Laparoscopic wedge resection of gastric submucosal tumors

Deciding laparoscopic approaches for wedge resection in gastric submucosal tumors: a suggestive flow chart using three major determinants

BACKGROUND

The aim of this study was to determine the optimal laparoscopic approach for wedge resection of gastric submucosal tumors (SMTs) based on tumor characteristics.

STUDY DESIGN

Between March 2008 and June 2010, 57 patients underwent laparoscopic wedge resection for suspected gastric SMT. Of these 57 patients, 40 underwent exogastric wedge resection (EWR), with the remaining undergoing transgastric wedge resection (TWR).

RESULTS

Fifty-seven consecutive patients undergoing surgical resection of gastric SMT were reviewed, with 40 and 17 tumors treated with EWR and TWR, respectively. The average tumor size was significantly greater in the EWR group (p = 0.004). A circular tumor location was a decisive factor for selecting the laparoscopic approach (p = 0.011). Tumors presenting with exophytic growths were predominantly found in the EWR group, and those with endophytic growth were dominant in the TWR group (p < 0.001). A multivariate analysis to determine the independent factors influencing the choice for EWR or TWR revealed that tumor size (95% CI, 1.1 to 20.0; p = 0.033) and circular location of tumor (95% CI, 1.4 to 106.9; p = 0.021) were statistically significant factors.

CONCLUSIONS

These data suggest a strategy for selection of appropriate laparoscopic wedge resection strategies based on tumor characteristics. This decision is affected by tumor size, location, and growth pattern.

[Surgical treatment of gastrointestinal stromal tumours. Analysis of our experience]

INTRODUCTION

Gastrointestinal stromal tumours (GIST) make up 2% of gastrointestinal tumours. Surgery is the only treatment method in localised cases. The laparoscopic approach has increased over the last few years. We present our experience in the treatment of GIST.

MATERIAL AND METHODS

A total of 40 patients with 45 GIST had been subjected to surgical treatment between 1997 and 2010. Data was retrospectively collected on, demographic characteristics, location and tumour biology, diagnosis, type of surgery and the results of that surgery.

RESULTS

A total of 24 males and 16 women, with a mean age of 66.7 years, were treated. The location was gastric in 24 cases (60%), small intestine in 13 (32.5%), colon in 2 (5%) and oesophagus in 1 case (2.5%). Laparotomy was performed in 27 cases, 12 by laparoscopy (1 thoracoscopy), and 1 endoscopic sigmoid tumour resection. Four cases (10%), all after laparotomy, had recurred after a median follow-up of 31 months (2-120), and 2 patients of the laparotomy group died due to their cancer. After a univariate analysis, the prognostic factors for a laparoscopic recurrence were: tumour size (P=.0001), mitosis number (P=.001), being a locally advanced tumour (P=.01) and a ruptured tumour (P=.002). Only size remained as a prognostic factor after the multivariate analysis (P=.029; RR 1.363; 95% CI; 1.033-1.799). The presence of a locally advanced tumour was shown to be significant in the univariate analysis, while there were no significant factors after the multivariate analysis.

CONCLUSIONS

Correct preoperative staging is essential for deciding which surgical approach to employ.

Laparoscopic sleeve gastrectomy for a large gastrointestinal stromal tumor

The biological behavior of gastrointestinal stromal tumor (GIST) makes resection of the tumor with adequate margins, a mode of curative treatment. GIST does not have lymphatic permeation. Hence, the goal of therapy is complete resection of visible and microscopic disease, which can be achieved by adequate tumor-free margins. Laparoscopic management of large GIST tumors is discouraged because of the fear of spillage of the tumor or rupture of the tumor capsule while handling a large tumor and thus causing metastasis.

Single-Incision Laparoscopic Surgery for Partial Gastrectomy in Patients with a Gastric Submucosal Tumor

Since 2010, we have used single-incision laparoscopic surgery (SILS) for patients with a gastric submucosal tumor, as a less invasive alternative to conventional laparoscopy. From September 2010 to January 2011, five patients underwent a local resection for a gastric submucosal tumor using a SILS™ port at Keio University Hospital. We performed partial gastrectomy via the SILS™ port using a 5 mm flexible endoscope, a vessel sealing system, and a stapling device. There were no major intraoperative complications, conversion to laparotomy, or cases of tumor rapture. The average operative time was 89 (range, 72–129) minutes with minimal blood loss. Pathological examination revealed four cases of gastrointestinal stromal tumor and one case of inflammatory fibrosis caused by nonspecific inflammation. Although we examined only a small number of cases in this study, the results suggested that SILS gastrectomy can be performed safely and effectively for gastrointestinal stromal tumor.

Laparoscopic wedge resection for gastric submucosal tumors: a size-location matched case-control study

BACKGROUND

Laparoscopic local resection for gastric submucosal tumors (SMTs) has become accepted as a standard treatment because it offers less postoperative pain and faster recovery. However, until recently, the laparoscopic approach has been limited by tumor location and size. The aim of this study was to examine the efficacy and safety of laparoscopic wedge resection (LWR) in comparison to open wedge resection (OWR), based on tumor size and location.

STUDY DESIGN

In this case-control study, 50 patients who received LWR for gastric SMTs were carefully matched by size and location of the tumor; 50 patients underwent OWR during the same period. Patient demographics, clinicopathologic characteristics, and postoperative courses were compared.

RESULTS

After matching for tumor size and location, the LWR group showed more favorable results than the OWR group in terms of the starting time of soft meals (mean days, 3.4 vs 4.8, respectively; p < 0.001) and length of hospital stay (mean days, 5.7 vs 7.8, respectively; p < 0.001), but not in terms of operative time (mean minutes, 153 vs 127, respectively; p < 0.05). The rate of postoperative complications did not differ between the groups.

CONCLUSIONS

This case-control study suggests that laparoscopic surgery can be safely performed for gastric SMTs and results in a better postoperative recovery, regardless of tumor size or location.

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.

[Controversies in the surgical treatment of primary gastrointestinal stromal tumours (GIST)]

It is estimated that 50% of GIST are located at the time of their diagnosis. A complete surgical resection can be performed in up to 95% of these cases, making this the most important prognostic factor. This surgery must fulfil a series of technical requirements so as to be really effective, as it has to be R0, with no tumour rupture, with preservation of the pseudo-capsule, etc. Although the majority of GIST are gastric, their location in other anatomical areas, such as the oesophagus, duodenum or rectum, require the surgeon to use more complex techniques. Laparoscopy is increasingly used; however, we must avoid its use, due to there being few experienced groups or if there are large tumours. The use of neoadjuvant therapy has revived great interest by allowing to resection tumours that were once non-resectable or in very compromised anatomical locations, with less aggressive surgery. The use of pre-surgical biopsy is not exempt from serious risks, thus it should only be used for establishing a neoadjuvant treatment or if there are diagnostic doubts with other diseases in high risk patients.

Laparoscopic antrectomy for the treatment of type I gastric carcinoid tumors

BACKGROUND

While the optimal treatment for type I gastric carcinoid tumors remains controversial, there is evidence to suggest that in multifocal disease, antrectomy may not only control local disease but also may lead to enterochromaffin-like cell (ECL) hyperplasia regression compared to medical and endoscopic treatments.

MATERIALS AND METHODS

A single institution retrospective review of eight consecutive patients with multifocal type I gastric carcinoid tumor patients with no evidence of metastatic disease was performed from 2005 to 2006. All of these patients underwent laparoscopic antrectomy with Billroth II reconstruction. Patients' preoperative gastrin, chromogranin A levels, and biopsy and surgical specimen slides were compared with postoperative laboratory and biopsy slides. Pathology slides were reanalyzed by a blinded pathologist from our institution for evidence of tumor and ECL hyperplasia regression.

RESULTS

All patients tolerated the procedure well with no reoperations or mortalities. Six of eight patient complained of mild reflux which was treated medically. One of eight had a mild wound infection which resolved with a course of cephalexin. Gastrin levels significantly decreased (98.9%) in all patients (P = 0.001). Furthermore, chromogranin A levels also significantly decreased (81.4%). Eight of eight patients showed no evidence of carcinoid tumor after surgery at mean biopsy follow-up of 17 mo (range 2-35 mo), however there was ECL hyperplasia after resection. Four of eight patients (50%) showed regression of ECL hyperplasia on postop biopsy, while the remaining four of eight showed no evidence of regression.

CONCLUSIONS

This is the largest case series to investigate the surgical, clinical, and histologic outcomes of laparoscopic antrectomy in type I gastric carcinoid. Our data suggest that laparoscopic antrectomy is a safe and minimally invasive approach to treat nonmetastatic type I gastric carcinoid. All patients had no evidence of gross or microscopic disease at follow-up biopsy and almost half had regression of ECL hyperplasia at follow-up suggesting that antrectomy may be sufficient to prevent tumor recurrence. However, continued regular endoscopic surveillance and medical follow-up of patients with ECL hyperplasia are recommended.

Minimally invasive resection of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are rare neoplasms. The advent of electron microscopy and immunohistochemistry has led to the realization that these tumors originate from a pleuropotential cell known as the interstitial cell of Cajal (ICC). The morphologic features demonstrated as most predictive of recurrence or metastases are tumor size and mitotic rate. There is oncologic justification for minimally invasive resection techniques with gross margins for GISTs. Minimally invasive resection provides advantages to patients in terms of morbidity and recovery. A variety of endoscopic, laparoscopic, and hybrid techniques are described for surgically excising GISTs in different anatomic locations.

Application of laparoscopic techniques for resection of individual gastric submucosal tumors

Large gastric submucosal tumors should be excised to prevent ischemic mucosal ulceration of the overlying surface and central necrosis of the neoplasm, which may in turn lead to massive hemorrhage. Large tumors near the esophagocardiac junction or on the posterior wall are usually resected by an open procedure. We describe 2 cases of upper gastrointestinal tract bleeding owing to huge submucosal tumors in the posterior gastric high body treated by laparoscopic resection of the gastric tumors. These 2 patients recovered smoothly without major or minor complications. We emphasize that design of specific strategies for individual tumors is essential for the successful laparoscopic resection of tumors adjacent to the esophagocardiac junction and large tumors on the posterior wall.

Laparoscopic approach of gastric gastrointestinal stromal tumors (GISTs): is it still a courageous choice? Report of two cases

Gastrointestinal stromal tumors (GISTs) are a well-defined clinicopathologic and molecular tumor entity, representing the most common gastrointestinal mesenchymal neoplasm. Differential diagnosis between GIST and other mesenchymal malignancies is crucial, given the successful management using targeted therapy in metastatic GIST. The mainstay of treatment remains surgery, complete tumor resection being the most important independent prognostic factor. Videolaparoscopic approach is still controversial for the high risk of tumor rupture or bleeding. Here we report 2 cases of GIST surgically resected using a videolaparoscopic approach and discuss the efficacy of this technique in selected patients.

Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration

AIM: To evaluate the role of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) in the preoperative diagnosis of gastrointestinal stromal tumor (GIST).

METHODS: From September 2002 to June 2006, Fifty-three consecutive EUS-FNAs of GI tract subepithelial hypoechoic tumors with continuity to proper muscle layer suspected as GIST by standard EUS were evaluated prospectively. The reference standards for the final diagnosis were surgery (n = 31), or clinical follow-up (n = 22). Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared.

RESULTS: In 2 cases puncture was not performed because of anatomical problems. The collection rate of adequate specimens from the GI tract subepithelial hypoechoic tumor with continuity to proper muscle layer was 82% (42/51). The diagnostic rate for the tumor less than 2 cm, 2 to 4 cm, and 4 cm or more were 71% (15/21), 86% (18/21), and 100% (9/9), respectively. In 29 surgically resected cases, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EUS-FNA using immunohistochemical analysis of GIST were 100% (24/24), 80% (4/5), 96% (24/25), 100% (4/4), and 97% (28/29), respectively. No major complications were encountered.

CONCLUSION: EUS-FNA with immunohistochemical analysis is a safe and accurate method in the prethera-peutic diagnosis of GIST. It should be taken into consideration in decision making, especially in early diagnosis following minimal invasive surgery for GIST.

Laparoscopic wedge resection for gastric GIST: long-term follow-up results

AIM

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Recently, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST. However, no study has provided long-term follow up results of laparoscopic surgery for gastric GIST. The aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure.

MATERIALS AND METHODS

Between January 1998 and August 2005, 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients' clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively.

RESULTS

The mean age of patients was 59.7 years, and 12 patients were women. Twelve patients (47%) presented with epigastric pain. The mean tumor size was 4.2+/-2.1 cm, and most tumors were located in the upper stomach (52.2%). The mean operative time was 104.3 min. No case of open conversion, reoperation and operative mortality occurred in the present study. Most patients had very low and low risk (60.6%), while only two patients had high risk malignancy. During a median follow-up period of 61 months (range, 7-98 months), there have been no recurrences or metastases.

CONCLUSION

Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon.

Combining Imatinib with Surgery in Gastrointestinal Stromal Tumors: Rationale and Ongoing Trials

Gastrointestinal stromal tumor (GIST) has become a well-recognized pathologic entity defined by expression of the KIT protein and often associated with gain of function mutations of the c-KIT oncogene. Imatinib, a specific inhibitor of the aberrant KIT protein, is an approved, well-tolerated oral drug for the management of metastatic or inoperable GIST. Traditional radical surgery resection for locally advanced, recurrent, or metastatic GIST is associated with a poor outcome. The rationale for combining imatinib with surgery for GIST, either as an adjuvant agent in the situation of primary resection for patients at high risk or in the neoadjuvant setting for patients with locally advanced, recurrent, or metastatic disease, is compelling in the continuous effort to improve disease-free and overall survival. Several clinical trials are addressing these issues as well as timing of surgery, assessment of drug response, and the addition of surgical resection in the situation of focal progressive disease on imatinib. The results of these studies will be meaningful in future standard therapy consideration.

Operative indications for relatively small (2-5 cm) gastrointestinal stromal tumor of the stomach based on analysis of 60 operated cases

BACKGROUND

Removal of the primary lesion with a clear operative margin is the standard treatment for gastrointestinal stromal tumor (GIST) of the stomach. However, there are few reports on the operative indications for relatively small GIST.

METHODS

Clinicopathologic features and survival data of all 60 patients with GIST of the stomach treated at Keio University Hospital from 1993 to 2004 were analyzed. Laparoscopic wedge resection was used as the primary procedure for tumors between 2 to 5 cm. Tumors larger than 5 cm were resected by laparotomy or laparoscopy-assisted operation.

RESULTS

Thirty-five lesions (58.3%) were resected by laparoscopic wedge resection, 3 by laparoscopic operation with a small skin incision and 22 by conventional open procedures. The mean size of the tumors was 42.5 mm, with a range of 18 to 150 mm and a median value of 35.5 mm. All operative margins were clear, but 1 patient had liver metastases at the time of resection of the primary lesion. The median follow-up period was 53 months and the 5-year disease-free survival rate (DFS) was 96.1%. No local recurrence or distant metastasis was encountered in patients with tumors smaller than 4 cm. A statistically significant correlation was observed between tumor size and mitotic count in this cohort (P = .010). Tumors from the intermediate- (n = 14) and high-risk (n = 10) groups as classified by the Risk Assessment Classification showed significantly worse DFS than the low-risk and very low risk group (n = 35) (89.9% vs 100% in 5-year DFS, P = .045). Even among tumors smaller than 3 cm, 2 of 14 cases (14.3%) were classified into the intermediate-risk group.

CONCLUSIONS

Although a prospective randomized trial remains to be performed, this study provides additional evidence suggesting that the early removal of GIST, at 5 cm or less in size, provides better DFS than later removal of the tumor at a larger size.

Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are identified pathologically by the expression of KIT. The management of GISTs has been altered significantly by the development of imatinib mesylate, a tyrosine kinase inhibitor with activity against KIT and platelet-derived growth factor receptors. This article reviews the management of GISTs in the era of molecular therapies. The role of surgery alone or in combination with imatinib in the adjuvant and metastatic setting is discussed. GISTs resistant to imatinib are becoming a clinical challenge; this article discusses novel therapies under development.

Minimally invasive surgery for gastric carcinoid tumor

Minimally invasive laparoscopic wedge resection for gastric mucosal carcinoma and submucosal tumor was first performed in Keio University hospital in 1992. Since then, 172 gastric tumor patients, including four cases of carcinoid tumor, have been successfully treated at the Keio University hospital using this procedure. No local disease recurrence or distant metastases have been observed in follow-ups over as long as 10 years. Chronic atrophic gastritis patients with carcinoid tumors occurring secondary to hypergastrinemia are candidates for the minimally invasive surgery. With careful patient selection according to tumor size, depth of invasion, and histopathological findings of malignancy grade, endoscopic and laparoscopic therapy for these patients can be a safe, curative, and minimally invasive procedure.