Laparoscopic-Assisted Endoscopic Resection of a Gastric Leiomyoma

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

A scoring model for radiologic diagnosis of gastric leiomyomas (GLMs) with contrast-enhanced computed tomography (CE-CT): Differential diagnosis from gastrointestinal stromal tumors (GISTs)

OBJECTIVES

To investigate CT findings and develop a diagnostic score model to differentiate GLMs from GISTs.

METHODS

This retrospective study included 109 patients with pathologically confirmed GLMs (n = 46) and GISTs (n = 63) from January 2013 to August 2018 who received CE-CT before surgery. Demographic and radiological features was collected, including lesion location, contour, presence or absence of intralesional necrosis and ulceration, growth pattern, whether the tumor involved EGJ, the long diameter (LD) /the short diameter (SD) ratio, pattern and degree of lesion enhancement. Univariate analyses and multivariate logistic regression analyses were performed to identify independent predictors and establish a predictive model. Independent predictors for GLMs were weighted with scores based on regression coefficients. A receiver operating characteristic (ROC) curve was created to determine the diagnostic ability of the model. Overall score distribution was divided into four groups to show differentiating probability of GLMs from GISTs.

RESULTS

Five CT features were the independent predictors for GLMs diagnosis in multivariate logistic regression analysis, including esophagogastric junction (EGJ) involvement (OR, 367.9; 95 % CI, 5.8-23302.8; P =  0.005), absence of necrosis (OR, 11.9; 95 % CI, 1.0-138. 1; P =  0.048) and ulceration (OR, 151.9; 95 % CI, 1.4-16899.6; P =  0.037), degree of enhancement (OR, 9.3; 95 % CI, 3.2-27.4; P <  0.001), and long diameter/ short diameter (LD/SD) ratio (OR,170.9; 95 % CI, 8.4-3493.4; P =  0.001). At a cutoff of 9 points, AUC for this score model was 0.95, with 95.65 % sensitivity, 79.37 % specificity, 77.19 % PPV, 96.15 % NPV and 86.24 % diagnostic accuracy. An increasing trend was showed in diagnostic probability of GLMs among four groups based on the score (P <  0.001).

CONCLUSIONS

The newly designed scoring system is reliable and easy-to-use for GLMs diagnosis by distinguishing from GISTs, including EGJ involvement, absence of ulceration and necrosis, mild enhancement and high LD/SD ratio. The overall score of model ranged from 1 to 17 points, which was divided into 4 groups: 1-7 points, 7-10 points, 10-13 points and 13-17 points, with a diagnostic probability of GLMs 0%, 45 %, 83 % and 100 %, respectively.

Application of laparoscopy, endoscopy and laparoscopic and endoscopic cooperative surgery in gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) constitute the most common mesenchymal neoplasms of the gastrointestinal tract, among which 60%-70% are located in the stomach. All GISTs have malignant potential, varying from small lesions to aggressive sarcomas. Surgical resection with negative margins remains the best treatment for GISTs. Lymphadenectomy is not necessary because GISTs rarely metastasize to lymph nodes. Because of these biological behavior characteristics, the advantages of minimally invasive surgeries such as laparoscopic surgery and endoscopic surgery can be fully reflected in the surgical management of GISTs. The advent of laparoscopic and endoscopic cooperative surgery has broadened the scope and enhanced the safety of minimally invasive surgical treatment of GISTs. In this paper we will discuss the application of laparoscopy, endoscopy and laparoscopic and endoscopic cooperative surgery in the treatment of GISTs.

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

AIM

To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors.

METHODS

A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach.

RESULTS

The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described.

CONCLUSION

Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.