Laparoscopic excision of a benign gastric tumor

Optimizing surgical and imatinib therapy for the treatment of gastrointestinal stromal tumors

INTRODUCTION

The discovery of activating KIT and PDGFRα mutations in gastrointestinal stromal tumors (GISTs) represented a milestone as it allowed clinicians to use tyrosine kinase inhibitors, like imatinib, to treat this sarcoma. Although surgery remains the only potentially curative treatment, patients who undergo complete resection may still experience local recurrence or distant metastases. Therapeutic strategies that combine surgical resection and adjuvant imatinib may represent the best treatment to maximize patient outcomes. In addition to the use of imatinib in the adjuvant and metastatic settings, neoadjuvant imatinib, employed as a cytoreductive therapy, can decrease tumor volume, increase the probability of complete resection, and may reduce surgery-related morbidities. Thus, selected patients with metastatic disease may be treated with a combination of preoperative imatinib and metastasectomy. However, it is critical that patients with GIST be evaluated by a multidisciplinary team to coordinate surgery and targeted therapy in order to maximize clinical outcomes.

DISCUSSION

Following a systematic literature review, we describe the presentation, diagnosis, and treatment of GIST, with a discussion of the risk assessment for imatinib therapy. The application of surgical options, combined with adjuvant/neoadjuvant or perioperative imatinib, and their potential impact on survival for patients with primary, recurrent, or metastatic GIST are discussed.

Tailored-approach of laparoscopic wedge resection for treatment of submucosal tumor near the esophagogastric junction

BACKGROUND

Laparoscopic wedge resection (LWR) of the stomach cannot easily be applied to tumors that are located near the esophagogastric junction (EGJ). To define the tailored approach for this type of tumors, we evaluated our laparoscopic surgical technique and clinical outcomes.

METHODS

We successfully performed 10 LWRs for patients with submucosal tumor (SMT) located 3 cm or less from the esophagogastric junction. A presumptive diagnosis of gastrointestinal stromal tumor (GIST) was made in all the cases, based on endoscopic and radiologic examinations. The patient demographics, perioperative parameters and outcomes of 10 patients were assessed.

RESULTS

Neither intraoperative complications nor conversion to open surgery was required, and we were able to perform complete tumor excision with negative surgical margins for all the patients. The laparoscopic approaches of resection included the transgastric method (n = 5) and the exogastric method (n = 5). The mean operation time was 92.5 minutes (range 60-125 minutes). No blood transfusion was given for all cases in the perioperative period. The patients' oral intake was restored on the third postoperative day. The hospital stay ranged from three to seven days (mean: 4.9 days). Pathologic analysis of the resected specimens showed six GISTs, three leiomyomas, and one lipoma.

CONCLUSIONS

Laparoscopic resection of gastric SMTs located near the EGJ is a feasible and safe procedure. The laparoscopic approaches to this area should be tailored, based on the location, size and expanding pattern of the tumor.

Laparoscopic resection of gastric gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are neoplasms with low malignant potential. They occur most commonly in the stomach, where they are amenable to laparoscopic resection.

METHODS

A case note review of all patients undergoing laparoscopic resection of a presumed gastric GIST at the Norfolk and Norwich University Hospital, United Kingdom, was conducted.

RESULTS

Since September 1995, 30 patients have undergone this procedure. The patients had a mean age of 64.2 years (range, 31-87 years) and a mean weight of 74.1 kg (range, 44-104 kg). A presumptive diagnosis of GIST was made in all the cases based on the endoscopic and radiologic appearance of the lesion. Laparoscopic resection was completed successfully in 23 patients with a mean operating time of 73.8 min (range, 26-160 min). Seven procedures were converted to open surgery: three because the tumor was deemed too large for laparoscopic resection, two because the tumor could not be identified, one because of dense peritoneal adhesions, and one because of bleeding. The mean estimated blood loss was 196 ml (range, 0-1,000 ml), and the mean hospital stay was 5 days (ranges, 1-11 days). Pathologic analysis of the resected specimens showed 22 GISTs, 3 inflammatory fibroids, 2 submucosal lipomas, 1 submucosal varix, and 1 nest of heterotopic pancreatic tissue. D: uring a median follow-up period of 18 months (range, 2-101 months) there have been two cases of recurrence. In both cases, the tumor was catagorized as high risk for aggressive behavior after primary resection.

CONCLUSION

Stapled laparoscopic resection is a safe and effective treatment option for nonmetastatic primary gastric GIST.

Completely laparoscopic resection of a rare pyloric tumor with laparoscopically sutured gastroduodenostomy

We report the case of a 31-year-old woman who presented with epigastric pain and weight loss. Esophagogastroduodenoscopy revealed a submucosal mass in the distal antrum and pylorus. Endoscopic biopsy of the mass was nondiagnostic. A CT scan confirmed a 3.0-cm mass in the posterior wall of the distal antrum. She underwent laparoscopic resection of the distal antrum and pylorus with end-to-end gastroduodenostomy. Pathologic examination showed an adenomyoma of the antrum and pylorus. Her postoperative course was uncomplicated, and she continues to do well 38 months postoperatively. Gastric adenomyoma is a rare, benign intramural tumor of the antrum and pylorus. Fewer than 40 cases have been described in the literature. The lesions are generally within 4 cm of the pylorus. Histologically, they are characterized by ductal structures lined by cuboidal to columnar epithelium surrounded by smooth muscle bundles and, occasionally, Brunner's-type glands and heterotopic pancreas. Treatment is by resection, and recurrence has not been reported. Laparoscopic resection of portions of the stomach has been reported. Side-to-side gastrojejunostomies (Billroth II) performed laparoscopically have been reported. This is the first report in the English-language literature of a completely laparoscopically performed sutured gastroduodenostomy. Technical details of the procedure and adenomyomas are discussed.

Laparoscopic local resection for benign nonepithelial gastric tumors

After experience in laparoscopic cholecystectomy and improvement of laparoscopic instruments, we attempted laparoscopic resection of benign nonepithelial gastric tumors using Endo-GIA. We achieved successful results with this procedure in 2 cases. There were no intra- and postoperative complications. For both patients there was no recurrence during the follow-up period (3.3 and 1.5 years). The important points of this approach are confirmation of the location of the tumor by both gastroendoscopy and laparoscopy, proper selection of the trocar site for insertion of the Endo-GIA, and secure grasping and lifting of the gastric wall, including of the tumor. We conclude that this procedure is technically feasible, safe and useful for benign nonepithelial gastric tumors.

Benign gastric tumors. Minimally invasive approach

BACKGROUNDS

Historically, major subsets of benign gastric tumors requiring surgical excision have required open laparotomy.

METHODS

We have used laparoscopy to resect lesions in eight such patients. Lesion locations were gastroesophageal junction (one), gastric body (three), and pylorus (four). Four lesions were successfully located by instrument palpation. Six lesions were excised using gastrotomy, eversion of tumor, and resection, followed by stapled gastrotomy closure. The lesion at the posterior GE junction was evaluated through a gastrotomy and resected transgastrically. The two pyloric lesions were removed by laparoscopic distal gastrectomy and gastrojejunostomy.

RESULTS

Procedure times were 55-210 min; oral feeding was instituted on postoperative day 1-5; patients were discharged 1-6 days postoperatively.

CONCLUSIONS

Benign tumors of the stomach may be approached and resected laparoscopically; a transgastric, intra-organ approach is safe and efficient; laparoscopic distal gastrectomy is safe and technically feasible; patients have a shorter recovery interval and shorter postoperative hospital stay. Cautious progress in this field is recommended.