions should be chosen based on tumor location and the surgeon's experience.

Serosal and muscular layers incision technique in laparoscopic surgery for gastric gastrointestinal stromal tumors

INTRODUCTION

To minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we developed laparoscopic wedge resection with the serosal and muscular layers incision technique (SAMIT) for gastric gastrointestinal stromal tumors.

MATERIALS AND SURGICAL TECHNIQUE

SAMIT involves resection of the mucosal and submucosal layers and then an incision in serosal and muscular layers around the tumor. SAMIT is simple and does not require special devices. The data of 13 patients who underwent laparoscopic wedge resection with SAMIT for primary gastric gastrointestinal stromal tumors were reviewed. No intraoperative complications were observed, and postoperative stenosis occurred in only one case of a middle stomach lesion. Adequate oncological resection was performed in all cases.

DISCUSSION

Laparoscopic wedge resection with SAMIT is technically and oncologically safe. It is useful for treating gastric gastrointestinal stromal tumors, including those close to the esophagogastric junction or pyloric ring.

Comparison of minilaparoscopy and single-incision intragastric surgery for gastric submucosal tumor resection in a porcine model

BACKGROUND

The aim of this study was to develop an easy-to-induce and reproducible model of gastric submucosal tumor in swine to compare minilaparoscopy (ML) with single-incision (SI) intragastric surgery.

METHODS

Twelve healthy female pigs (weight 30.94 ± 2.49 kg) underwent a transparietal injection of sterile alginate at the level of Z-line (n = 6) and at the pre-pyloric area (n = 6) creating a model of gastric submucosal pseudotumor. The operative procedures included intragastric resection with ML and SI approaches of cardiac and pre-pyloric lesions, with gastroscopic assistance. After resection, the gastric mucosal layer was closed using intracorporeal sutures. The operative time, complication rate and clinical evolution after 1 month were compared in the four groups that the pigs were arranged.

RESULTS

The pseudotumors ranged in size from 3 to 6 cm in diameter. The access of the gastric cavity and resection of the experimental SMP and suturing of the mucosa were performed successfully in 12 animals using both approaches. Mean time to perform the exeresis of gastric cardia tumors was significantly higher in single-incision approach. No significant differences were observed in the surgical time during pyloric surgery. Minilaparoscopic approach reduced significantly the mucosa closure time in esophagogastric and pyloric pseudotumors. One month after, no alterations were shown in the abdominal cavity using exploratory laparotomy.

CONCLUSIONS

The technical feasibility of performing safe and efficient intragastric approach of submucosal pseudotumors in swine model was verified in this study. Intragastric ML has advantages over SI, namely regarding the reduction in total surgical times and the fewer technical difficulties.

Endoscopic and Laparoscopic Full-Thickness Resection of Endophytic Gastric Submucosal Tumors Very Close to the Esophagogastric Junction

Purpose

Gastric submucosal tumors (SMTs) located very close to the esophagogastric junction (EGJ) are a challenge for gastric surgeons. Therefore, this study reports on the experience of using endoscopic and laparoscopic full-thickness resection (ELFR) with laparoscopic two-layer suturing in such tumors.

Materials and Methods

Six patients with gastric SMTs very close to the EGJ underwent ELFR with laparoscopic two-layer suturing at Kyungpook National University Medical Center. With the patient under general anesthesia, the lesser curvature and posterior aspect adjacent to the EGJ were meticulously dissected and visualized using a laparoscopic approach. A partially circumferential full-thickness incision at the distal margin of the tumor was then made using an endoscopic approach under laparoscopic guidance. The SMT was resected using laparoscopic ultrasonic shears, and the gastric wall was closed using two-layer suturing. Thereafter, the patency and any leakage were checked through endoscopy.

Results

All the ELFR procedures with laparoscopic two-layer suturing were performed successfully without an open conversion. The mean operation time was 139.2±30.9 minutes and the blood loss was too minimal to be measured. The tumors from four patients were leiomyomas, while the tumors from the other two patients were gastrointestinal stromal tumors with clear resection margins. All the patients started oral intake on the third postoperative day. There was no morbidity or mortality. The mean hospital stay was 7.7±0.8 days.

Conclusions

ELFR with laparoscopic two-layer suturing is a safe treatment option for patients with an SMT close to the EGJ, as major resection of the stomach is avoided.

Strategy of Laparoscopic Partial Resection for Gastric Gastrointestinal Stromal Tumors According to the Growth Pattern

Laparoscopic partial gastrectomy is the standard surgical treatment for gastric gastrointestinal stromal tumor (GIST). However, to reduce gastric deformation, the tumor margins should be secured so as to minimize the size of the resection as much as possible. This is the report on the 3 laparoscopic resection techniques for gastric GIST depending upon the growth pattern and location of the tumor, and their results. We performed laparoscopic partial gastrectomy for 41 gastric GISTs between 2004 and 2012. Simple resection was used on exophytic or small GISTs. Seromuscular resection was used on exoendophytic (intramural) and relatively small endophytic tumors. Transgastric resection was used in cases of large endophytic tumors. We performed simple resection on 24 lesions (58.5%), seromuscular resection on 14 lesions (34.1%), and transgastric resection on 3 lesions (7.3%). There were no intraoperative complications. Postoperative complications included 1 case (2.5%) of bleeding from the staple line.

Clinical effects of endoscopic submucosal dissection in treatment of upper gastrointestinal submucosal tumors

AIM: To explore the therapeutic efficiency of endoscopic submucosal dissection (ESD) in the treatment of upper gastrointestinal submucosal tumors and the risk factors for complications.

METHODS: Seventy-three patients with upper gastrointestinal submucosal tumors were collected from Chengdu Military Medical Hospital from May 2009 to March 2014. All the patients underwent ESD and were followed by endoscopy. The complete resection rate, the frequency of complications and the risk factors for complications were analyzed.

RESULTS: The overall rate of R0 resection was 98.6% (68/69), with six endoscopic failures. Complete resection was achieved in all submucosal tumor (SMT) cases. The median procedure time was 100.9 min (range, 30.0-275.0 min). Perforation occurred in 7 patients. Bleeding occurred in 15 patients. No death occurred. No recurrence cases were noted.

CONCLUSION: ESD is an effective treatment in SMT patients with a high success rate and a low incidence of complications.

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.

Higher incidence of gastroesophageal reflux disease after gastric wedge resections of gastric submucosal tumors located close to the gastroesophageal junction

Purpose

We hypothesized that gastroesophageal reflux disease (GERD) would be more prevalent after a gastric wedge resection of a submucosal tumor (SMT) located close to the gastroesophageal junction (GEJ) than after a gastric wedge resection of an SMT at other locations because of the damage to the lower esophageal sphincter during surgery.

Methods

Fifty-eight patients with gastric SMT who underwent open or laparoscopic gastric wedge resection between January 2000 and August 2012 at the Department of Surgery, Incheon St. Mary's Hospital were enrolled into this study. The patients were divided into 2 groups according to the location of the tumor, upper or lateral border of the tumor within 5 cm of the GEJ (GEJ ≤ 5 cm group) and upper or lateral border of the tumor greater than 5 cm distal to the GEJ (GEJ > 5 cm group). The surgical records, clinicopathologic findings, postoperative GERD symptoms, postoperative use of acid suppressive medications and preoperative and postoperative endoscopic findings were retrospectively reviewed and compared between the 2 groups.

Results

There was no difference in the frequency of the preoperative GERD symptoms between the 2 groups, whereas postoperative GERD symptoms and postoperative use of acid suppressive medications were more frequent in the GEJ ≤ 5 cm group (P = 0.045 and P = 0.031). However, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and Hill's grade between the 2 groups.

Conclusion

The incidence of GERD was higher after gastric wedge resection of SMTs located close to the GEJ. Hence, adequate care should be taken during the follow-up of these patients.

Endoscopic submucosal dissection in the treatment of gastric submucosal tumors: results from a retrospective cohort study

BACKGROUND

A submucosal tumor (SMT) of the stomach, which is an occasional finding during routine upper gastrointestinal endoscopy, may pose diagnostic and therapeutic challenges.

METHODS

To assess whether endoscopic submucosal dissection (ESD) is a feasible approach to definitively cure SMTs, the authors performed a retrospective cohort study with two endoscopic italian centers.

RESULTS

The study consisted of 20 patients with SMTs who underwent ESD. The patients underwent ESD and were followed up by endoscopy. We analyzed complete resection rate, frequency of complications, and survival. The overall rate of R0 resection was 90 % (18/20), with two endoscopic failures, one for a submucosal tumor and one for a neoplasm deeply infiltrating the proper muscle layer. The median procedure time was 119.1 min (range 40-240 min). The median size of the resected specimens was 29 mm (range 15-60 mm). Perforation occurred in 3 patients; all were treated conservatively. There were no cases of severe bleeding. Based on histopathological findings, 6 cases of ectopic pancreas, 1 of ectopic spleen, 3 of leiomyoma, and 10 of gastrointestinal stromal tumor (GIST) were diagnosed. Complete resection was obtained in all GIST cases. Among the 10 GIST cases treated by ESD, no death occurred: the 5-year disease-specific survival rate was 100 %.

CONCLUSIONS

The high success rate of 90 % and the low incidence of complications should indicate ESD is the correct diagnostic and definitive treatment in selected patients.

Laparoscopic-endoscopic cooperative surgery for gastric submucosal tumors

AIM: To assess the feasibility, safety, and advantages of minimally invasive laparoscopic-endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMT).

METHODS: We retrospectively analyzed 101 consecutive patients, who had undergone partial, proximal, or distal gastrectomy using LECS for gastric SMT at Peking Union Medical College Hospital from June 2006 to April 2013. All patients were followed up by visit or telephone. Clinical data, surgical approach, pathological features such as the size, location, and pathological type of each tumor; and follow-up results were analyzed. The feasibility, safety and effectiveness of LECS for gastric SMT were evaluated, especially for patients with tumors located near the cardia or pylorus.

RESULTS: The 101 patients included 43 (42.6%) men and 58 (57.4%) women, with mean age of 51.2 ± 13.1 years (range, 14-76 years). The most common symptom was belching. Almost all (n = 97) patients underwent surgery with preservation of the cardia and pylorus, with the other four patients undergoing proximal or distal gastrectomy. The mean distance from the lesion to the cardia or pylorus was 3.4 ± 1.3 cm, and the minimum distance from the tumor edge to the cardia was 1.5 cm. Tumor pathology included gastrointestinal stromal tumor in 78 patients, leiomyoma in 13, carcinoid tumors in three, ectopic pancreas in three, lipoma in two, glomus tumor in one, and inflammatory pseudotumor in one. Tumor size ranged from 1 to 8.2 cm, with 65 (64.4%) lesions < 2 cm, 32 (31.7%) > 2 cm, and four > 5 cm. Sixty-six lesions (65.3%) were located in the fundus, 21 (20.8%) in the body, 10 (9.9%) in the antrum, three (3.0%) in the cardia, and one (1.0%) in the pylorus. During a median follow-up of 28 mo (range, 1-69 mo), none of these patients experienced recurrence or metastasis. The three patients who underwent proximal gastrectomy experienced symptoms of regurgitation and belching.

CONCLUSION: Laparoscopic-endoscopic cooperative surgery is feasible and safe for patients with gastric submucosal tumor. Endoscopic intraoperative localization and support can help preserve the cardia and pylorus during surgery.

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.