Laparoscopic surgery versus open resection in patients with gastrointestinal stromal tumors: An updated systematic review and meta-analysis

Consecutive surgeries with complications: the impact of scheduling decisions

Purpose

The authors determine how the scheduling and sequencing of surgeries by surgeons impacts the rate of post-surgical complications and patient length-of-stay in the hospital.

Design/methodology/approach

Leveraging a dataset of 29,169 surgeries performed by 111 surgeons from a large hospital network in Ontario, Canada, the authors perform a matched case-control regression analysis. The empirical findings are contextualized by interviews with surgeons from the authors’ dataset.

Findings

Surgical complications and longer hospital stays are more likely to occur in technically complex surgeries that follow a similarly complex surgery. The increased complication risk and length-of-hospital-stay is not mitigated by scheduling greater slack time between surgeries nor is it isolated to a few problematic surgery types, surgeons, surgical team configurations or temporal factors such as the timing of surgery within an operating day.

Research limitations/implications

There are four major limitations: (1) the inability to access data that reveals the cognition behind the behavior of the task performer and then directly links this behavior to quality outcomes; (2) the authors’ definition of task complexity may be too simplistic; (3) the authors’ analysis is predicated on the fact that surgeons in the study are independent contractors with hospital privileges and are responsible for scheduling the patients they operate on rather than outsourcing this responsibility to a scheduler (i.e. either a software system or an administrative professional); (4) although the empirical strategy attempts to control for confounding factors and selection bias in the estimate of the treatment effects, the authors cannot rule out that an unobserved confounder may be driving the results.

Practical implications

The study demonstrates that the scheduling and sequencing of patients can affect service quality outcomes (i.e. post-surgical complications) and investigates the effect that two operational levers have on performance. In particular, the authors find that introducing additional slack time between surgeries does not reduce the odds of back-to-back complications. This result runs counter to the traditional operations management perspective, which suggests scheduling more slack time between tasks may prevent or mitigate issues as they arise. However, the authors do find evidence suggesting that the risk of back-to-back complications may be reduced when surgical pairings are less complex and when the method involved in performing consecutive surgeries varies. Thus, interspersing procedures of different complexity levels may help to prevent poor quality outcomes.

Originality/value

The authors empirically connect choices made in scheduling work that varies in task complexity and to patient-centric health outcomes. The results have implications for achieving high-quality outcomes in settings where professionals deliver a variety of technically complex services.

Comparison of effectiveness and safety between endoscopic and surgical resection for 2-5 cm gastric stromal tumors

BACKGROUND

As endoscopic resection remains controversial, this study aims to compare the effectiveness and safety between endoscopic and surgical resection for 2-5 cm gastric stromal tumors (GSTs).

METHODS

Patients with 2-5 cm GST resected at West China Hospital from March 2008 to April 2019 were enrolled. Propensity score matching (PSM) (1:1) was performed to achieve baseline data consistency.

RESULTS

112 patients were matched between the endoscopic resection group (ER) and the open surgery group. There were no significant differences in the complete resection rate (94.6% vs. 100%), the incidence of complications (25.0% vs. 14.3%), the recurrence rate (0% vs. 1.8%) and the 5-year relapse-free survival (100% vs. 97.9%) (P > 0.05). The ER had a shorter fasting time (3.5 days vs. 5 days), a shorter postoperative hospital stay (7 days vs. 8 days) and a lower hospitalization cost (3,589.16 USD vs. 5,931.24 USD) (P < 0.05). 54 cases were matched between the ER and the laparoscopic surgery group (LS). There were no significant differences in the complete resection rate (92.6% vs. 96.3%), the incidence of complications (22.2% vs. 11.1%), the fasting time (4 days vs. 3 days), the recurrence rate (0% vs. 3.7%) and the 5-year relapse-free survival (100% vs. 96.3%) (P > 0.05). The hospitalization cost (3,589.25 USD vs. 4,715.16 USD) was lower in the ER, and the postoperative hospital stay was shorter in the LS (6 days vs. 7 days) (P < 0.05).

CONCLUSIONS

Although slightly higher incidences of incomplete resection and perforation were shown in the endoscopic resection group, there was insignificant difference between groups (P > 0.05). Endoscopic resection might be an alternative surgical method for 2-5 cm GSTs.

Early experience of laparoscopic resection and comparison with open surgery for gastric gastrointestinal stromal tumor: a multicenter retrospective study

The advantages of laparoscopic resection over open surgery in the treatment of gastric gastrointestinal stromal tumor (GIST) are not conclusive. This study aimed to evaluate the postoperative and oncologic outcome of laparoscopic resection for gastric GIST, compared to open surgery. We retrospectively reviewed the prospectively collected database of 1019 patients with gastric GIST after surgical resection at 13 Korean and 2 Japanese institutions. The surgical and oncologic outcomes were compared between laparoscopic and open group, through 1:1 propensity score matching (PSM). The laparoscopic group (N = 318) had a lower rate of overall complications (3.5% vs. 7.9%, P = 0.024) and wound complications (0.6% vs. 3.1%, P = 0.037), shorter hospitalization days (6.68 ± 4.99 vs. 8.79 ± 6.50, P < 0.001) than the open group (N = 318). The superiority of the laparoscopic approach was also demonstrated in patients with tumors larger than 5 cm, and at unfavorable locations. The recurrence-free survival was not different between the two groups, regardless of tumor size, locational favorableness, and risk classifications. Cox regression analysis revealed that tumor size larger than 5 cm, higher mitotic count, R1 resection, and tumor rupture during surgery were independent risk factors for recurrence. Laparoscopic surgery provides lower rates of complications and shorter hospitalizations for patients with gastric GIST than open surgery.

Current treatment strategies and future perspectives for gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that originate from the gastrointestinal tract, mostly from the stomach. GISTs are derived from the myenteric interstitial cells of Cajal and are caused by several mutations in the c-kit and platelet-derived growth factor receptor genes. Clinically, GISTs are detected by endoscopic and imaging findings and are diagnosed by immunostaining. Surgery is the first line of treatment, and if the tumor is relatively small, minimally invasive surgery such as laparoscopy is performed. In recent years, neoadjuvant therapy has been administered to patients with GISTs that are suspected of having a large size or infiltration to other organs. Postoperative adjuvant imatinib is the standard therapy for high-risk GISTs. It is important to assess the risk of recurrence after GIST resection. However, the effect of tyrosine kinase inhibitor use will vary by the mutation of c-kit genes and the site of mutation. Furthermore, information regarding gene mutation is indispensable when considering the treatment policy for recurrent GISTs. This article reviews the clinicopathological characteristics of GISTs along with the minimally invasive and multidisciplinary treatment options available for these tumors. The future perspectives for diagnostic and treatment approaches for these tumors have also been discussed.

Novel surgical approach for gastric gastrointestinal stromal tumor (GIST): Robotic single port partial gastrectomy

BACKGROUND

Minimally invasive resection of gastrointestinal stromal tumors (GIST) results in faster recovery and similar oncological safety when compared to conventional approach [1-3]. The new robotic Single Port platform (Da Vinci SP) could help decreasing invasiveness while overcoming technical limitations of previous single incision surgical approaches [4].

METHODS

A 69-year-old male was treated for a 3 cm non-ulcerated GIST in the anterior wall of the proximal gastric body.

RESULTS

A robotic partial gastric resection was performed. The Da Vinci SP platform, which hosts three multi jointed, wristed instruments and a 3D HD articulating scope was used. The camera and instruments were introduced in the abdominal cavity through a 25 mm multichannel port. The lesion was identified in the lesser curvature at the level of the body, approximately 3 cm above the incisura. The gastric wall was resected en-bloc with the tumor using a combination of monopolar hook and bipolar forceps. The lesion was lifted using the third robotic arm and was not manipulated during the dissection. The gastric defect was closed with two running sutures of polydioxanone 3/0. Operative time was 82 minutes. Postoperative course was uneventful, and the patient was discharged home on postoperative day 2 with adequate pain control. Histopathology analysis found a 2.3 × 2 cm low grade GIST.

CONCLUSIONS

Robotic SP partial gastrectomy is safe and feasible in patients with gastric GIST. The robotic SP approach might help expanding the indications of previous single incision techniques.

Recent Progress and Challenges in the Diagnosis and Treatment of Gastrointestinal Stromal Tumors

Simple Summary

Gastrointestinal stromal tumors (GIST) are potentially malignant tumors and require evidence-based surgical and/or medical treatment. Laparoscopy has similar safety and prognostic outcomes to those of laparotomy and is currently a standard procedure for localized GISTs. However, surgery for gastric GISTs less than 2 cm may be re-evaluated due to the indolent nature of the GIST and other competing risks among GIST patients. A work-up with endoscopy and endoscopic ultrasonography as well as endoscopic or percutaneous biopsy is important for the preoperative diagnosis of GISTs. Medical treatment with tyrosine kinase inhibitors is the mainstay for recurrent/metastatic GISTs. The activity of an individual drug is well correlated with gene alterations, and, in the era of precision medicine, cancer genome profiling should be considered before medical treatment.

Abstract

Gastrointestinal stromal tumors (GISTs) are the most frequent malignant mesenchymal tumors in the gastrointestinal tract. The clinical incidence of GISTs is estimated 10/million/year; however, the true incidence is complicated by frequent findings of tiny GISTs, of which the natural history is unknown. The initial work-up with endoscopy and endoscopic ultrasonography plays important roles in the differential diagnosis of GISTs. Surgery is the only modality for the permanent cure of localized GISTs. In terms of safety and prognostic outcomes, laparoscopy is similar to laparotomy for GIST treatment, including tumors larger than 5 cm. GIST progression is driven by mutations in KIT or PDGFRA or by other rare gene alterations, all of which are mutually exclusive. Tyrosine kinase inhibitors (TKIs) are the standard therapy for metastatic/recurrent GISTs. Molecular alterations are the most reliable biomarkers for TKIs and for other drugs, such as NTRK inhibitors. The pathological and genetic diagnosis prior to treatment has been challenging; however, a newly developed endoscopic device may be useful for diagnosis. In the era of precision medicine, cancer genome profiling by targeted gene panel analysis may enable potential targeted therapy even for GISTs without KIT or PDGFRA mutations.

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.

Strategies for care of patients with gastrointestinal stromal tumor or soft tissue sarcoma during COVID-19 pandemic: A guide for surgical oncologists

The coronavirus disease-2019 (COVID-19) pandemic is deeply impacting the accessibility of cancer patients to surgery. In resource-limited conditions, the standard of care might not be deliverable, but evidence to support alternative management strategies often exists. By revisiting available treatment options, this review provides surgical oncologists with an evidence-based framework for treating patients with gastrointestinal stromal tumor, extremity/truncal soft tissue sarcoma, and retroperitoneal sarcoma to rapidly adapt their decision-making to the constant evolution of the COVID-19 pandemic.

Positive microscopic surgical margins: Is there an association with survival in resected small gastrointestinal stromal tumors?

BACKGROUND

Few studies evaluate the relationships between surgical approach, histologic margin, and overall survival in gastrointestinal stromal tumor. We test the hypothesis that margin positive resection is associated with compromised overall survival.

METHODS

We queried the National Cancer Data Base to identify patients undergoing resections for gastrointestinal stromal tumors ≤3 cm in size between 2010 and 2015. Multivariable logistic regression was used to identify factors associated with positive microscopic margins on final pathology. Cox proportional hazard methods were used to evaluate factors associated with overall survival.

RESULTS

2064 patients met inclusion criteria; 135 (6.5%) had a microscopically positive surgical margin. On multivariable regression, minimally invasive approach was not associated with risk of a positive margin (OR 1.06 95% CI [0.71, 1.59]). On Cox analysis, positive margin status was not associated with OS (R1: 1.03, CI [0.46-2.31], reference R0).

CONCLUSIONS

Positive microscopic surgical margins are not associated with compromised overall survival in patients undergoing resection of small gastrointestinal stromal tumors. Minimally invasive surgical approaches do not compromise oncologic outcomes in these cases.

Robotic Wedge Resection for Unfavorably Located Gastric Gastrointestinal Stromal Tumors: Perioperative and Long-Term Oncological Outcomes

Background and Objectives: Robotic wedge resection for gastrointestinal stromal tumors (GISTs) located in the stomach offers remarkable advantages, especially for lesions in unfavorable places. Although promising, long-term oncological results associated with this surgical procedure are poorly represented in literature. We present our experience of robotic wedge resection with gastrotomy for challenging gastric GISTs, in terms of both surgical outcomes and long-term oncological results. Methods: From April 2014 to February 2020, all consecutive patients affected by unfavorably located gastric GISTs (based on the Privette/Al-Thani classification system) underwent robotic wedge resection. Clinicopathological, surgical, and long-term oncological results were retrospectively analyzed. Results: Seventeen patients underwent full-thickness gastric wedge resection with primary robot-sewn closure of the defect. In 64.7% of cases, the lesion was ≥5 cm in diameter. No conversion nor tumor rupture were recorded and complete R0 resection was achieved in all cases. Median hospital stay was 5 days (range 3-18). At a median follow-up of 46 months (range 7-67), the disease-free survival rate and the overall survival rate were 94.1% and 82.3%, respectively. Conclusions: Robotic wedge resection with gastrotomy and robotic-sewn suture is a safe and feasible procedure for GISTs located in unfavorable anatomic positions, without compromising oncological outcomes.

Robotic surgery for gastric gastrointestinal stromal tumors: A single center case series

BACKGROUND AND OBJECTIVES

The aim of surgical treatment of gastrointestinal stromal tumors (GIST) is a microscopically complete resection. Initial indications for laparoscopic surgery were limited to smaller tumors, in favorable locations. Over time, indications for minimal invasive surgery (MIS) have expanded, however concerns remain when considering resection of larger GISTs. Our aims were to assess the utility of robotic resection of gastric GISTs for challenging tumors.

METHODS

GIST resections, in this study were performed using the Intuitive Da Vinci Surgical Xi System. GIST's were considered challenging if tumor size was >50 mm at the time of surgery and/or the location of the tumor was type II, III, or IV using Privette/Al-Thanai classification.

RESULTS

Robotic resections were performed on 12 consecutive patients, 83% were considered challenging cases, 6 out of 12 for location and 5 out of 12 for size. Initial median tumor size on imaging was 53.7 mm, and post-imatinib was 45.8 mm. All tumors were removed with clear margins (R0) via wedge resections, with no complications. Median operative time was 192 minutes (95-250). Length of hospital stay was 2 days (2-6).

CONCLUSIONS

Robotic resection of gastric GIST's appears oncologically safe, and may expand the benefits of MIS to a greater cohort of complex cases.

Primary Gastrointestinal Stromal Tumor Mimicking as Gynecologic Mass: Characteristics, Management, and Prognosis

BACKGROUND

Primary gastrointestinal stromal tumor (GIST)-mimicking gynecologic masses are easily misdiagnosed. This study aimed to investigate the clinicopathological features, management, and prognosis of primary GIST mimicking as gynecologic mass.

METHODS

Clinicopathological and survival data of GIST mimicking as gynecologic mass admitted to our center from January 2005 to December 2017 were retrospectively analyzed.

RESULTS

Thirty-eight patients were included. The most common primary tumor site was the jejunoileum (n = 33, 86.9%), and 33 patients (86.9%) were classified as high recurrence risk. The short-term outcomes of operative incision length (P = 0.004), time to gas passage (P = 0.002), and hospital stay (P = 0.012) with laparoscopy-assisted resection were significantly shorter than those with open resection, showing no significant differences of long-term outcomes. With a median follow-up of 56 mo for 31 patients (81.6%), 18 (58.1%) received adjuvant therapy with imatinib. The 5-year disease-free survival and disease-specific survival of pelvic high-risk GIST was 37.0% and 48.3%, respectively; both were significantly lower than those of the other female high-risk group (both P < 0.05).

CONCLUSIONS

GIST mimicking as gynecologic mass is not uncommon, most originate from the jejunoileum and have a high risk of recurrence. Laparoscopy-assisted resection may be preferable for more favorable short-term outcomes. Compared with the other female high-risk GIST, pelvic high-risk GIST has a significantly worse prognosis; a longer duration of adjuvant therapy with imatinib than recommended may be beneficial.

Safety and efficiency of endoscopic resection versus laparoscopic resection in gastric gastrointestinal stromal tumours: A systematic review and meta-analysis

The application of endoscopic resection (ER) in gastric gastrointestinal stromal tumours (GIST) is controversial. We carried out a meta-analysis to compare the safety and efficiency of ER with laparoscopic resection (LR) in patients with gastric GISTs. We searched PubMed to identify studies comparing ER with LR in GIST. The outcomes focused on two areas: safety, including operation time, blood loss, length of hospital stay, time to flatus, time to liquid, time to soft diet, and postoperative complications; and efficiency, including positive margin, recurrence, and long-term survival. A total of 1292 patients from 12 studies were included in the meta-analysis. Patients undergoing ER had a shorter operation time (standardised mean difference [SMD] -1.48, 95% confidence interval [CI] -2.18 to -0.78) and shorter time to soft diet (SMD -1.02, 95% CI -1.52 to -0.52) than those undergoing LR. No significant differences were observed between the groups in terms of blood loss, length of hospital stay, time to flatus, time to liquid, and postoperative complications. ER was also associated with greater positive margins compared with LR (relative risk 6.32, 95% CI 1.41-28.26). There were no significant differences between ER and LR for recurrence and 5-year disease-free survival. The limited evidence suggests that ER is a more effective strategy for improving postoperative recovery without increasing the risk of surgery and recurrence in gastric GIST. However, close attention should be paid to margin status after ER.

Effects of a multifaceted individualized pneumoperitoneum strategy in elderly patients undergoing laparoscopic colorectal surgery: A retrospective study

BACKGROUND

Laparoscopic colorectal surgery may adversely affect respiration, circulation, and acid-base balance in elderly patients, owing to the relatively long duration of CO2 absorption. We conducted this retrospective study to determine the safety and efficacy of warmed, humidified CO2 pneumoperitoneum in elderly patients undergoing laparoscopic colorectal surgery.

METHODS

We enrolled 245 patients between January 2016 and August 2018.The experimental group (warming and humidification group [WH]) received warmed (37°C), humidified (98%) insufflation of CO2, and the control group (cold, dry CO2/control group [CD]) received standard CO2 (19°C, 0%). All other aspects of patient care were standardized. Intraoperative hemodynamic data, arterial blood pH, and lactic acid levels were recorded. We also recorded intra-abdominal pressure, incidence of shivering 1 hour after surgery, satisfaction scores of patients and surgeons 24 hours after surgery, times to first flatus/defecation, first bowel movement, and tolerance of semiliquid food, discharge time, and incidence of vomiting, diarrhea, and surgical site infections.

RESULTS

Compared with the WH group, heart rate and mean arterial pressure were significantly higher from T3 to T8 (P < .05), lactic acid levels were significantly higher from T4 to T9 (P < .05), and recovery time in the post-anesthesia care unit (PACU) was significantly longer in the CD group (P < .05). Patient and surgeon satisfaction scores were significantly higher in the WH group than the CD group (P < .05). In addition, the times to first flatus/defecation and bowel movement were significantly longer in the CD group (P < .05). No significant differences were noted between the groups in the time to tolerance of semiliquid food and time of discharge (P > .05). The incidence of vomiting, diarrhea, and shivering was significantly lower in the WH group (P < .05). The number of patients with a shivering grade of 0 was significantly higher in the WH group, whereas the number with a shivering grade of 3 was significantly higher in the CD group (P < .05).

CONCLUSION

Warmed, humidified insufflation of CO2 in elderly patients undergoing laparoscopic colorectal surgery could stabilize hemodynamics, and reduce lactic acid levels, recovery time in the PACU, and the incidence of acute gastrointestinal injury-related symptoms.

Laparoscopic Repair for Perforated Peptic Ulcer Disease Has Better Outcomes Than Open Repair

PURPOSE

Over the last 3 decades, laparoscopic procedures have emerged as the standard treatment for many elective and emergency surgical conditions. Despite the increased use of laparoscopic surgery, the role of laparoscopic repair for perforated peptic ulcer remains controversial among general surgeons. The aim of this study was to compare the outcomes of laparoscopic versus open repair for perforated peptic ulcer.

METHODS

A systemic literature review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database of all randomised controlled trials (RCT) that compared laparoscopic (LR) with open repair (OR) for perforated peptic ulcer (PPU). Data was extracted using a standardised form and subsequently analysed.

RESULTS

The meta-analysis using data from 7 RCT showed that LR for PPU has decreased overall post-operative morbidity (LR = 8.9% vs. OR = 17.0%) (OR = 0.54, 95% CI 0.37 to 0.79, p < 0.01), wound infections, (LR = 2.2% vs. OR = 6.3%) (OR = 0.3, 95% CI 0.16 to 0.5, p < 0.01) and shorter duration of hospital stay (6.6 days vs. 8.2 days, p = 0.01). There were no significant differences in length of operation, leakage rate, incidence of intra-abdominal abscess, post-operative sepsis, respiratory complications, re-operation rate or mortality. There was no publication bias and the quality of the studies ranged from poor to good.

CONCLUSION

These results demonstrate that laparoscopic repair for perforated peptic ulcer has a reduced morbidity and total hospital stay compared with open approach. There are no significant differences in mortality, post-operative sepsis, abscess and re-operation rates. LR should be the preferred treatment option for patients with perforated peptic ulcer disease.

Surgery for Gastrointestinal Stromal Tumors: State of the Art of Laparoscopic Resection and Surgery for M1 Tumors

BACKGROUND

The principles of surgery for primary gastrointestinal stromal tumor (GIST) are resection with clear margins without lymphadenectomy, thus enabling organ-preserving resection in many cases. Tumor rupture needs to be avoided, because it entails peritoneal sarcomatosis. Given these preconditions, there is a rationale for laparoscopic resection of primary GIST. In metastatic GIST, surgery cannot achieve cure, but constitutes an important cornerstone of treatment. Resection can be performed either for residual lesions in responding patients, for focally progressive lesions, or as palliative measure in generalized progression.

METHODS

Selective literature review.

RESULTS

There is ample evidence on laparoscopic resection of gastric GIST, but none from randomized trials. The studies show favorable perioperative outcomes and suggest adequate oncological results; however, a direct comparison to open resection is difficult. For surgery in M1 stages, survival outcomes are better for resection in generalized response than in focal progression. Perioperative morbidity is acceptable. Surgery in generalized progression does not prolong survival and bears relevant morbidity risks.

CONCLUSION

Laparoscopy seems an adequate surgical approach for primary gastric GIST, as long as the surgical principles relevant for this entity are respected. For other tumor sites, there is no sufficient evidence available. In M1 stages, selected patients may benefit from surgery. Survival differences between resection at different stages probably mirror the biology of the disease rather than the effect of the timing of the operation.

Is the Surgical Margin in Gastrointestinal Stromal Tumors Different?

Background

Radical surgical excision is the mainstay of therapy of primary, nonmetastatic gastrointestinal stromal tumors (GIST) and margin status after surgery is a significant prognostic factor.

Methods and Results

The aim of this paper is to review principles in primary GIST surgery, i.e. differences between R0, R1, and R2 resection, to describe how surgical margin status and tumor intraperitoneal rupture influence the patients' outcome, and how this may be effected by neoadjuvant and adjuvant treatment in locally advanced tumors. A systematic search of literature published between 2000 and 2018 was performed regarding this topic.

Conclusion

Correct interpretation of margin status after surgery can be affected by many factors during operation and preparation of tissue.

Minimally invasive versus open surgery in the Medicare population: a comparison of post-operative and economic outcomes

BACKGROUND

Despite strong evidence demonstrating the clinical and economic benefits of minimally invasive surgery (MIS), utilization of MIS in the Medicare population is highly variable and tends to be lower than in the general population. We sought to compare the post-operative and economic outcomes of MIS versus open surgery for seven common surgical procedures in the Medicare population.

METHODS

Using the 2014 Medicare Provider Analysis and Review Inpatient Limited Data Set, patients undergoing bariatric, cholecystectomy, colectomy, hysterectomy, inguinal hernia, thoracic, and ventral hernia procedures were identified using DRG and ICD-9 codes. Adjusting for patient demographics and comorbidities, the odds of complication and all-cause 30-day re-admission were compared among patients undergoing MIS versus open surgery stratified by operation type. A generalized linear model was used to calculate the estimated difference in length of stay (LOS), Medicare claim cost, and Medicare reimbursement.

RESULTS

Among 233,984 patients, 102,729 patients underwent an open procedure versus 131,255 who underwent an MIS procedure. The incidence of complication after MIS was lower for 5 out of the 7 procedures examined (OR 0.36-0.69). Re-admission was lower for MIS for 6 out of 7 procedures (OR 0.43-0.87). MIS was associated with shorter LOS for 6 procedures (point estimate range 0.35-2.47 days shorter). Medicare claim costs for MIS were lower for 4 (range $3010.23-$4832.74 less per procedure) and Medicare reimbursements were lower for 3 (range $841.10-$939.69 less per procedure).

CONCLUSIONS

MIS benefited Medicare patients undergoing a range of surgical procedures. MIS was associated with fewer complications and re-admissions as well as shorter LOS and lower Medicare costs and reimbursements versus open surgery. MIS may represent a better quality and cost proposition in the Medicare population.

Minimally invasive surgery for gastric gastrointestinal stromal tumors

Minimally invasive surgery has been increasingly performed for gastric gastrointestinal stromal tumors (GIST). In this review we discuss and summarize the current evidence on minimally invasive surgery for gastric GISTs. Laparoscopic resection for gastric GIST has been consistently shown to be associated with superior perioperative outcomes with no compromise in oncological outcomes when compared to open resection in numerous retrospective case-control studies. It has also been shown to be safe and feasible for large tumors or tumors located in unfavorable sites. However, to date, there remains a lack of level 1 evidence from prospective randomized control trials in support of laparoscopic resection.