Comparison Analysis of Three Different Types of Minimally Invasive Procedures for Gastrointestinal Stromal Tumors ≤5 cm

Minimally invasive treatment strategies for submucosal tumors of the upper gastrointestinal tract: Advances in innovative endoscopy-based therapies

The increasing detection of submucosal tumors (SMTs) in the upper gastrointestinal tract (UGI) is due to the increased clinical use of endoscopy and imaging technology. Some of these SMTs have malignant potential and may cause clinical symptoms. Thus, it is recommended in clinical guidelines to consider resection of these SMTs. Endoscopic techniques have become widely used in the diagnosis and treatment of SMT in the UGI as compared with traditional surgery due to their advantages of minimally invasive, quick recovery, and economical cost. Recently, new endoscopic techniques and instruments have been continuously implemented, leading to revolutionary innovation in endoscopic treatments. However, the safety and efficacy of these innovative techniques remain unclear. Therefore, we have comprehensively summarized the various techniques used in the treatment of UGI tumors in recent years, evaluated the indications and effects of each technique, and compared their benefits and disadvantages. We hope that this review will provide a more comprehensive reference for clinical and endoscopic practitioners, and help them develop more individualized treatment plans for different patients. This will ultimately expand the patient population that can benefit from these innovative technologies.

Advancements in Endoscopic Treatment for Gastric Subepithelial Tumors

Peroral flexible endoscopy is a minimally invasive technique that enables the local resection of gastric subepithelial tumors (SETs) with malignant potential. Resection techniques are mainly chosen on the basis of the lesion size. Minute SETs less than 1 cm should be managed through a watch and wait strategy, with the exception of histologically diagnosed superficial lesions, which require endoscopic mucosal resection or endoscopic submucosal dissection. For 1- to 3-cm small SETs, endoscopic enucleation techniques, such as endoscopic submucosal excavation, submucosal tunneling endoscopic resection, and peroral endoscopic tumor resection, can be used. However, endoscopic full-thickness resection is preferred for histologically complete removal with negative surgical margins. When endoscopic full-thickness resection is considered technically difficult, laparoscopic and endoscopic cooperative surgery (LECS) is a safe and dependable alternative. Moderate-sized SETs (3 to 5 cm) require surgical intervention because the lesions must be removed transabdominally. LECS is a less invasive surgical procedure as it reduces the resection area; however, some LECS techniques that require transoral tumor retrieval are not available. Endoscopic intervention for lesions larger than 5 cm should be used with caution for research purposes. With advancements in endoscopic diagnosis, the indications for endoscopic treatment for SETs are expected to improve, thereby enhancing patients' quality of life.

AGA Clinical Practice Update on Endoscopic Full-Thickness Resection for the Management of Gastrointestinal Subepithelial Lesions: Commentary

DESCRIPTION

Subepithelial lesions of the gastrointestinal tract are not encountered uncommonly during routine endoscopy. There has been remarkable progress in the development of endoscopic options for the resection of subepithelial lesions, including full-thickness resection. The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to describe the various techniques for endoscopic full-thickness resection and to facilitate their appropriate application in the management of subepithelial lesions.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology.

Learning curve for endoscopic resection of gastric gastrointestinal stromal tumors: a single-center experience

BACKGROUND

endoscopic resection (ER) is widely used in the treatment of gastric gastrointestinal stromal tumors (gGISTs). However, no studies have previously described the learning curve (LC) for ER of gGISTs. This study aimed to evaluate the LC based on multifarious operative outcomes.

METHODS

one hundred consecutive patients who underwent ER of gGISTs by a single endoscopist from January 2017 to December 2022 were included. Patients were analyzed in groups of ten to minimize demographic differences, and operative time (OT), conversion rate, intraoperative and postoperative complication were assessed to evaluate the LC. Meanwhile, for the OT, the LC was further analyzed using the cumulative sum (CUSUM) method and patients were organized chronologically in three phases.

RESULT

there was a statistically significant decrease in OT, conversion to laparoscopic surgery, and postoperative complication after 30 cases (median 80.0 min vs 56.0 min, p < 0.001; 10.0 % vs 0 %, p = 0.025; 33.3 % vs 10.0 %, p = 0.004), rate of intraoperative complications after 20 cases (15.0 % vs 1.3 %, p = 0.025). CUSUM chart demonstrated that OT increased dramatically before around 30 cases (phase 1) and decreased after 60 cases (phase 3), with a plateau phase in the middle 30 cases (phase 2). Among the three phases, the R0 resection and conversion rate were not significantly different. However, OT, intraoperative and postoperative complications were gradually decreased (p < 0.05).

CONCLUSIONS

the LC of ER of gGISTs is approximately 60 cases. However, about 30 cases were sufficient to acquire skills to reduce complications and conversion rate during the ER procedure.

Is it enough to observe less than 2 cm sized gastric SET?

BACKGROUND AND AIMS

The recent surge in demand for screening endoscopy has led to an increased detection of gastric subepithelial tumors (SETs). According to current guideline, SETs less than 2 cm in size are recommended for periodic surveillance. In light of recent advancement in therapeutic endoscopy in resection of small SET, we analyzed the histopathological features and the effectiveness of endoscopic resection for these small SETs.

METHODS

Retrospectively study was performed on 74 patients who underwent endoscopic resection of gastric small (≤ 2 cm) upper gastrointestinal tract SETs. The outcomes including histopathology and en bloc resection were analyzed.

RESULTS

The mean SET size was 11.69 ± 5.11 mm. The mean procedure time was 81.26 ± 42.53 min. Of the 74 patients, 28 patients had leiomyomas, 26 had gastrointestinal stromal tumors (GISTs), 14 had ectopic pancreas, 4 had lipomas, and 2 had neuroendocrine tumors. Among those with GIST, two patients exhibited high-risk histology. All patients underwent successful and uneventful endoscopy.

CONCLUSIONS

Endoscopic resection can be recommended even for the small gastric SETs. In our study, we found that SETs with a size of less than 2 cm have significant proportion of GISTs which harbor malignant transformation potential.

Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

BACKGROUND

Minimally invasive surgery had been tailored to individual cases of gastric subepithelial tumors (SETs) after comparing the clinical outcomes of endoscopic resection (ER), laparoscopic resection (LR), and hybrid methods.

AIM

To study the use of Goldilocks principle to determine the best form of minimally invasive surgery for gastric SETs.

METHODS

In this retrospective study, 194 patients of gastric SETs with high probability of surgical intervention were included. All patients underwent tumor resection in the operating theater between January 2013 and December 2021. The patients were divided into two groups, ER or LR, according to the tumor characteristics and the initial intent of intervention. Few patients in the ER group required further backup laparoscopic surgery after an incomplete ER. The patients who had converted open surgery were excluded. A logistic regression model was used to assess the associations between patient characteristics and the likelihood of a treatment strategy. The area under the curve was used to assess the discriminative ability of tumor size and Youden's index to determine the optimal cut-off tumor size.

RESULTS

One-hundred ninety-four patients (100 in the ER group and 94 in the LR group) underwent tumor resection in the operating theater. In the ER group, 27 patients required backup laparoscopic surgery after an incomplete ER. The patients in the ER group had small tumor sizes and shorter procedure durations while the patients in the LR group had large tumor sizes, exophytic growth, malignancy, and tumors that were more often located in the middle or lower third of the stomach. Both groups had similar durations of hospital stays and a similar rate of major postoperative complications. The patients in the ER group who underwent backup surgery required longer procedures (56.4 min) and prolonged stays (2 d) compared to the patients in the LR group without the increased rate of major postoperative complications. The optimal cut-off point for the tumor size for laparoscopic surgery was 2.15 cm.

CONCLUSION

Multidisciplinary teamwork leads to the adoption of different strategies to yield efficient clinical outcomes according to the tumor characteristics.

Lap-Endo cooperative surgery (LECS) in gastric GIST: updates and future advances

BACKGROUND

With advancements in the field of laparoscopic and endoscopic techniques leading to improved patient outcomes, open resection has become increasingly outdated for the treatment of gastric gastrointestinal stromal tumours (GIST). This is further superseded with the advent of laparoscopic and endoscopic cooperative surgery (LECS), an amalgamation of the two techniques to further improve results garnered while overcoming prior limitations each had individually.

METHODS

The electronic databases MEDLINE, Embase and PubMed were reviewed up to August 2021, using terms relating to LECS and gastric GIST. Relevant in-article references not returned in the searches were also considered.

RESULTS

Advancements in the field of laparoscopic and endoscopic techniques has led to improved patient outcomes, making open resection a thing of the past for gastric GIST. This has become even more apparent with the advent of LECS, coupling two cutting edge techniques to further improve results garnered while overcoming prior limitations each had individually. LECS has gained much favour by reducing surgical margins due to endoscopic visualisation without being limited to smaller tumours, allowing for better anatomical and functional preservation of prior anatomy. Furthermore, hybrid approaches have improved perioperative outcomes, with reduction in procedure time, post-procedure hospital stay and lesser complications. Additionally, subtypes of LECS such as inverted LECS, closed LECS, non-exposed endoscopic wall-inversion surgery (NEWS) and laparoscopy-assisted endoscopic full-thickness resection (LAEFR) have been developed that allows the abdominal cavity to not be exposed to tumour cells and gastric contents by extracting the lesion transorally.

CONCLUSIONS

LECS and its subtypes being a combination of two advanced techniques shows a synergistic effect that is promising. However, despite all these advantages of enhanced safety and certainty, there remains areas that require further improvement.

ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions

Subepithelial lesions (SEL) of the GI tract represent a mix of benign and potentially malignant entities including tumors, cysts, or extraluminal structures causing extrinsic compression of the gastrointestinal wall. SEL can occur anywhere along the GI tract and are frequently incidental findings encountered during endoscopy or cross-sectional imaging. This clinical guideline of the American College of Gastroenterology was developed using the Grading of Recommendations Assessment, Development, and Evaluation process and is intended to suggest preferable approaches to a typical patient with a SEL based on the currently available published literature. Among the recommendations, we suggest endoscopic ultrasound (EUS) with tissue acquisition to improve diagnostic accuracy in the identification of solid nonlipomatous SEL and EUS fine-needle biopsy alone or EUS fine-needle aspiration with rapid on-site evaluation sampling of solid SEL. There is insufficient evidence to recommend surveillance vs resection of gastric gastrointestinal stromal tumors (GIST) <2 cm in size. Owing to their malignant potential, we suggest resection of gastric GIST >2 cm and all nongastric GIST. When exercising clinical judgment, particularly when statements are conditional suggestions and/or treatments pose significant risks, health-care providers should incorporate this guideline with patient-specific preferences, medical comorbidities, and overall health status to arrive at a patient-centered approach.

Therapeutic Effects of 4 Surgical Approaches for Small Gastrointestinal Stromal Tumors: A Network Meta-analysis

This study aims to systematically evaluate the efficacy of endoscopic resection (ER), laparoscopic resection (LR), laparoscopic endoscopic cooperative surgery (LECS), and open surgery (OpS) for gastrointestinal stromal tumors with small diameters (≤5 cm). Relevant studies were collected through Pubmed, Cochrane Library, and Embase databases. Operative time, hospital stays, time to liquid diet, intraoperative bleeding, and complications were used as outcome indicators for meta-analysis. Twenty-four retrospective cohort studies with 2406 participants were analyzed. LR and OpS groups had longer operating time than the ER group. ER, LECS, and LR groups had decreased lengths of hospital stay than the OpS group. Moreover, patients in LR and LECS groups had fewer complications than those in the OpS group. Endoscopic operation for small gastrointestinal stromal tumors contributes to shortened lengths of surgery and hospital stay. This reduces intraoperative blood loss and promotes gastroenteric functional recovery without increasing the risk of complications or tumor recurrence.

Comparative Study on the Clinical Effects of Different Surgical Methods in the Treatment of Gastrointestinal Stromal Tumors

Objective

The objective is to compare the clinical efficacy of laparoscopic resection (LAP), endoscopic full-thickness resection (EFR), and endoscopic submucosal dissection (ESD) in the treatment of gastrointestinal stromal tumors.

Methods

The clinical data of 105 patients who were treated in our hospital and diagnosed with GIST by pathology after surgery from March 2019 to March 2021 were collected. Patients were divided into the LAP group, EFR group, and ESD group according to different surgical methods. The clinical data, surgical conditions, complications, and postoperative conditions of the patients were recorded retrospectively. Patients were followed up closely after surgery.

Results

The operation time of the EFR group and ESD group was shorter than that of the LAP group, and the operation time of the EFR group was shorter than that of the ESD group (P < 0.05). The amount of intraoperative blood loss in the EFR group and ESD group was lower than that in the LAP group (P < 0.05). There was no significant difference in the complete resection rate among the three groups (P > 0.05). There was no significant difference in the total incidence of complications among the three groups (P > 0.05). The postoperative abdominal pain time, postoperative hospital stay, and total hospitalization costs of the EFR group and ESD group were lower than those of the LAP group (P < 0.05). No recurrence or metastasis cases were found in the three groups during the follow-up period, and there were no GIST-related deaths in the three groups.

Conclusion

LAP, EFR, and ESD have good curative effect, good safety, and good prognosis in the treatment of GIST. But compared with LAP, EFR and ESD have the advantages of less trauma, faster recovery, shorter hospitalization time, and lower hospitalization cost.

Comparable long-term survival of patients with colorectal or gastric gastrointestinal stromal tumors treated with endoscopic vs. surgical resection

BACKGROUND AND AIMS

With the development of endoscopic technology, endoscopic treatment has been widely used in Gastrointestinal stromal tumors (GISTs). However, population-based studies comparing the long-term results of patients who received endoscopic treatment vs. Surgery are lacking. We used the Surveillance, Epidemiology, and End Results (SEER) database to analyze the long-term survival of colorectal or gastric GISTs who underwent primary tumor resection (endoscopic therapy or surgery) in the USA.

METHODS

Patients with colorectal or gastric GISTs were selected from the SEER database between 2010 and 2015. Kaplan-Meier analyses and log-rank tests were used to evaluate the difference in the long-term survival between the endoscopic therapy group and the surgery group. We examined the association between different treatments and survival after using the multivariate cox proportional hazards model to adjust the relevant covariates. Besides, we used Propensity score matching (PSM) to overcome the different distributions of covariates between the two groups and then further compare the survival difference.

RESULTS

In total, 2355 patients were enrolled in our study, of which 1999 (84.9%) received surgical treatment and 356 (15.1%) received endoscopic treatment. There was no significant difference in overall survival (OS) between the two groups before PSM. The median OS (73.5 months vs. 72.2 months) and 5-year OS rate (85.7% vs. 81.5%) of endoscopic therapy were similar to surgical patients (P = 0.34). The median Cancer-specific survival (CSS) and 5-year CSS rate in the endoscopic treatment group were higher than the surgical group before PSM, with 81.3 months, 97.1% versus 78.8 months, 92.7% (P = 0.011). After adjusting for other clinical factors and PSM, the long-term OS and CSS did not significantly differ between those treated surgically and treated endoscopically.

CONCLUSION

Based on the American population, we preliminarily found that the long-term OS and CSS did not differ between patients undergoing endoscopic therapy and surgery.

Comparison Among Endoscopic, Laparoscopic, and Open Resection for Relatively Small Gastric Gastrointestinal Stromal Tumors (<5 cm): A Bayesian Network Meta-Analysis

Background

Endoscopic resection (ESR) is a novel minimally invasive procedure for superficial tumors. Its safety, efficiency, and outcome for gastric gastrointestinal stromal tumors (gGISTs) less than 5 cm remains unclear compared to laparoscopic resection (LAR) and open resection (ONR). The current network meta-analysis aimed to review and analyze the available evidence of this question.

Methods

PubMed, Embase, Cochrane Library, and Web of Science databases were searched to identify eligible studies published up to July 6, 2020. The perioperative and long-term oncological outcomes among ESR, LAR, and ONR for gGIST (<5 cm) were estimated through the Bayesian network meta-analysis with a random-effect model.

Results

Fifteen studies with 1,631 patients were included. ESR was associated with a shorter operative time [mean difference, MD: -36; 95% confidence interval, CI (-55, -16)], a higher rate of positive margin [odds ratio, OR: 5.1 × 10¹⁰, 95% CI (33, 2.5 × 10³²)], and less costs [MD: -1 × 10⁴, 95% CI (-1.6 × 10⁴, -4.4 × 10³)] but similar time to resume flatus [MD: 0.52, 95% CI (-0.16, 1.1)] and diet [MD: -3.5, 95% CI (-5.6, -1.6)] compared to LAR. A higher rate of total complications [OR: 11, 95% CI (1.2, 140)] was observed in patients who received ESR compared to patients who received LAR. After excluding perforation from the total complication category, the difference of complication between ESR and LAR disappeared [OR: 0.87, 95% CI (0.22, 2.3)]. The recurrence rate [OR: 1.3, 95% CI (0.40, 4.5)] and disease-free survival [hazard ratio: 1.26, 95% CI (0.60, 2.63)] showed no significant difference between ESR and LAR. ESR was associated with better or equivalent perioperative and long-term outcomes compared to ONR, except for positive margin. A subgroup analysis (<2 and 2–5 cm) showed no significantly different results among these three procedures either.

Conclusion

ESR was shown to be a safe and efficient alternative procedure to both LAR and ONR for gGISTs less than 2 cm and within 2–5 cm, respectively, without worsening the oncologic outcomes. However, preoperative assessment of tumor site is of importance for the determination of procedures regarding the increased incidence of a positive margin related to ESR.

Endoscopic Resection of Gastrointestinal Stromal Tumor: Is It Safe?

Recently, results from clinical studies of endoscopic resection of gastrointestinal stromal tumor (GIST) in the stomach are being reported. This procedure has several advantages, such as the provision of a definite diagnosis and therapeutic plan, avoidance of frequent follow-up examination, and reduction of patients’ anxiety. However, several concerns also exist such as a limited number of studies, low R0 resection rate, and relatively shorter follow-up period compared with surgical resection. Nevertheless, it is encouraging that most of the post-procedural complications have been treated with conservative management and that some of the patients did not show recurrence of the tumor during long-term follow-up. The selection of suitable cases and the experience of the endoscopists are the most important factors for successful endoscopic resection of gastric GIST. Development of novel procedures as well as collaboration with laparoscopic surgeons are currently in progress.

Endoscopic or laparoscopic resection for small gastrointestinal stromal tumors: a cumulative meta-analysis

BACKGROUND

Despite the recent large number of studies comparing endoscopic and laparoscopic resection for small gastrointestinal stromal tumors (GISTs) (diameter ≤ 5 cm), the results remain conflicting. The objective of this work was to perform a cumulative meta-analysis to assess the advantages and disadvantages of endoscopic resection vs. laparoscopic resection.

METHODS

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched medical databases up to January 2020. Meta-analytical random or fixed effects models were used in pooled analyses. Meta-regression, cumulative meta-analyses, and subgroup analyses were performed to improve the accuracy of the conclusion. Sensitivity analyses were applied to assess the robustness of the results.

RESULTS

A total of 12 cohort studies with 1383 participants comparing endoscopic resection and laparoscopic resection were identified, while three cohort studies with 167 participants comparing endoscopic resection and laparoscopic and endoscopic cooperative surgery were found. We found that endoscopic resection had shorter operation times (weighted mean difference [WMD] = -27.1 min, 95% confidence interval [CI]: -40.8 min to -13.4 min) and lengths of hospital stay (WMD = -1.43 d, 95% CI: -2.31 d to -0.56 d) than did laparoscopic resection. The results were stable and reliable. There were no significant differences in terms of blood loss, hospitalization costs, incidence of complications or recurrence rates. For tumor sizes 2 - 5 cm, endoscopic resection increased the risk of positive margins (relative risk [RR] = 5.78, 95% CI: 1.31 - 25.46). Although operation times for endoscopic resection were shorter than those of laparoscopic and endoscopic cooperative surgery (WMD = -41.03 min, 95% CI: -59.53 min to -22.54 min), there was a higher incidence of complications (RR = 4.03, 95% CI: 1.57 - 10.34).

CONCLUSIONS

In general, endoscopic resection is an alternative method for gastric GISTs ≤ 5 cm. Laparoscopic and endoscopic cooperative surgery may work well in combination. Further randomized controlled trials are recommended to validate or update these results.

Comparison of endoscopic versus laparoscopic resection for gastric gastrointestinal stromal tumors: A preliminary meta-analysis

BACKGROUND AND AIM

For localized disease, complete surgical resection is regarded as the "gold standard" therapeutic modality. With the rapid development of endoscopic techniques, endoscopic resection (ESR) has been confirmed as an efficient and safe alternative for the treatment of gastrointestinal stromal tumors (GISTs) in the stomach. Nevertheless, the management of gastric GISTs remains poorly defined. The purpose of this study is to evaluate the security and effectiveness of ESR with laparoscopic resection (LAR) for gastric GISTs.

METHODS

A literature search of online databases was conducted to identify relevant comparative studies of ESR and LAR procedures for gastric GISTs published before April 10, 2020. The cumulative data analysis was also performed utilizing the software STATA.

RESULTS

In total, 10 studies involving 1165 patients met the inclusion criteria for analysis (651 for ESR and 514 for LAR). From the results of meta-analysis, patients who underwent ESR experienced decreased operative time (P = 0.000), less intraoperative blood loss (P = 0.002), earlier time to diet (P = 0.000), shorter hospital stay (P = 0.000), and lower total charges (P = 0.000) compared with LAR. Moreover, there were no significant differences between these two approaches concerning tumor rupture, conversion rate to other procedure, complete resection rate, postoperative complication rate, recurrence rate, and disease-free survival.

CONCLUSIONS

Endoscopic resection, as an effective alternative treatment strategy with satisfactory outcomes, is acceptable for selective patients with gastric GISTs compared with LAR. Further well-designed randomized controlled trials with large samples are warranted to corroborate our observations.

Factors Associated with Operation Time of Laparoscopic Gastric Wedge Resection for Gastric Subepithelial Tumors

PURPOSE

Gastric subepithelial tumor (GST) is a disease entity that includes all gastric subepithelial lesions. The oncologically safe surgical technique is complete resection with adequate resection margins. Most of the studies about laparoscopic gastric wedge rsection (LGWR) in GST focus on oncologic curability or surgical effectiveness. However, studies on the factors associated with the operation time are rare. Therefore, this study was conducted to analyze and compare the factors associated with the operation time of LGWR.

METHODS

From 2010 to 2019, 145 consecutive patients undergoing LGWR were reviewed retrospectively. Clinical characteristics of GST and operation time were analyzed and compared.

RESULTS

A total of 145 patients was enrolled and reviewed. There were 59 males (40.7%) and 86 females (59.3%) with a mean age of 53.6 years and mean body mass index (BMI) of 23.9 kg/m2. Mean tumor size was 2.9 cm and mean operation time was 66.0 minutes. In statistically, the mean operation time showed significant association with tumor size, BMI, longitudinal tumor location and tumor location between lesser and greater curvature. In multivariate analysis, tumor size, BMI and longitudinal classification of tumor location are statistically significant.

CONCLUSION

A shorter operation time is expected when there is a small tumor, low BMI and mid portion of the stomach GST. Preoperative evaluation for tumor size and body weight is important. In patients with large GST, obesity and both end stomach GST, we think that pre-operative preparation for long operation time should be considered.

Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract

BACKGROUND/AIMS

Endoscopic treatment (ET) has been applied for decades to treat subepithelial tumors, including gastrointestinal stromal tumors (GISTs). However, the efficacy of ET remains debatable. In this study, we evaluated the efficacy and safety of ET for GISTs in the upper gastrointestinal tract.

METHODS

This retrospective single-center study included 97 patients who underwent ET. All patients were enrolled from July 2014 to July 2018. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time, total cost, and follow-up were investigated and analyzed.

RESULTS

Our study achieved 100% en bloc resection and 77.4% (72/93) R0 resection. The most common location was the fundus with a mean tumor size of 2.1±1.43 cm. The mean age, procedure time, hospital stay, and cost were 59.7±11.29 years, 64.7±35.23 minutes, 6.8 days, and 5,337 dollars, respectively. According to National Institutes of Health classification, 63 (64.9%), 26 (26.8%), 5 (5.2%), and 3 (3.1%) patients belonged to the very low, low, intermediate, and high risk classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 21.3±13.0 months showed no recurrence or metastasis.

CONCLUSION

ET is effective and safe for curative removal of GISTs in the upper gastrointestinal tract, and it can be a treatment of choice for patients with no metastasis.

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.

Laparoscopic Treatment of Gastric Subepithelial Tumor: Finding Ways to Manage with Shorter Hospitalization Days

Purpose

The standard treatment for gastric subepithelial tumor (SET) is surgical resection, which is primarily performed via laparoscopy. The aims of this study were firstly to evaluate factors influencing morbidity and hospitalization after treatment of gastric SET, and secondly, to figure out the factors how to make shorter hospitalization with equal safety.

Methods

We retrospectively enrolled 229 consecutive patients who underwent laparoscopic gastric wedge resection (LGWR) for gastric SET between August 2003 and December 2015. Patients were divided into two groups: the 3 days or less hospitalization group (N=82, group A) and the greater than 3 days hospitalization group (N=147, group B).

Results

Median tumor size was 3.0 cm (range, 0.2~13.0 cm) and mean postoperative hospitalization was 4.27±2.15 days. There were 6 complications (2.6%), with no cases of mortality. In group A, tumors were smaller (3.0±1.1 cm vs. 3.6±1.9 cm, p<0.01) and more likely to be located on the greater curvature (28% vs. 15%, p<0.01) compared with group B. The tumor growth pattern (exophytic tumor: 72% in group A vs. 65% in group B, p=0.25) was not different between the two groups. Multivariate analysis showed that tumor size larger than 5 cm and posterior wall tumor location were risk factors for longer hospital stay.

Conclusion

We could reduce the hospitalization of patients with gastric SET less than 5cm sized and located on other than the posterior wall within 3days. Those patients could be a candidate for day surgery.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Clinical Overview of GIST and Its Latest Management by Endoscopic Resection in Upper GI: A Literature Review

AIMS

To review the clinical presentation, diagnosis, assessment of risk of malignancy, and recent advances in management (mainly focusing on the role of endoscopic resection) of gastrointestinal stromal tumors (GISTs) in upper GI.

METHOD

We searched Embase, Web of science, and PubMed databases from 1993 to 2018 by using the following keywords: "gastrointestinal stromal tumors," "GIST," "treatment," and "diagnosis." Additional papers were searched manually from references of the related articles.

FINDINGS

The improvement of endoscopic techniques in treating upper gastrointestinal subepithelial tumors especially gastrointestinal tumors has reduced the need for invasive surgery in patients unfit for surgery. Many studies have concluded that modified endoscopic treatments are effective and safe. These treatments permit minimal tissue resection, better dissection control, and high rates of en bloc resection with an acceptable rate of complications.

Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor

BACKGROUND AND AIM

A retrospective study was conducted to compare two resection methods, namely, endoscopic resection (ER) procedures (endoscopic submucosal dissection [ESD], endoscopic muscularis dissection [EMD], and endoscopic full-thickness resection [EFTR]) and laparoscopic resections (LR) (laparoscopic endoscopic cooperative surgery [LECS] and laparoscopic wedge resection).

METHODS

Seventy-three patients who underwent ER (N = 33: ESD, N = 4; EMD, N = 15; EFTR, N = 14) or LR (N = 39: LECS, N = 16; wedge resection, N = 23) for gastric submucosal tumor (G-SMT) smaller than 50 mm were included in this study. Patient/tumor characteristics and intra/postoperative factors were compared between the ER and LR groups.

RESULTS

The ER group had a significantly higher percentage of intraluminal growing type of tumor (100% vs 41%) and smaller tumor size (23 vs 33 mm) than the LR group. The ER group had a significantly shorter operative time (93 vs 145 min) and less blood loss (13 vs 30 mL) than the LR group. In the ER group, three patients who had tumors located on the anterior wall of the stomach required laparoscopic closure after EFTR because of difficulty in endoscopic closure of the gastric-wall defect. Postoperative complication rates and duration of postoperative hospital stays did not differ between the two groups.

CONCLUSIONS

ER may be technically feasible, safe, less invasive, and oncologically appropriate options for selected patients with the intraluminal growing type of G-SMT smaller than 30 mm. EFTR may be more reasonable alternatives to LR in selected patients with a small G-SMT located on the lesser curvature side.