Long-term outcome of laparoscopic wedge resection for gastric submucosal tumor compared with open wedge resection

Single-port intragastric wedge resection using the tunnel method: a novel surgical approach for treating endophytic gastric subepithelial tumors

BACKGROUND

Intragastric wedge resection is an effective method for treating endophytic gastric subepithelial tumors (SETs). However, retracting the stomach wall to the umbilicus is difficult in certain patients. In response, we developed a novel surgical technique for single-port intragastric wedge resection, which we termed the "tunnel method."

METHODS

A transumbilical incision is made, and a wound retractor is applied. After diagnostic laparoscopy, a gastrostomy is made on the greater curvature, lower body. Another small wound retractor is inserted into the gastrostomy, and extracted through the transumbilical incision, creating a tunnel from the gastrostomy site to the umbilicus. Articulating laparoscopic instruments are inserted via the tunnel, and intragastric wedge resection is performed. We collected and analyzed the clinicopathologic and operative data of patients who underwent intragastric wedge resection via the tunnel method.

RESULTS

Twenty-seven patients who underwent single-port intragastric wedge resection via the tunnel method in a single tertiary referral hospital were included in this study. The mean age of the patients was 54.6 ± 11.4 years, body mass index was 26.5 ± 3.4 kg/m2. Twenty-four (88.9%) patients had tumors located in the upper third of the stomach. The average operative time was 65.0 ± 24.2 min. None of the patients experienced Clavien-Dindo grade IIIa or higher postoperative complications. The average postoperative hospital stay length was 2.5 ± 0.8 days. Thirteen gastrointestinal stromal tumors, nine leiomyomas, and one neuroendocrine carcinoma, schwannoma, lipoma, spindle cell proliferative lesion, and fibrotic lesion were pathologically diagnosed. The average tumor size was 2.6 ± 1.3 cm. All cases had negative resection margins.

CONCLUSIONS

Single-port intragastric wedge resection by the tunnel method is a feasible and safe approach for treating endophytic gastric SETs.

Effect of endoscopic resection of gastrointestinal stromal tumors in the stomach under double-channel gastroscopy: A retrospective observational study

We aimed to investigate the safety and efficacy of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors (GISTs) under single-channel gastroscopy and double-channel gastroscopy. We identified 154 patients with GISTs of the stomach who underwent endoscopic resection and were retrospectively analyzed at our hospital between May 2016 and March 2020, including 49 patients by single-channel gastroscopy and 105 patients by double-channel gastroscopy. We observed the clinical efficacy, complications, and safety of endoscopic resection of gastric GISTs, and the data were evaluated retrospectively. All patients underwent endoscopic resection successfully, without conversion to open surgery. In the single-channel gastroscopy group, 7 patients had lesions in the gastric cardia, 17 in the gastric fundus, 20 in the gastric corpus, and 5 in the gastric antrum. In the double-channel gastroscopy group, 13 patients had lesions in the gastric cardia, 34 in the gastric fundus, 46 in the gastric body, 10 in the gastric antrum, 1 in the pylorus, and 1 in the gastric angular incisure. The double-channel gastroscopy group had a shorter operation time than the single-channel gastroscopy group (59.9 ± 34.9 minutes vs 74.8 ± 26.7 minutes; P = .009 and P < .01, respectively), while they also had a lower perforation rate than the single-channel gastroscopy group (34.3% vs 51.0%; P = .048 and P < .05, respectively). No residual or recurrent lesions were discovered in any patients by gastroscopy reexamination. Both single-channel gastroscopy and double-channel gastroscopy can provide safe, effective, feasible endoscopic resection. However, double-channel gastroscopy has some distinct advantages in endoscopic resection.

Endoscopic Removal of Gastrointestinal Stromal Tumors in the Stomach: A Single-Center Experience

BACKGROUND AND AIMS

Endoscopic removal of GISTs (gastrointestinal stromal tumors) is recently recognized, but less is known about its efficacy and safety. This study is aimed at assessing the feasibility, clinical efficacy, and safety of the endoscopic removal of gastric GISTs.

PATIENTS AND METHODS

Endoscopic removal (ER) of GISTs was performed in 134 patients at our hospital between January 2015 and January 2019. The clinical features, surgical outcomes, complications, pathological diagnosis, and risk classification were evaluated retrospectively.

RESULTS

ER was successful in 131 cases (98%), including 58 by ESD (endoscopic submucosal dissection), 43 by ESE (endoscopic submucosal excavation), 25 by EFTR (endoscopic full-thickness resection), and 5 by STER (submucosal tunneling endoscopic resection). In addition, GISTs of two cases were resected using LECS (laparoscopic and luminal endoscopic cooperative surgery) for the extraluminal and intraluminal growth pattern. The average tumor size was 1.89 ± 1.25 cm (range: 0.5-6.0 cm). Of these patients, 26 cases had a large tumor size (range: 2.0-6.0 cm), and endoscopic removal was successful in all of them. During the procedure, endoclips were used to close the perforation in all cases, without conversion to open surgery. The average length of hospital stay was 5.50 ± 2.15 days (range: 3-10 days). In the risk classification, 106 (79.7%) were of a very low risk, 25 (18.8%) of a low risk, and 2 (1.5%) of a moderate risk. The moderate-risk cases were treated with imatinib mesylate after ER. No recurrence or metastasis was observed during the follow-up period of 23 ± 8 months (range: 3-48 months).

CONCLUSIONS

The endoscopic treatment is feasible, effective, and safe for gastric GISTs, and individualized choice of approaches is recommended for GISTs.

Laparoscopic versus open wedge resection for gastrointestinal stromal tumors of the stomach: a meta-analysis

Introduction

With the rapid development of minimally invasive surgery, laparoscopic (LAP) wedge resection has become the first-choice treatment for primary gastrointestinal stromal tumors (GISTs) of the stomach.

Aim

To investigate the safety and feasibility of LAP wedge resection and the choice of surgical treatment for GISTs of the stomach through a meta-analysis and systematic review.

Material and methods

The literature was widely searched for comparative studies on open (OPEN) and LAP wedge resection for GISTs published before April 2017. The articles were selected after quality assessment.

Results

Ten reports met the inclusion criteria, with a total sample size of 485 cases. The operation time was similar between the 2 groups (weighted mean difference (WMD): 8.67 min, 95% confidence interval (CI): –8.60 to 25.94, p = 0.33). However, LAP resulted in less blood loss (WMD –32.20 ml, 95% CI: –56.15 to –8.26, p < 0.01), earlier time to flatus (WMD –1.48 days, 95% CI: –1.90 to –1.06, p < 0.01) and to an oral diet (WMD –1.50 days, 95% CI: –2.25 to –0.47, p < 0.01), shorter hospital stay (WMD –2.03 days, 95% CI: –2.68 to –1.38, p < 0.01), and a decreased overall complication rate (relative risk: 0.48, 95% CI: 0.25–0.89, p = 0.01) compared with OPEN. Moreover, long-term follow-up findings indicated no obvious difference between the 2 groups.

Conclusions

The use of LAP wedge resection for suitable cases is safe and feasible because it causes less blood loss and fewer overall complications and enables faster recovery.

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.

Laparoscopic Endoscopic Cooperative Surgery for Gastrointestinal Stromal Tumors

With the development of laparoscopy and digestive endoscopy, multiple laparoscopic and endoscopic cooperative surgeries (LECSs) for gastrointestinal stromal tumors have recently been developed. Classic LECS has been confirmed as a feasible and safe treatment procedure for gastrointestinal stromal tumors with regard to both short-term surgical and long-term oncological outcomes; however, classic LECS has the potential risk of gastric contents or tumor cells spilling into the abdominal cavity because the gastric wall has to be opened during the procedure. Various modified LECS techniques have aimed at further minimizing invasiveness, such as the full-thickness resection method using the nonexposure technique (combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique), nonexposed endoscopic wall-inversion surgery, and closed LECS. This review describes and summarizes the current LECS for gastrointestinal tumor.

Minimally Invasive Intragastric Approach to Gastroesophageal Junction Disease

BACKGROUND

A minimally invasive intragastric approach to the gastroesophageal junction (GEJ) allows resection of intramural disease while avoiding disruption of the lower esophageal sphincter and vagus nerves. Few surgeons use this approach; thus little is known regarding its indications, feasibility, technical aspects, complication profile, and long-term outcomes. This study reviewed the experience with this technique.

METHODS

A retrospective review was performed of a prospectively maintained, Institutional Review Board-approved database covering the period from January 1, 2005 to August 1, 2017. Indications, operative details, postoperative complications, and outcomes were assessed.

RESULTS

There were 12 patients identified. The mean age of these patients was 51.9 years. The indications for resection included 10 symptomatic leiomyomas, one gastrointestinal stromal tumor, and three cancers of the GEJ. Mean and median length of stay were 4.9 and 2.5 days, respectively. There were two postoperative esophageal leaks managed with laparoscopic repair. Of the 3 patients with cancer, 2 underwent an R0 resection, whereas 1 patient underwent an R1 resection. There were no other complications or recurrences. Mean follow-up was 6.0 years (range, 0.5 to 12.6 years); no patients had stricture or symptomatic gastroesophageal reflux on long term follow-up.

CONCLUSIONS

Resection of selected intramural GEJ disorders through a minimally invasive transgastric approach can be performed safely with acceptable morbidity and good long-term results. The approach allows preservation of the lower esophageal sphincter and vagus nerves, a potential advantage compared with other surgical alternatives to resection in this region.

Meta-analysis of laparoscopic vs. open resection of gastric gastrointestinal stromal tumors

Background

This meta-analysis compared laparoscopic surgery (LAP) and open resection (OPEN) for the treatment of gastric gastrointestinal stromal tumors (GISTs) with regard to feasibility and safety.

Methods

We searched PubMed, Embase, and Web of Science for studies published before March 2016 comparing the LAP and OPEN procedures for GISTs. RevMan 5.1 software was used for the meta-analysis.

Results

In total, 28 studies met the inclusion criteria for the meta-analysis. The mean tumor sizes in the OPEN and LAP groups were 4.54 and 5.67 cm. Compared with the OPEN patients, the LAP patients experienced shorter surgical times (P = 0.05), less blood loss (P<0.01), earlier time to flatus (P<0.01) and an oral diet (P<0.01), and shorter hospital stays (P<0.01). The LAP patients also exhibited a decrease in overall complications (P<0.01). In addition, regarding the subgroup of larger GISTs (>5 cm), the present study did not report significant differences in operation time (P = 0.93), postoperative complications (P = 0.30), or recurrence rate (P = 0.61) between the two groups, though LAP was associated with favorable results regarding blood loss (P = 0.03) and hospital stay (P<0.01).

Conclusions

Compared with the OPEN procedure, the LAP procedure is associated with preferable short-term postoperative outcomes and does not compromise long-term oncological outcomes. For gastric GISTs >5 cm, no significant difference was detected between LAP and OPEN if patient selection and intraoperative decisions were carefully considered.

Long-term outcomes of endoscopic resection of gastric GISTs

OBJECTIVE

Although the endoscopic treatment of gastric stromal tumors is a recently accepted therapy, the long-term outcomes of this approach remain unknown. The aims of this study were to assess the long-term effectiveness and safety of endoscopic resection for gastric GISTs.

METHODS

A total of 60 consecutive patients undergoing endoscopic resection of gastric GISTs were enrolled in a retrospective single-center study. Clinical data, perioperative complications, histopathologic characteristics of the tumors, and long-term outcomes were recorded.

RESULTS

Sixty patients successfully underwent complete resection of lesions, including 25 cases of endoscopic submucosal dissection (ESD) and 35 cases of endoscopic full-thickness resection (EFTR), with an average tumor size of 1.76 ± 1.55 cm (range 0.5-7.6 cm). The average operation time was 43.97 ± 26.95 min (range 11.7-138.9 min). Two cases were observed with an intraoperative hemorrhage of 200 mL, which were successfully managed by hemostatic forceps. Perforations of 2-11 mm of ESD occurred in four cases (4/25) and were well closed with endoclips, with no conversions to surgical operation. Mucosal laceration of esophagus occurred in 1 case, when a large tumor was removed. The average length of hospitalization was 6.50 ± 3.06 days (range 3-21 days). Out of a total of 60 patients, 44 (73.3%) were at very low risk, 10 (16.7%) were at low risk, 5 (8.3%) were at intermediate risk, and 1 (1.7%) was at high risk. All patients were followed-up for 36.15 ± 12.92 months (range 14-73 months). Primary tumor recurrence occurred in 1 patient who underwent a second operation after 32 months, and no other cases were observed to have either tumor recurrence or metastasis.

CONCLUSIONS

For long-term outcomes, endoscopic resection of ESD or EFTR is a safe and effective approach for removing gastric stromal tumors (<5 cm), and it can be a resection technique for them with no metastasis.

Laparoscopic surgery versus open resection in patients with gastrointestinal stromal tumors: An updated systematic review and meta-analysis

PURPOSES

The contemporary surgery has reported the safety of laparoscopic surgery (LAP) for patients with gastrointestinal stromal tumors (GISTs). However, its use is still debated due to suspicion of the oncologic equivalence to open surgery (OPEN). We conducted a systematic review and meta-analysis of updated original articles to investigate the short- and long-term clinical outcomes of LAP compared with OPEN for GISTs.

METHODS

A systematic search was performed in PubMed, Embase, Web of Science, Cochrane Library and CNKI. Comparative studies of laparoscopic and open surgery for GISTs were published before November 2016. The Newcastle-Ottawa scale was utilized to conduct quality assessment. The Review Manager (RevMan) software version 5.0 was used for meta-analysis.

RESULTS

Twenty-four studies involving 2140 patients were included for the meta-analysis. The meta-analysis results showed that, compared with OPEN, LAP indicated potentially favorable outcomes in terms of operative time (WMD, -30.71; 95% CI, -58.48 to -2.95; P = 0.03); intraoperative blood loss (WMD, -60.90; 95% CI, -91.53 to -30.28; P < 0.0001); time to flatus (WMD, -1.10; 95% CI, -1.41 to -0.79; P < 0.00001); time to oral intake (WMD, -1.25; 95% CI, -1.64 to -0.86; P < 0.00001); length of hospital stay (WMD, -3.42; 95% CI, -4.37 to -2.46; P < 0.00001); overall complications (OR, 0.38; 95% CI, 0.27 to 0.54; P < 0.00001); and recurrence (OR, 0.45; 95% CI, 0.30 to 0.66; P < 0.0001).

CONCLUSIONS

Laparoscopic surgery is safe and feasible for the treatment of GISTs including less operative time and intraoperative blood loss, earlier postoperative recovery, shorter hospital stay, and lower rate of overall complications and recurrence.

Laparoscopic and endoscopic cooperative surgery for gastrointestinal tumor

With technological progress of endoscopic submucosal dissection (ESD) in the last decade, several laparoscopic and endoscopic cooperative surgeries (LECS) for gastrointestinal tumor have recently been developed. LECS is definitely favorable to the minimization of surgical margin, which leads to functional and anatomical preservation of gastrointestinal tract. LECS for gastrointestinal tumor is mainly sorted by two categories: exposure procedures and non-exposure procedures between endoluminal and extraluminal spaces. Exposure procedures have the potential risk of gastric contents or tumor cells spilling out over the abdominal cavity, because the stomach wall has to be perforated intentionally during the procedure. In order to avoid the potential these risks, non-exposure procedures have been developed. Currently, the LECS concept has rapidly permeated for treatment of gastrointestinal tumor due to its certainty and safety, although there is still room for improvement to lessen its technical difficulty. This review describes the current LECS for gastrointestinal tumor based on the several articles.

Laparoscopic versus open wedge resection for gastrointestinal stromal tumors of the stomach: a single-center 8-year retrospective cohort study of 156 patients with long-term follow-up

BACKGROUND

The aim of this study was to compared laparoscopic (LWR) and open wedge resection (OWR) for the treatment of gastric gastrointestinal stromal tumors (GISTs).

METHODS

The data of 156 consecutive GISTs patients underwent LWR or OWR between January 2006 and December 2013 were collected retrospectively. The surgical outcomes and the long-term survival rates were compared. Besides, a rapid systematic review and meta-analysis were conducted.

RESULTS

Clinicopathological characteristics of the patients were similar between the two groups. The LWR group was associated with less intraoperative blood loss (67.3 vs. 142.7 ml, P < 0.001), earlier postoperative flatus (2.3 vs. 3.2 days, P < 0.001), earlier oral intake (3.2 vs. 4.1 days, P < 0.001) and shorter postoperative hospital stay (6.0 vs. 8.0 days, P = 0.001). The incidence of postoperative complications was lower in LWR group but did not reach statistical significance (4/90, 4.4% vs. 8/66, 12.1%, P = 0.12). No significant difference was observed in 3-year relapse-free survival rate between the two groups (98.6% vs. 96.4%, P > 0.05). The meta-analysis revealed similar results except less overall complications in the LWR group (RR = 0.49, 95% CI, 0.25 to 0.95, P = 0.04). And the recurrence risk was similar in two group (RR = 0.80, 95% CI, 0.28 to 2.27, P > 0.05).

CONCLUSIONS

LWR is a technically and oncologically safe and feasible approach for gastric GISTs compared with OWR. Moreover, LWR appears to be a preferable choice with mini-invasive benefits.

Single-incision intragastric resection for upper and mid gastric submucosal tumors: a case-series study

PURPOSE

Laparoscopic gastric wedge resection is a standard treatment for removing gastric submucosal tumors (SMTs). So far, however, there have been few reports of single-incision laparoscopic intragastric wedge resection. Our aim was to describe this procedure and our experience with it.

METHODS

From January 2010 to December 2013, a total of 21 consecutive patients with gastric SMTs underwent single-incision intragastric resection at our institution. Their clinicopathologic data were analyzed retrospectively.

RESULTS

The patients consisted of nine men and 12 women with a mean age of 51.9 ± 12.9 years (22-69 years). Their mean body mass index was 22.6 ± 2.0 kg/m(2). Mean tumor size was 2.4 ± 0.7 cm, with the following anatomic distribution: esophagogastric junction in three patients, fundus in twelve, upper body in three, and lower body in two. Mean operating time was 68.6 ± 12.0 minutes. There were no conversions to open surgery and no major intraoperative complications. Time to resumption of water intake was 1.4 ± 0.5 days. Mean hospital stay was 4.9 ± 1.7 days. There were no recurrences or deaths during the mean 19-month follow-up.

CONCLUSION

Single-incision intragastric wedge resection is a feasible and safe procedure. It is especially efficient for treating small endophytic gastric SMTs located on the upper and mid portion of the stomach.

Laparoscopic versus open resection for gastric gastrointestinal stromal tumors: an updated systematic review and meta-analysis

BACKGROUND

In past decades, laparoscopic surgery has been introduced for the treatment of gastrointestinal stromal tumors (GISTs). Recently, additional studies comparing laparoscopic versus open surgery for gastric GISTs have been published, and an updated meta-analysis of this subject is necessary.

METHODS

A systematic search was conducted in PubMed, Embase, Cochrane Library, and Web of Science. Comparative studies of laparoscopic and open surgery for gastric GISTs published before June 2014 were identified from databases. The Newcastle-Ottawa Quality Assessment Scale was used to perform quality assessment and original data were extracted. The statistical software STATA (version 12.0) was used for the meta-analysis.

RESULTS

Finally, 22 studies, including a total of 1,166 cases, meet the inclusion criteria for meta-analysis. The operation time was similar between laparoscopic and open surgery. Compared to open surgery, laparoscopic resection was associated withless blood loss (WMD = -58.91 ml; 95% CI, -84.60 to -33.22 ml; P <0.01); earlier time to flatus (WMD = -1.31 d; 95% CI, -1.56 to -1.06, P <0.01) and oral diet (WMD = -1.75 d; 95% CI, -2.12 to -1.39; P <0.01); shorter hospital stay (WMD = -3.68 d; 95% CI, -4.47 to -2.88; P <0.01); and decreased overall complications (relative risk = 0.57; 95% CI, 0.37 to 0.89; P = 0.01). For long-term outcomes, there were no significant differences between two surgical procedures on recurrence.

CONCLUSION

Laparoscopic surgery for gastric GISTs is acceptable for selective patients with better short-term outcomes compared with open surgery. The long-term survival situation of patients mainly depends on the nature of tumor itself, and laparoscopic surgery was not associated with worse oncological outcomes.

Systematic review and meta-analysis of safety and efficacy of laparoscopic resection for gastrointestinal stromal tumors of the stomach

OBJECTIVE

To evaluate the safety and efficacy of laparoscopic resection for gastrointestinal stromal tumors (GISTs) of the stomach with systematic review and meta-analysis.

METHODS

The literature database before March, 2014 was extensively searched to retrieve the comparative studies of laparoscopic (LAP) and open resection (OPEN) for GISTs with a relevance of study goal. The inclusion and exclusion criteria were formulated. After a quality evaluation, the data were extracted. The Cochrane collaboration RevMan5.1 version software was used for meta-analysis.

RESULTS

There are nineteen studies meeting the inclusion criteria for meta-analysis. The total sample size of these studies was 1,060 cases. The operation time was similar between the two groups [weighted mean difference (WMD) -7.20 min, 95 % confidence interval (CI) -25.65 to 11.25, P = 0.44)]. Compared to OPEN, however, LAP experienced less blood loss (WMD -54.21 ml, 95 % CI -82.65 to -25.77, P < 0.01), earlier time to flatus (WMD -1.34 days, 95 % CI -1.62 to -1.06, P < 0.01) and oral diet (WMD -1.80 days, 95 % CI -2.18 to -1.42, P < 0.01), shorter hospital stay (WMD -3.68 days, 95 % CI -4.52 to -2.85, P < 0.01) and decrease in overall complications [relative risk (RR) 0.51, 95 % CI 0.32-0.80, P < 0.01)]. In addition, the long-term follow-up result shows that there is no significant difference in the two groups of patients.

CONCLUSION

Laparoscopic resection for gastric GISTs is a safe and feasible procedure with less blood loss, less overall complications and quicker recovery. The long-term survival situation of patients mainly depends on the tumor itself risk, and laparoscopic surgery will not increase the risks of tumor relapse and metastasis.

Feasibility and safety of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors, including esophagogastric junction tumors

BACKGROUND AND AIM

Recently, the use of endoscopic submucosal dissection (ESD) for gastric submucosal tumor (gSMT) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either preservation of the stomach or minimization of the extent of partial resection. In the present study, the outcomes following the recent introduction of LECS for gSMT are presented. The aim of this retrospective study was to evaluate the feasibility and safety of LECS for gSMT, including esophagogastric junction (EGJ) SMT.

METHODS

LECS is indicated for lesions that have an intragastric growth pattern, or for which fundusectomy can be avoided despite an extragastric growth pattern. We retrospectively evaluated the outcome of LECS carried out in 25 patients including five EGJ SMT.

RESULTS

Surgery was completed achieving an R0 resection rate of 100% with no postoperative complications. Mean tumor size was 32.3 ± 13.5 mm and mean resected specimen size was 37.6 ± 13.5 mm. Resection margins were tumor-free in all cases, with adequate minimum surgical margins, and precise conclusive diagnosis was achieved with perfect operative specimens. Endoscopic confirmation of the EGJ enabled the extent of resection to be minimized and the stomach to be preserved, avoiding fundusectomy. Although there were significant differences in tumor size and resected specimen size between EGJ SMT and non-EGJ SMT, there were no significant differences in outcomes of the LECS procedure.

CONCLUSION

LECS is feasible and safe for cases with gSMT including lesions adjacent to the EGJ.

Does laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors preserve residual gastric motility? Results of a retrospective single-center study

Background

Laparoscopic and endoscopic cooperative surgery (LECS) is a minimally invasive surgical technique used to resect gastric submucosal tumors with intraluminal growth. Endoscopic submucosal dissection is used to determine the appropriate resection line from within the stomach lumen as it minimizes the stomach wall resection area and prevents postoperative stomach deformity. Although LECS is intended to preserve gastric function, few reports have evaluated postoperative residual gastric motility. Therefore, we conducted a retrospective analysis of patients who underwent LECS to determine the effects of LECS on residual gastric motility.

Methods

Twenty-two patients underwent endoscopy 3 to 12 months after LECS. Patients were evaluated for endoscopic evidence of gastric motility disorder, namely food residue and occurrence/exacerbation of reflux esophagitis. We considered patients with new onset of gastric symptoms and endoscopic evidence of gastric motility disorder to have clinically relevant gastric motility disorder. We described patient characteristics, tumor location, and surgical findings.

Results

Two of 22 patients developed clinically relevant gastric motility disorder after LECS. In one of these patients, the symptoms were not severe; only one had reduced dietary intake and had lost weight. We identified clinically relevant gastric motility disorder in two patients with gastrointestinal stromal tumors located in the lesser curvature of the stomach. The major axis of these two tumors was 34 mm and 38 mm.

Conclusions

Many patients did not have clinically relevant gastric motility disorder after LECS. Further investigation is required to identify predisposing factors for gastric motility disorder.

Endolumenal endoscopic full-thickness resection of muscularis propria-originating gastric submucosal tumors

BACKGROUND

This study retrospectively reviewed 48 cases of gastric submucosal tumors (SMTs) treated by endolumenal endoscopic full-thickness resection (EFR) microsurgery in our gastrointestinal endoscopy center.

PATIENTS AND METHODS

From November 2009 to October 2012, 48 cases underwent endolumenal EFR for resection of muscularis propria-originating gastric SMTs. Characteristics of the 48 patients, clinical efficacy, safety of EFR, and post-EFR pathological diagnoses were evaluated retrospectively.

RESULTS

EFR was successfully performed in 48 cases with 52 lesions. The median operation time was 59.72 minutes (range, 30-270 minutes; standard deviation, 39.72 minutes). The mean tumor size was 1.59 cm (range, 0.50-4.80 cm; standard deviation, 1.01 cm). During the EFR process, dual-channel gastroscopy was applied in 20 cases of SMTs, and paracentesis during the EFR process was applied in 9 cases. EFR for larger SMTs and gastric corpus-originating SMTs had longer operative times. Pathological diagnosis included 43 gastrointestinal stromal tumors, 4 leiomyomas, and 1 schwannoma. A larger tumor size was associated with higher risk of malignancy. No severe postoperative complications were observed. No tumor recurrences were confirmed in follow-up gastroscopy.

CONCLUSIONS

The endolumenal EFR technique proved to be feasible and minimally invasive, even for the resection of large gastric tumors originating from the muscularis propria. However, more data on EFR must be obtained and analyzed.

Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases

OBJECTIVE. Subepithelial tumors (SETs) in the stomach are usually considered benign. However, some do have potential for malignant transformation, especially when originating in the muscularis propria (MP). Our study aimed to evaluate the clinical efficacy and safety of endoscopic submucosal dissection (ESD) for gastric SETs originating in MP. MATERIAL AND METHODS. A total of 145 gastric MP SETs in 144 patients were treated by ESD between September 2008 and December 2012. Characteristics of patients and SETs, therapeutic outcomes, pathologic characteristics, complications and follow-up outcomes were evaluated. RESULTS. Among the 144 patients, 104 were female (72.22%) and 40 were male (27.78%), and the mean age was 55.75 ± 11.29 years (range 18-78 years). The mean size of the tumors determined by endoscopic ultrasound (EUS) was 15.14 ± 9.70 mm (range 3-50 mm). En bloc complete resection was achieved in 134 of 145 tumors, giving a complete resection rate of 92.41%. The final histopathologic diagnoses included 52 leiomyomas, 89 gastrointestinal stromal tumors, 3 neurogenic tumors and 1 lipoma. Perforations occurred in 21 patients (14.48%) and were endoscopically repaired with clips or nylon bands. Intraoperative bleeding occurred in seven patients (4.83%) and was corrected with argon plasma coagulation (APC) or hot biopsy forceps. No local recurrence or distant metastasis was detected during a mean follow-up of 19.14 ± 10.29 months (range 3-51 months). CONCLUSIONS. ESD appears to be an effective and safe treatment for gastric SETs originating in MP.

Laparoscopic surgery for submucosal tumor near the esophagogastric junction

BACKGROUND

Laparoscopic surgery is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, laparoscopy is not easily applied to tumors near the esophagogastric junction (EGJ). This study was conducted to evaluate laparoscopic techniques for treating SMTs near the EGJ.

SUBJECTS AND METHODS

Between March 2008 and August 2012 at the Asan Medical Center, Seoul, Korea, we performed laparoscopic surgery on 71 patients who had SMTs located within 3 cm of the EGJ. The laparoscopic approach chosen depended on the position of the tumor, which was located accurately by preoperative diagnosis.

RESULTS

None of the patients required conversion to open surgery. Of the 71 patients in the study, 66 had laparoscopic wedge resection (LAPWR), 4 had laparoscopic enucleation, and 1 had laparoscopic proximal gastrectomy. Two patients had intraoperative events during LAPWR. One had EGJ stricture, which required laparoscopic esophagogastrostomy. The other had a muscle defect of the posterior wall of the distal esophagus, and the defect was covered using fundus-like fundoplication. All patients had tumor-free resection margins, and there were no deaths.

CONCLUSIONS

Laparoscopic resection of SMTs near the EGJ may be performed safely. The laparoscopic approach used depends on the location and size of the tumor and on the extent of gastric resection.

Totally laparoscopic resection for a large gastrointestinal stromal tumor of stomach

A debate is currently ongoing about whether a large gastrointestinal stromal tumor (GIST) should be treated by the laparoscopic approach because of the increased risk of tumor rupture during manipulation of the tumor with laparoscopic instruments and the resultant peritoneal tumor dissemination. Herein, we report a case of a large GIST of the stomach which was successfully treated by the laparoscopic approach. A 57 year old female patient visited our institution complaining of postprandial epigastric discomfort. An esophagogastroduodenoscopy and an abdominal computed tomography scan revealed a 10×8 cm sized submucosal tumor at the greater curvature side of the gastric antrum. The patient underwent laparoscopic distal gastrectomy with intracorporeal Billroth-II reconstruction without any breakage of the tumor. Her postoperative course was uneventful and she was discharged on the 7th postoperative day. Even a large GIST of the stomach can safely be treated by the laparoscopic approach when it is performed with proper techniques by an experienced surgeon.

New method of endoscopic full-thickness resection: a pilot study of non-exposed endoscopic wall-inversion surgery in an ex vivo porcine model

The indications for endoscopic full-thickness resection (EFTR) are limited because transmural communication during the entire procedure, causing tumor dissemination into the abdominal space, is inevitable. We invented a new method of EFTR without transmural communication, and explored its feasibility in an ex vivo porcine model. Three explanted porcine stomachs were used. First, markings around a model lesion were made with a flexible endoscope, and 0.9% normal saline with indigocarmine was injected into the submucosa around the markings. Second, a circumferential sero-muscular incision was made from the outside with an electrocautery knife, guided by the color of the submucosal injection and intragastric navigation with the endoscope. Third, the muscle layer was linearly sutured with the lesion inverted into the inside. Finally, a circumferential muco-submucosal incision was made with an electrocautery knife employed with the endoscope. The method was performed for 3 lesions (1 anterior wall, 1 lesser curve, and 1 posterior wall of the gastric body), and all lesions were successfully resected in en-bloc fashion. The mean size of the resected specimen was 4.5 cm in diameter. Neither perforation nor apparent air leakage was seen during or after the resection. Non-exposed endoscopic wall-inversion surgery (NEWS) is thought to be effective as a minimally invasive, and minimal-size endoluminal surgery for gastric submucosal tumors with or without ulceration, or even node-negative early gastric cancer that is difficult to resect by endoscopic submucosal dissection.

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.

Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor

BACKGROUND AND OBJECTIVE

Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients.

METHODS

Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect.

RESULTS

LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients.

CONCLUSIONS

LAEFR may be considered one of the so-called hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.

Laparoscopic surgery for submucosal tumors located at the esophagogastric junction and the prepylorus

BACKGROUND

Laparoscopic partial gastric resection is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, SMTs of either end of the stomach are generally managed by subtotal gastrectomies or total gastrectomies. This study was conducted to evaluate surgical techniques for management of SMTs located at the ends of the stomach.

METHODS

Among 63 patients who were diagnosed and underwent laparoscopic surgery for gastric SMTs at Seoul National University Bundang Hospital from May 2003 to May 2007, 11 SMTs located at the ends of the stomach were identified. The clinicopathologic results of these 11 SMTs were analyzed.

RESULTS

Laparoscopic partial wedge resections or tumor excisions were successfully performed on all patients except for those who had prepyloric tumors. Six men and five women had SMTs at the ends of the stomach. The patients ranged in age from 21-63 years (mean 43.4 +/- 13.5 years). Of six esophagogastric junctional tumors that showed low, homogeneous contrast enhancement on computed tomography (CT) scans, five were treated by laparoscopic transgastric enucleation and one by tumor-everting resection. One esophagogastric junctional tumor that leaned toward the fundus and showed a 6-cm-diameter endophytic mass with heterogeneous enhancement on CT scan was resected by laparoscopic wedge resection. The mean operation time was 100 min (range 60-210 min). Three laparoscopy-assisted distal gastrectomies and one laparoscopic wedge resection were performed on SMTs located near the prepyloric antrum. There were no intra- or postoperative complications. Duration of postoperative hospital stay ranged from 4-7 days.

CONCLUSION

Laparoscopic local resection is an effective treatment for SMTs located at the esophagogastric junction and can be used instead of a total or proximal gastrectomy. However, gastrectomies should be considered for SMTs located near the pylorus because of the small volume of the lower third of the stomach.