Safety and efficacy of laparoscopic wedge gastrectomy for large gastrointestinal stromal tumors

Efficacy and Safety of Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors Originating from the Muscularis Propria

BACKGROUND

The role of endoscopic resection (ER) in gastric gastrointestinal stromal tumors (GISTs) has not been fully elucidated.

AIMS

The purpose of this work was to evaluate the clinical effectiveness and safety of ER in patients with GISTs originating from the muscularis propria (MP).

METHODS

A total of 233 consecutive patients with gastric GISTs originating from the MP layer, who underwent ER between February 2012 and May 2023, were included in this study. Clinical characteristics, tumor features, and outcomes were recorded and compared between patients who underwent en bloc resection and piecemeal resection.

RESULTS

Among the 233 patients, the median size of GISTs was 12 mm (range 5-60 mm). Risk assessment categorized 190 patients as very low risk, 26 as low risk, 10 as moderate risk, and 7 as high risk. The procedures performed included endoscopic submucosal excavation (127 cases), endoscopic full-thickness resection (103 cases), and submucosal tunneling endoscopic resection (3 cases). The complete and R0 resection rate was 93.1%. Complications occurred in 4.7% of cases (perioperative perforations 1.7%, perioperative bleeding 1.3%, both 0.9%), resulting in conversion to surgery in 1.3% of cases. Risk factors associated with piecemeal resection were tumor size [odds ratio (OR) 0.402, 95% confidence interval (CI) 0.207-0.783; P = 0.007] and shape (OR 0.045, 95% CI 0.009-0.235; P < 0.001).

CONCLUSIONS

ER is proven to be an effective and reasonably safe approach for gastric GISTs originating from the MP. Notably, larger tumor size and irregular shape are identified as risk factors for piecemeal resection during ER procedures.

Risk factors for postoperative complications in endoscopic resection of gastric gastrointestinal stromal tumors: a multi-center analysis

BACKGROUND

Endoscopic resection (ER) is widely used in treating gastric gastrointestinal stromal tumors (gGISTs); however, complications occur frequently after resection. We aimed to determine factors associated with postoperative complications for ER of gGISTs.

METHODS

This was a retrospective, multi-center, observational study. Consecutive patients who underwent ER of gGISTs at five institutes from January 2013 to December 2022 were analyzed. The risk factors for delayed bleeding and postoperative infection were assessed.

RESULTS

A total of 513 cases were finally analyzed. Of 513 patients, 27 (5.3%) had delayed bleeding and 69 (13.4%) had a postoperative infection. Multivariate analysis indicated that risk factors for delayed bleeding were long operative time (OR = 50.655; 95% CI, 13.777-186.252; P < 0.001) and severe intraoperative bleeding (OR = 4.731, 95% CI, 1.139-19.658; P = 0.032), and risk factors for postoperative infection were long operative time (OR = 13.749, 95% CI, 6.884-27.461; P < 0.001) and perforation (OR = 4.339, 95% CI, 2.178-8.644; P < 0.001).

CONCLUSIONS

Our study indicated the risk factors for postoperative complications in ER of gGISTs. Long operation time is a common risk factor for delayed bleeding and postoperative infection. Patients with these risk factors should be given careful observation postoperatively.

Development and validation of a preoperative difficulty scoring system for endoscopic resection of gastric gastrointestinal stromal tumor: a multi-center study

BACKGROUND

Endoscopic resection (ER) is a promising technique for resecting gastric gastrointestinal stromal tumors (gGISTs); however, ER is technically challenging. This study aimed to develop and validate a difficulty scoring system (DSS) to determine the difficulty for ER of a gGIST.

METHODS

This retrospective study enrolled 555 patients with gGISTs in multi-centers from December 2010 to December 2022. Data on patients, lesions, and outcomes of ER were collected and analyzed. A difficult case was defined as an operative time ≥ 90 min, or the occurrence of severe intraoperative bleeding, or conversion to laparoscopic resection. The DSS was developed in the training cohort (TC) and validated in the internal validation cohort (IVC) and external validation cohort (EVC).

RESULTS

The difficulty occurred in 97 cases (17.5%). The DSS comprised the following: tumor size ≥ 3.0 cm (3 points) or 2.0-3.0 cm (1 point); location in the upper third of the stomach (2 points); invasion depth beyond the muscularis propria (2 points); lack of experience (1 point). The area under the curve (AUC) of DSS in IVC and EVC was 0.838 and 0.864, respectively, and the negative predictive value (NPV) was 0.923 and 0.972, respectively. The proportions of difficult operation in easy (score 0-3), intermediate (score 4-5), and difficult (score 6-8) categories were 6.5%, 29.4%, and 88.2% in the TC, 7.7%, 45.8%, and 85.7% in the IVC, and 7.0%, 29.4%, and 85.7% in the EVC, respectively.

CONCLUSIONS

We developed and validated a preoperative DSS for ER of gGISTs based on tumor size, location, invasion depth, and endoscopists' experience. This DSS can be used to grade the technical difficulty before surgery.

Predictive Factors for Anastomotic Leakage after Laparoscopic and Open Total Gastrectomy: A Systematic Review

The aim of this systematic review is to identify patient-related, perioperative and technical risk factors for esophago-jejunal anastomotic leakage (EJAL) in patients undergoing total gastrectomy for gastric cancer (GC). A comprehensive literature search of PubMed/MEDLINE, Embase and Scopus databases was performed. Studies providing factors predictive of EJAL by uni- and multivariate analysis or an estimate of association between EJAL and related risk factors were included. All studies were assessed for methodological quality, and a narrative synthesis of the results was performed. A total of 16 studies were included in the systematic review, with a total of 42,489 patients who underwent gastrectomy with esophago-jejunal anastomosis. Age, BMI, impaired respiratory function, prognostic nutritional index (PNI), alcohol consumption, chronic renal failure, diabetes and mixed-type histology were identified as patient-related risk factors for EJAL at multivariate analysis. Likewise, among operative factors, laparoscopic approach, anastomosis type, additional organ resection, blood loss, intraoperative time and surgeon experience were found to be predictive factors for the development of EJAL. In clinical setting, we are able to identify several risk factors for EJAL. This can improve the recognition of higher-risk patients and their outcomes.

Hand-assisted laparoscopic resection versus total laparoscopic gastric surgery for primary gastric gastrointestinal stromal tumors (GISTs): an analysis from a high-volume institution

Background

Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) is technically feasible and associated with favorable outcomes. We compared the clinical efficacy of hand-assisted laparoscopic surgery (HLS) and total laparoscopic surgery (TLS) for gastric GISTs.

Methods

We retrospectively analyzed the clinical data of 69 consecutive patients diagnosed with a gastric GIST in a tertiary referral teaching hospital from December 2016 to December 2020. Surgical outcomes were compared between two groups.

Results

Fifty-three patients (TLS group: n = 36; HLS group: n = 17) were included. The mean age was 56.9 and 58.1 years in the TLS and HLS groups, respectively. The maximum tumor margin was significantly shorter in the HLS group than in the TLS group (2.3 ± 0.9. vs. 3.0 ± 0.8 cm; P = 0.004). The operative time of the HLS group was significantly shorter than that of the TLS group (70.6 ± 19.1 min vs. 134.4 ± 53.7 min; P < 0.001). The HLS group had less intraoperative blood loss, a shorter time to first flatus, and a shorter time to fluid diet than the TLS group (P < 0.05). No significant difference was found between the groups in the incidence or severity of complications within 30 days after surgery. Recurrence or metastasis occurred in four cases (HLS group; n = 1; TLS group; n = 3).

Conclusions

This study demonstrated that compared with TLS, HLS for gastric GISTs has the advantages of simpler operation, shorter operative time, and faster postoperative recovery.

Efficacy and Safety of Endoscopic Resection for Small Gastric Gastrointestinal Stromal Tumors in Elderly Patients

Background

Gastrointestinal stromal tumors (GISTs) are prevalent in elderly patients. Endoscopic resection has become popular for treating small (≤5 cm) gastric GISTs. However, little is known about the outcomes of endoscopic resection in elderly patients.

Aim

To assess the efficacy and safety of endoscopic resection for small (≤5 cm) gastric GISTs in elderly patients (≥65 years old).

Methods

A total of 260 patients (265 lesions) with gastric GISTs treated via endoscopic resection from January 2011 to May 2020 were retrospectively analyzed. Among them, 65 patients were ≥65 years old (elderly group), and 195 patients were <65 years old (nonelderly group). Clinicopathological characteristics, postoperative complications, and tumor recurrence rates between the two age groups were compared.

Results

A total of 260 patients with primary small (≤5 cm) gastric GISTs were treated with endoscopic resection. The median ages of the elderly and nonelderly groups were 68 (range 65-83) years and 55 (range 32-64) years, respectively. Elderly patients showed a higher incidence of comorbidities compared with nonelderly patients (61.5% versus 32.3%s, respectively; p < 0.001). All elderly patients and 99.0% of nonelderly patients underwent en bloc resection; only two nonelderly patients received piecemeal resection. No significant differences were found regarding postoperative complications or tumor recurrence rates between the two groups.

Conclusions

Although elderly patients had more comorbidities than nonelderly patients, both groups had similar postoperative complications and recurrence rates. We suggest that endoscopic resection performed by experienced endoscopists is safe and effective for treating small (≤5 cm) gastric GISTs in elderly patients.

Laparoscopic Versus Open Surgery for Rectal Gastrointestinal Stromal Tumor: A Multicenter Propensity Score-Matched Analysis

BACKGROUND

The safety and feasibility of laparoscopic surgery for the management of rectal gastrointestinal stromal tumors are unknown.

OBJECTIVE

This study aimed to compare the surgical and oncologic results of laparoscopic versus open surgery for the treatment of rectal gastrointestinal stromal tumors.

DESIGN

This was a retrospective multicenter propensity score-matched study to minimize heterogeneity between groups and focus on the difference between surgery strategies.

SETTINGS

Eleven Chinese tertiary hospitals participated in this study.

PATIENTS

A total of 364 patients with pathologically confirmed rectal gastrointestinal stromal tumors were retrospectively analyzed.

MAIN OUTCOME MEASURES

Relapse-free survival, postoperative hospital stay length, and 30-day postoperative complication rate were the main outcome measures.

RESULTS

We enrolled 214 patients who underwent surgical operation for primary localized rectal gastrointestinal stromal tumors. After propensity score matching, 134 cases involved in the comparison (67 laparoscopic vs 67 open surgery) were randomly matched (1:1) by sex, age, tumor size, tumor site, and neoadjuvant therapy. The laparoscopic surgery group had superior relapse-free survival (χ2 = 4.46, p = 0.04), and fewer complications (6.0% vs 25.4%, p = 0.002). No significant difference was found in the length of postoperative hospital stay between the laparoscopic surgery and open surgery groups (9.66 ± 5.42 vs. 10.64 ± 4.93, p = 0.28). Subgroup analysis showed that the laparoscopic surgery group had superior relapse-free survival (χ2 = 4.14, p = 0.04) and fewer complications after surgery (2.9% vs 24.4%, p = 0.01) in the rectal gastrointestinal stromal tumors ≤5 cm subgroup.

LIMITATIONS

This study was limited by the nature of retrospective reviews and relatively short follow-up period.

CONCLUSIONS

Laparoscopic surgery offers a safe and feasible option for the radical resection of primary localized rectal gastrointestinal stromal tumors, especially for patients with rectal gastrointestinal stromal tumors ≤5 cm. See Video Abstract at http://links.lww.com/DCR/B764.

CIRUGA LAPAROSCPICA VERSUS CIRUGA ABIERTA PARA TUMORES DEL ESTROMA GASTROINTESTINAL DE RECTO UN ANLISIS MULTICNTRICO EMPAREJADO POR PUNTAJE DE PROPENSIN

ANTECEDENTES:Se desconoce la seguridad y factibilidad de la cirugía laparoscópica para el tratamiento de los tumores del estroma gastrointestinal de recto.OBJETIVO:Comparar los resultados quirúrgicos y oncológicos de la cirugía laparoscópica versus cirugía abierta para el tratamiento de los tumores del estroma gastrointestinal de recto.DISEÑO:Estudio retrospectivo multicéntrico emparejado por puntuación de propensión para minimizar la heterogeneidad entre los grupos y centrarse en las diferencias entre las estrategias quirúrgicas.AJUSTES:Once hospitales terciarios de la China participaron en este estudio.PACIENTES:Se analizaron retrospectivamente un total de 364 pacientes con tumores del estroma gastrointestinal de recto confirmados patológicamente.PRINCIPALES MEDIDAS DE VALORACION:Supervivencia sin recidiva, duración de la estancia hospitalaria postquirúrgica y tasa de complicaciones postquirúrgicas a los 30 días.RESULTADOS:Inscribimos a 214 pacientes que fueron sometidos a cirugía por tumores primariamente localizados del estroma gastrointestinal de recto. Después del emparejamiento por puntaje de propensión, 134 casos involucrados en la comparación (67 laparoscópicos versus 67 cirugía abierta) fueron emparejados aleatoriamente (1: 1) por sexo, edad, tamaño del tumor, sitio del tumor y terapia neoadyuvante. El grupo de cirugía laparoscópica tuvo una supervivencia sin recidiva superior (χ2 = 4,46, p = 0,04) y menos complicaciones (6,0% frente a 25,4%, p = 0,002). No se encontraron diferencias significativas en la duración de la estancia hospitalaria postquirúrgica entre los grupos de cirugía laparoscópica y cirugía abierta (9,66 ± 5,42 frente a 10,64 ± 4,93, p = 0,28). El análisis de subgrupos mostró que el grupo de cirugía laparoscópica tuvo una supervivencia sin recidiva superior (χ2 = 4,14, p = 0,04) y menos complicaciones después de la cirugía (2,9% frente a 24,4%, p = 0,01) en el subgrupo de tumores del estroma gastrointestinal de recto ≤ 5 cm.LIMITACIONES:La naturaleza de la revisión retrospectiva y el período de seguimiento relativamente corto son limitaciones de este estudio.CONCLUSIONES:La cirugía laparoscópica ofrece una opción segura y factible para la resección radical de tumores primariamente localizados del estroma gastrointestinal de recto, especialmente para pacientes con tumores ≤5 cm. Consulte Video Resumen en http://links.lww.com/DCR/B764.

Predictors of the difficulty for endoscopic resection of gastric gastrointestinal stromal tumor and follow-up data

BACKGROUND AND AIM

Gastrointestinal stromal tumors (GISTs) are among the most common submucosal tumors in the stomach that require therapeutic intervention. We aim to identify the predictors of technical difficulty during endoscopic resection of gastric GIST and to investigate follow-up outcomes.

METHODS

Patients with gastric GISTs were reviewed from June 2009 to June 2020 at Zhongshan Hospital. Clinical and pathological features, endoscopic procedure information, and follow-up data were collected and analyzed. A nomogram was developed and validated internally and externally.

RESULTS

A total of 628 GISTs were finally analyzed. The difficulty was experienced in 66 cases. GISTs size (2-3 cm: OR 2.431 P = 0.018 and > 3 cm: OR 9.765 P < 0.001), invasion depth beyond submucosal (MP: OR 2.280, P = 0.038 and MP-ex: OR 4.295, P = 0.002), and lack of experience (OR 2.075, P = 0.016) were independent risk factors of difficulty. The nomogram prediction model showed a bias-corrected C-index value of 0.778 and acquired an area under curve (AUC) of 0.756 on the external validation cohort. At the cut-off of 0.15, the nomogram's negative predictive value (NPV) and accuracy (ACC) were 94.9% and 79.8% in identifying non-difficult GISTs. Follow-up results showed that only five GIST patients had local recurrence after endoscopic resection.

CONCLUSIONS

Tumor size, invasion depth, and endoscopists' experience were risk factors for the difficulty of endoscopic GIST resection. Our nomogram provided a valuable tool for screening non-difficult GIST resection.

Complete laparoscopic wedge resection of a giant locally advanced gastric GIST with near pathological complete response after preoperative treatment with imatinib mesylate: A case report

Introduction and importance

Surgical resection is the only curative treatment for gastrointestinal stromal tumor (GIST). Laparoscopic approach for large (>5 cm) and giant (>10 cm) gastric GIST remains under controversy. What's more, whether laparoscopic surgery could be performed after preoperative imatinib treatment of giant gastric GIST is still unknown.

Case presentation

We report a 68-year-old man with a giant (almost 30 cm) locally advanced gastric GIST which required resection of contiguous organs initially. After received 12 months imatinib therapy, the tumor became resectable and he finally achieved a complete laparoscopic wedge resection. Pathological evaluation of the resected specimen revealed a near pathological complete response was obtained. The imatinib treatment was ongoing after surgical resection and there was no radiological or clinical evidence of disease recurrence until to October 2021.

Clinical discussion

Laparoscopic approach is safe and effective for gastric GIST. Even for lesions greater for 5 cm. However, there are few reports for the application of laparoscopic wedge resection for gastric GIST larger than 10 cm. Preoperative use of imatinib can decrease the tumor size, so that may increase the chance of laparoscopic approach.

Conclusion

Preoperative imatinib therapy was effective for reducing the gastric GIST, which may increase the chance of minimally invasive approach and organ preservation. Patients with locally advanced GIST could benefit from the multidisciplinary approach.

•

A man with a giant (almost 30 cm) locally advanced gastric GIST achieved a complete laparoscopic wedge resection with preoperative imatinib therapy.

•

Pathological evaluation of the resected specimen revealed a near pathological complete response was obtained.

•

Preoperative imatinib therapy may facilitate R0 resection, organ preservation and increase the chance of minimally invasive approach.

•

Multidisciplinary approach is the optimal treatment for patients with locally advanced GIST.

Laparoscopic vs Open Resection of Gastrointestinal Stromal Tumors (GISTs) from Gastric Origin: different approaches for different diseases

BACKGROUND

Although minimally invasive techniques are currently recognized as effective and validated treatment for small gastric gastrointestinal stromal tumors (GISTs), the role of laparoscopy is not yet established. The aim of this study was to evaluate the outcomes of laparoscopic treatment of gastric GISTs compared to the results obtained in a group of patients treated with conventional surgery.

METHODS

A retrospective analysis was performed, using a prospectively maintained comprehensive database of 100 patients treated for gastric GIST in the period from 2000 to 2015. Thirty-six patients were treated laparoscopically and 64 patients underwent conventional surgery. The analyzed medical data included clinical and pathological features of removed tumors, perioperative parameters as well as short and long-term results of surgical treatment.

RESULTS

Histopathological examination confirmed radical resection for all patients. No deaths were reported in the 90-day post-operative period. Patients in laparoscopic group had significantly shorter length of hospital stay (5.5 vs. 7 days, p<0.0001), fewer extended and combined surgical procedures (11.2% vs 34.4% and 2.8% vs 39%; p=0.02 and p<0.001, respectively), and a smaller tumor size compared to laparotomic group (3 vs 6 cm, p<0.0001). The median post-operative follow-up for the entire study population was 42 months. During this period, 11 patients died and 4 of them developed a tumor recurrence. None of them was in the laparoscopic group.

CONCLUSIONS

Laparoscopy in the treatment of gastric GISTs has unquestionable advantages, but its choice is strictly related to tumor features.

Barbed suture in gastro-intestinal surgery: A review with a meta-analysis

BACKGROUND

The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures.

MATERIALS AND METHODS

A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass.

RESULTS

We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used.

CONCLUSION

Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Clinical outcomes and functional analysis of third space robotic and endoscopic cooperative surgery versus laparoscopic wedge resection for gastric submucosal tumours: a propensity score-matched study

Third space robotic and endoscopic cooperative surgery (TS-RECS) is a novel minimally invasive surgery for resecting gastric submucosal tumours (GSMTs), which could accomplish the completely oncological curability and maximal functional preservation. This study investigated the clinical outcomes and gastrointestinal function after TS-RECS versus laparoscopic wedge resection (LWR) for GSMTs. This was a single-centre retrospective study that included 130 patients with GSMTs who underwent LWR or TS-RECS from 2013 to 2019. To overcome selection biases, we performed propensity score matching (1:1) using seven covariates that could impact the group assignment and outcomes. Then, the clinical outcomes and gastrointestinal function in the LWR and TS-RECS groups were compared in a matched cohort. Among the 130 enrolled patients, 96 patients underwent LWR, and 34 underwent TS-RECS and were matched into 30 patients for each group. There was no significant difference in the operation time between the two groups (P = 0.543). However, the TS-RECS group had significantly less blood loss (20,5–100 vs 95,10–310 ml, P < 0.0001) and better postoperative recovery in terms of time to oral intake (2,2–4 vs 3,2–6 days, P < 0.0001) and postoperative hospital stay (5,4–10 vs 8.5,5–16 days, P < 0.0001) than the LWR group. The severity and frequency scores of postoperative gastrointestinal symptoms in the TS-RECS group were significantly lower than those in the LWR group. The median follow-up period was 24 months (10–60 months) in the LWR group and 18 months (10–27 months) in the TS-RECS group, and there was in total a single recurrence in the LWR group. TS-RECS appears to be a technically safe and effective surgery with preservation of gastrointestinal function for resection of GSMT resection.

Incidence and risk factors of portomesenteric venous thrombosis after colorectal surgery for cancer in the elderly population

BACKGROUND

Although it is known that portomesenteric venous thrombosis (PMVT) is associated with total colectomy and proctocolectomy in young patients with inflammatory bowel disease, little is known about incidence and risk factors of PMVT among the elderly population undergoing colorectal surgery for cancer.

METHODS

Data of elderly patients (> 70 years) undergoing surgery for colorectal cancer were retrospectively registered. The occurrence of PMVT was correlated with the patients' characteristics and operative variables. Data collected included age, sex, obesity, ASA score, tumor degree, type of surgical resection, surgical approach (laparoscopic or open), and duration of surgery (from skin incision to the application of dressings).

RESULTS

A total of 137 patients > 70 years who underwent surgery for colorectal cancer and developed an acute intraabdominal process with suggestive symptoms, needing a CT scan, were included. Three of these patients (2.1%) had portomesenteric venous thrombosis during the study period, which was proved with CT scan. There were no significant patients' characteristics or operative variables between patients with or without the occurrence of PMVT after surgery. Of interest, only operative time was significantly higher in patients with PMVT after surgery (256 ± 40 vs 140 ± 41, p < 0.001).

CONCLUSIONS

PMVT as a cause of abdominal pain after colorectal surgery for cancer in the elderly population is uncommon. An index of suspicion for PMVT in an elderly postoperative colorectal cancer patient with sudden onset of abdominal pain must be maintained.

Barbed Suture and Gastrointestinal Surgery. A Retrospective Analysis

Although minimally invasive surgery is recognized as the gold standard of many surgical procedures, laparoscopic suturing is still considered as the most difficult skill in laparoscopic surgery.

The introduction of barbed sutures facilitates laparoscopic suturing because it is not necessary to tie a knot. The efficacy of this method has been evaluated in different types of surgery; however, less is known about general surgery.

We retrospectively analysed data from 378 patients who had undergone bariatric or surgical treatment for colic or gastric malignancy requiring a closure of gastroentero, entero-entero or enterocolotomy from January 2014 to January 2019, admitted to the General Surgery Unit and Operative Unit of Surgical Endoscopy of the University Federico II (Naples, Italy).

We registered 12 anastomotic leaks (3.1%), 16 anastomotic intraluminal bleedings (4.2%) and 7 extraluminal bleedings. Other complications included 23 cases of postoperative nausea and vomit (6%), 14 cases of postoperative ileus (3.7%) and 3 cases of intra-abdominal abscess (0.8%). Overall complications rate was 19.8% (75/378). No postoperative death was registered.

Thus, by pooling together 378 patients, we can assess that barbed suture could be considered safe and effective for closure of holes used for the introduction of a branch of mechanical stapler to perform intracorporeal anastomosis.

Gastric gastrointestinal stromal tumors: clinical features and short- and long-term outcomes of laparoscopic resection

Introduction

Although minimally invasive techniques are currently recognized as effective and validated treatment for small gastric gastrointestinal stromal tumors (GISTs), the role of laparoscopy is not yet established, especially in the institutions that have less experience in minimally invasive surgery.

Aim

To evaluate the outcomes of laparoscopic treatment of gastric gastrointestinal stromal tumors compared to the results obtained in a group of patients treated with conventional surgery.

Material and methods

A retrospective analysis of data collected for a group of 68 patients treated for gastric GIST in the period from 2002 to 2017 was performed. Forty-six patients were treated laparoscopically (group 1) and 22 patients underwent conventional surgery (group 2). The analyzed medical data included clinical and pathomorphological features of removed tumors, perioperative parameters as well as short and long-term results of surgical treatment.

Results

Histopathological examination confirmed radical resection for all patients. No deaths were reported in the 30-day post-operative period. Patients in group 1 had significantly shorter length of hospital stay (3 vs. 9 days), less intra-operative blood loss (25 vs. 175 ml) and fewer perioperative complications (13% vs. 41%) compared to group 2. The mean post-operative follow-up was 57 months. During this period, four patients died for reasons unrelated to the primary disease. None of the patients who underwent a laparoscopic procedure had a recurrence of the tumor in the follow-up period.

Conclusions

Laparoscopy in the treatment of gastric GISTs has unquestionable advantages, including decreased blood loss, reduced risk of complications, and shorter hospital stay.

Laparoscopic treatment of large gastrointestinal stromal tumors (> 5 cm)

INTRODUCTION

Although laparoscopic techniques are currently a recognized type of treatment of small stromal tumors (GISTs) of the stomach, their application in the case of larger tumors has been the subject of debate.

AIM

To evaluate the technical feasibility, safety and early results of the laparoscopic treatment of large GISTs with a diameter of more than 5 cm.

MATERIAL AND METHODS

A retrospective analysis was performed using data on patients who underwent laparoscopic surgery for gastric GIST in the period from 2009 to 2016. The patients selected for the study were divided into two groups based on the diameter of the tumor: patients who developed a tumor with a diameter smaller than or equal to 5 cm (group 1), and those whose tumors exceeded 5 cm in diameter (group 2). The following factors were established and compared for the two groups: duration of surgery, amount of intra-operative blood loss, length of hospital stay, and the number and nature of post-operative complications.

RESULTS

No deaths occurred in the 30-day post-operative period, and no statistically significant differences regarding complications in the post-operative period were observed. In group 2, statistically significantly more pronounced blood loss and longer hospital length of stay were observed. No difference in the duration of surgery between the investigated groups was observed.

CONCLUSIONS

It appears that the surgical treatment of GISTs with a diameter of more than 5 cm by means of minimally invasive procedures is a viable and safe alternative.

Surgical treatment of gastric GIST with acute bleeding using laparoscopic sleeve gastrectomy: A report of two cases

In this report, we want to emphasize how a laparoscopic bariatric surgical procedure, in experienced hands, has shown to be a valid alternative for the hemorrhage control and the removal of a gastrointestinal tumor in a life-threatening situation.

Gastrointestinal stromal tumors: A multidisciplinary challenge

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors located in the alimentary tract. Its usual manifestation is gastrointestinal bleeding. However, small asymptomatic lesions are frequently detected as incidental finding. Characteristically, most GISTs (> 95%) are positive for the KIT protein (CD117) by IHC staining and approximately 80%-90% of GISTs carry a mutation in the c-KIT or PDGFRA genes. Mutational analysis should be performed when planning adjuvant and neoadjuvant therapy, due to its possible resistance to conventional treatment. The arise of tyrosine kinase inhibitor has supposed a revolution in GISTs treatment being useful as adjuvant, neoadjuvant or recurrence disease treatment. That is why a multidisciplinary approach to this disease is required. The correct characterization of the tumor at diagnosis (the diagnosis of recurrences and the evaluation of the response to treatment with tyrosine kinase inhibitors) is fundamental for facing these tumors and requires specialized Endoscopist, Radiologists and Nuclear Medicine Physician. Surgery is the only potentially curative treatment for suspected resectable GIST. In the case of high risk GISTs, surgery plus adjuvant Imatinib-Mesylate for 3 years is the standard treatment. Neoadjuvant imatinib-mesylate should be considered to shrink the tumor in case of locally advanced primary or recurrence disease, unresectable or potentially resectable metastasic tumors, and potentially resectable disease in complex anatomic locations to decrease the related morbidity. In the case of Metastatic GIST under Neoadjuvant treatment, when there are complete response, stable disease or limited disease progression, complete cytoreductive surgery could be a therapeutic option if feasible.

Laparoscopic total gastrectomy for a giant gastrointestinal stromal tumor (GIST) with acute massive gastrointestinal bleeding: a case report

Gastrointestinal stromal tumors (GISTs) include 80% of gastrointestinal mesenchymal tumors that originate from interstitial Cajal cells and include 0.1–3% of GI malignancies, and the stomach is the most commonly involved organ. The only potentially curative treatment is surgical resection with clear margins. Although laparoscopic resection of small GISTs is a standard treatment, there is controversy about laparoscopic surgical resection for large and giant GISTs. A 52-year-old woman, a known case of large GIST of the stomach that was under neoadjuvant imatinib therapy, was admitted to the emergency department due to acute massive gastrointestinal bleeding (GIB). The patient underwent laparoscopic total gastrectomy and received adjuvant imatinib after surgery. Laparoscopic resection is a safe and feasible method in large and giant GISTs with oncologic and long-term outcomes comparable to open surgery, and with better short-term outcomes.

Elderly patients with gastrointestinal stromal tumour (GIST) receive less treatment irrespective of performance score or comorbidity - A retrospective multicentre study in a large cohort of GIST patients

OBJECTIVE

Although gastrointestinal stromal tumours (GIST) predominantly occur in older patients, data on treatment patterns in elderly GIST patients are scarce.

METHODS

Patients registered in the Dutch GIST Registry (DGR) from January 2009 until December 2016 were included. Differences in treatment patterns between elderly (≥75 years) and younger patients were compared. Multivariate analyses were conducted using logistic regression.

RESULTS

Data of 145 elderly and 665 non-elderly patients were registered (median age 78 and 60 years respectively). In elderly patients, performance score (WHO-PS) and age-adjusted Charlson comorbidity index (ACCI) were significantly higher (p < 0.05; p < 0.001), and albumin level significantly lower (p = 0.04). Hundred-and-nine (75.2%) elderly and 503 (75.6%) non-elderly patients had only localised disease. Surgery was performed in 57% of elderly versus 84% of non-elderly patients (p = 0.003, OR: 0.26, 95% CI: 0.11-0.63). No differences in surgery outcome or complications were found. Thirty-eight percent of elderly with an indication for adjuvant treatment did receive imatinib versus 68% of non-elderly (p = 0.04, OR: 0.47, 95% CI: 0.23-0.95). Thirty-six elderly and 162 non-elderly patients had metastatic disease. Palliative imatinib was equally given (mean dose 400 mg) and adverse events were mostly minor (p = 0.71). In elderly, drug-related toxicity was in 32.7% reason to discontinue imatinib versus 5.1% in non-elderly (p = 0.001, OR 13.5, 95% CI: 2.8-65.0). Median progression-free survival (PFS) was 24 months in elderly and 33 months in non-elderly (p = 0.10). Median overall survival (OS) was 34 months and 59 months respectively (p = 0.01).

CONCLUSIONS

Elderly GIST patients with localised disease receive less surgery and adjuvant treatment, irrespective of comorbidity and performance score. Drug-related toxicity results more often in treatment discontinuation. This possibly results in poor outcome.

Effect of submucosal tunneling endoscopic resection for submucosal tumors at esophagogastric junction and risk factors for failure of en bloc resection

BACKGROUND AND AIMS

Most submucosal tumors (SMTs) in the esophagogastric junction (EGJ) are irregularly shaped and different from those in the esophagus, where submucosal tunneling endoscopic resection (STER) has been proven effective and safe. However, few reports paid attention to STER for SMTs in the EGJ. The aim of the study was not only to evaluate the effect of STER in patients with SMTs in the EGJ but to analyze the risk factors for failure of en bloc resection.

METHODS

A consecutive of 47 patients with SMTs originating from the muscularis propria (MP) layer in the EGJ underwent STER were retrospectively included between September 2012 and December 2016. Thirty-five tumors underwent en bloc resection, and the other 12 tumors received piecemeal resection. The tumor size, operation time, en bloc resection rate, complications, residual, and local recurrence were achieved and compared between the two groups.

RESULTS

Forty-six of 47 lesions (97.9%) were successfully resected. The mean lesion size was 29.7 ± 16.3 mm. Both the en bloc resection rate and complete resection rate were 74.5% (35/47). No severe complications occurred in the 47 patients. Patients in the piecemeal resection group had more irregularly shaped lesions, longer tumor diameter, larger tumor size (≥40 mm), longer operation time, and longer hospital stay after procedure (P < 0.05), and there were no statistically differences between the two groups in in-operative complications, post-operative complications, and residual rate (P > 0.05). By univariate analysis and stepwise logistic regression analysis, irregular shape and tumor diameter ≥20 mm were two risk factors for failure of en bloc resection.

CONCLUSIONS

STER is an effective and safe technique for the treatment of SMTs arising from the MP layer in the EGJ. Irregular shape and tumor diameter ≥20 mm are the reliable risk factors for en bloc resection failure.

Technical success and short-term results of surgical treatment of gastrointestinal stromal tumors: an experience of three centers

BACKGROUND

Gastrointestinal stromal tumors (GIST) comprise about 80% of gastrointestinal sarcomas. In patients with localized disease, surgery is considered as "Gold Standard" treatment. Organ-sparing radical en-block resection is widely accepted practice. Since lymph node dissection is not routinely indicated, minimally invasive approach is of particular interest. The aim of this study is to investigate the short-term outcomes of different surgical treatment of GISTs.

METHODS

We analyzed data of 116 patients who received surgical treatment for localized forms of GIST. Tumors were located in the stomach in 87 (75%) cases, in the small intestine in 26 (22.4%) cases, and extragastrointestinal GISTs were found in 3 (2.6%) patients. Four different approaches were used-open surgery (OpS, n=48), laparoscopic surgery (LS, n=40), endoscopic procedures (EP, n=22) and hybrid rendezvous (HR, n=6). Patient demographics, clinical presentation of tumors, characteristics of operation procedures (duration, intraoperative blood loss, frequency of R0-resection and fragmentation of tumor), postoperative complications and length of hospital stay were examined in all these groups.

RESULTS

Radical treatment (R0-resection) was performed in all patients. There were no cases of tumor ruptures during surgical procedure. Mean size of GIST in OpS was 9.1±2.0 [2-35] cm; in LS: 4.9±0.8 (1.5-15) cm; in HR: 3.5±0.8 (2-4.5) cm and in EP: 2.3±0.3 (0.4-3.5) cm. Intraoperative blood loss in OpS was 369.7±209.5 [0-4,000] mL; LS: 63.9±16.0 [0-150] mL; in HR: 96.7±44.3 [50-200] mL; in EP: 33.3±11.0 [0-150] mL. Duration of operation in OpS was 160±20.4 [50-310] min; in LS: 104.7±12.7 [50-185]; in HR: 176.7±44.0 [110-260] min and in EP: 89.8±15.5 [25-190] min. Complication rate in OpS was 5 (10.4%); in LS: 3 (7.5%); in HR: 0% and in EP: 3 (13.6%). Length of hospital stay in OpS was 13.8±2.2 [7-52] days; in LS: 11, 4±2.2 [4-21] days; in HR: 11±3.2 [7-15] days and in EP: 11, 9±2.1 [5-22] days. There were no postoperative deaths.

CONCLUSIONS

There is a diversity of surgical approaches for GISTs treatment. From our point of view, the main selection criteria for certain procedure are size, localization, growth type of the tumor and status of overlying mucosa. Nevertheless, due to relative rarity and heterogeneity of this pathology, individualization is necessary in each specific case. Laparoscopic and endoscopic surgery is proved to be safe and feasible for resection of the gastric GISTs, with a reasonable operation time, low blood loss, and an acceptable complication rate. Immediate results indicate that all interventions were performed radically without mortality or serious morbidity.