Laparoscopic wedge resection of gastric submucosal tumors

Hybrid surgical approach excision of gastrointestinal stromal tumor (GIST): A case report of GIST at an unusual location and review of the literature

Gastrointestinal stromal tumors are the most common malignant subepithelial lesions involving the gastrointestinal tract. Surgical techniques have been the mainstay of treatment, however, in recent times hybrid surgeries are being introduced yielding better clinical outcomes.

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of laparoscopic and endoscopic techniques leading to improved patient outcomes, open resection has become increasingly outdated for the treatment of gastric gastrointestinal stromal tumours (GIST). This is further superseded with the advent of laparoscopic and endoscopic cooperative surgery (LECS), an amalgamation of the two techniques to further improve results garnered while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

"A hybrid approach for GISTs near the esophagogastric junction, a case report"

Introduction and importance

Gastrointestinal stromal tumors are the most frequent mesenchymal tumors of the gastrointestinal tract. Complete resection of GISTs is the only chance of cure for patients. When these tumors are located near the esophagogastric junction, the surgical risk can cause deformity or stenosis in the gastric inlet, leading to higher complications and diminishing their quality of life. In such cases, a more sophisticated and tailored approach should be used.

Case presentation

We present the case of a 42-year-old female; she presented to our office with a 3-year history of nausea, vomiting and abdominal distension. Two GISTs were located near the EGJ, and with a combined approach we achieved complete resection. On follow-ups, the patient is doing well.

Clinical Discussion, Conclusion

When diagnosis is confirmed, surgical resection must be the first choice for GISTs as complete surgical excision is the only permanent cure. The rise of endoscopic surgery has become a valuable tool and a critical element in surgery. Hybrid techniques that combine laparoscopic and endoscopic approaches can improve the patient's outcomes and provide better results.

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The rise of endoscopic surgery has become a valuable tool and a critical element in surgery.

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Early histologic diagnosis and surgical resection is the most reliable way to improve patients' quality of life.

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The surgical decision will be what define the future of the patient and, ultimately, his life.

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.

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 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.

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

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

Successful Intracorporeal Suturing Following Laparoscopic Resection of a Large Gastrointestinal Stromal Tumor Located at the Esophagogastric Junction

Laparoscopic partial resection of gastric gastrointestinal stromal tumors (GISTs) ≤5 cm in size is widely performed, whereas that of large GISTs (size &gt;5 cm) is controversial because of oncologic and technical safety. Furthermore, laparoscopic resection of GISTs located at the esophagogastric junction (EGJ) is difficult because of the high risk of narrowing or/and deformity of the EGJ. In the current study we report a case of laparoscopic partial resection of a large GIST located at the EGJ. A 74-year-old female patient visited our institution complaining of epigastric discomfort. An esophagogastroduodenoscopy and an abdominal computed tomography scan revealed a 7.5 × 4.0 cm GIST at the EGJ and upper stomach. The patient underwent laparoscopic partial resection with intracorporeal suturing, without any breakage of the pseudocapsule. The defect of the esophagogastric wall after resection was closed by intracorporeal running suture. The patient's postoperative course was uneventful. To the best of our knowledge, this is the first report of laparoscopic resection of a large GIST located at the EGJ. Our technique of intracorporeal manual suturing following laparoscopic gastric resection can be a valid option for minimally invasive surgery for a large GIST located at the EGJ.

Laparoscopic surgery for gastric gastrointestinal stromal tumor is feasible irrespective of tumor size

PURPOSE

To compare the outcomes of laparoscopic surgery and open surgery for gastric gastrointestinal stromal tumors (GISTs) by size-matched analysis and evaluate whether laparoscopic surgery for lesions of >5 cm is feasible.

PATIENTS AND METHODS

Data of 44 consecutive patients with gastric GIST who underwent surgery from 1988 to 2011 were reviewed. Twenty-three patients who underwent successful laparoscopic surgery were compared with 10 patients with similar tumor sizes who underwent open surgery. Among the 23 patients in the laparoscopic group, we compared postoperative results between GISTs of ≤5 cm and >5 cm.

RESULTS

There were no differences in clinicopathological characteristics between the laparoscopic surgery group (LG) and the open surgery group (OG). The operation time was not different, but the blood loss (5.5 mL [range, 0-425 mL] in LG and 125 mL [range, 0-676 mL] in OG) (P=.008) and postoperative hospital stay (21 days in OG and 8 days in LG) (P<.001) were significantly less in the LG. Postoperative complications and recurrence were not different. Comparison between patients with lesions of >5 cm and patients with smaller lesions in the LG found that smaller lesions were associated with a shorter postoperative hospital stay (7.5 days versus 11 days) (P=.037).

CONCLUSIONS

Laparoscopic resection of primary gastric GISTs is feasible even for tumors of >5 cm.

Endoscopic-assisted laparoscopic resection for gastric subepithelial tumors

BACKGROUND

Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Occasionally, it is necessary to perform an intraoperative gastroscopy to localize the lesion. There are no data in the literature addressing the factors that can predict when a combined laparoscopic-endoscopic approach will be needed.

METHODS

A retrospective cohort study using a prospectively collected database was conducted. From January 2005 to December 2013, all the patients undergoing a laparoscopic gastric resection for subepithelial tumors irresectable by endoscopy were reviewed. Potential predictive factors for the need of an intraoperative endoscopy were analyzed.

RESULTS

Thirty-eight consecutive patients (22 men and 16 women) with a mean age of 67 (41-86) years underwent laparoscopic gastric resection for subepithelial tumors. Fourteen (36.8%) patients required intraoperative endoscopic assessment. The only significant factors related to the need of endoscopic assessment during surgery were tumor growth pattern (P = 0.002) and size (P = 0.001).

CONCLUSIONS

An accurate description of tumor growth pattern and size by EUS is recommended in the preoperative assessment of gastric subepithelial tumors. Small tumors (≤18 mm) with an intraluminal growth may need a combined endoscopic-assisted laparoscopic management.

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.

Laparoscopic transgastric resection of gastric submucosal tumors located near the esophagogastric junction

BACKGROUND

Laparoscopic wedge resection is widely accepted as a choice of treatment for gastric submucosal tumors (SMTs). But it cannot easily be applied to tumors located near the esophagogastric junction (EGJ) due to the high risk of causing deformity or stenosis in the gastric inlet. We evaluated our laparoscopic transgastric surgical technique for gastric SMTs located near the EGJ and clinical outcomes.

METHODS

Twelve consecutive patients with gastric intraluminal SMTs located 3 cm or less from the EGJ underwent laparoscopic transgastric resection at our institution from June 2010 to November 2012. The clinicopathological results of these 12 cases were analyzed.

RESULTS

Laparoscopic transgastric resection was successfully performed on all the patients. The mean operation time was 125 ± 25 min (range, 85-160 min) and the mean blood loss was 53 ± 32 mL (range, 10-120 mL). There was no death in our series. One patient experienced a postoperative complication of upper gastrointestinal tract bleeding due to the errhysis along the staple line treated with an endoscopic hemostatic clip. The mean postoperative length of hospital stay was 5.1 ± 1.2 days (range, 3-7 days). All patients received complete resection with a negative margin. Histopathologic diagnoses were gastrointestinal stromal tumor in seven cases, leiomyoma in four, and heterotopic pancreas in one. There was no tumor recurrence or evidence of stenosis of the EGJ during a mean follow-up of 15.3 ± 9.6 months (range, 1-30 months).

CONCLUSIONS

Laparoscopic transgastric resection is simple, safe, and effective for gastric intraluminal SMTs located near the EGJ.

Successful gastric submucosal tumor resection using laparoscopic and endoscopic cooperative surgery

BACKGROUND

Laparoscopic wedge resections are increasingly utilized to treat gastric submucosal tumors (SMTs). However, laparoscopic wedge resection is not applicable for tumors located near the gastric inlet or outlet and requires resection of relatively large sections of healthy stomach, particularly if laparoscopic linear staplers are used.

METHODS

Twenty consecutive patients underwent laparoscopic and endoscopic cooperative surgery (LECS) for resection of gastric SMTs. The procedure was performed under general anesthesia. The mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromuscular layer involving three-fourths of the line of the incision around the tumor was laparoscopically dissected. The submucosal tumor was then exteriorized to the abdominal cavity and dissected with an endoscopic linear stapling device.

RESULTS

In all cases, the LECS procedure was successful in dissecting the gastric SMT. The tumor was located in the upper third of the stomach in eight cases, in the middle third in eight cases, and in the lower third in four cases. The mean operating time was 157.0 ± 68.4 minutes, and the mean intraoperative blood loss was 3.5 ± 6.4 ml. The postoperative course was uneventful in all cases.

CONCLUSIONS

We demonstrated the feasibility and satisfactory surgical outcomes after LECS for gastric SMT. With LECS, relatively small sections of healthy gastric wall are resected without postoperative morbidity or mortality. Thus, LECS is safe, easy, and beneficial for laparoscopic resection of SMTs, although care should be taken to avoid gastric juice contamination.

Full-thickness laparoendoscopic excision in the stomach: the FLEx technique

BACKGROUND

The authors describe the initial validation of a novel full-thickness laparoendoscopic excision (FLEx) technique for the stomach.

METHODS

The technique was studied in seven 50-kg pigs. Secure full-thickness excision was ensured by inversion excision target with a 1-cm circumferential margin using laparoendoscopically placed brace bars passed intraluminally from the outside of the stomach, laparoscopic oversewing of the site of inversion, and endoscopic full-thickness excision using a dual scope approach. Pigs were sacrificed either immediately (n = 3) or between 7 and 10 days after surgery (n = 4).

RESULTS

The procedure achieved uncomplicated full-thickness excision in every case. Median procedure duration was 227 minutes (range = 210-245 minutes). Median specimen diameter was 5.5 cm (range = 2.5-8 cm). Investigative autopsy confirmed technical sufficiency in all animals. Median site bursting pressure was 130 mm Hg (range = 120-160 mm Hg).

CONCLUSIONS

The FLEx technique proved useful for excision of small localized lesions of the stomach in this animal study.

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.

Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses - analysis of 93 interventions

BACKGROUND

Subepithelial gastric tumors are common findings during upper gastrointestinal endoscopy. Tumor resection is mostly done laparoscopically, but there is still discussion concerning the size of lesion for which the treatment may be minimally invasive; additionally there is very little data available concerning patient outcome after minor access surgery.

METHODS

Clinicopathologic features and survival data of 93 consecutive patients undergoing a combined laparoscopic-endoscopic approach for gastric submucosal tumors were prospectively analyzed. Analysis included preoperative diagnostic work-up, perioperative data, and postoperative complications. Follow-up was carried out for patients with GIST to check for tumor recurrence.

RESULTS

It was possible to resect 88 of 93 lesions by the laparoscopic-endoscopic approach, with tumor-free margins in all patients. Intraoperative endoscopy facilitated exact tumor localization in 92 patients. Most lesions were removed by endoscopic-laparoscopic wedge resection or, less frequently, by a combined transgastric approach. Mean operative time was 90.7 min; the postoperative hospitalization was 7.3 days. Adverse events appeared in 7.5%, and conversion to open surgery was required in 6.5%. For patients suffering from gastrointestinal stromal tumors, there was no tumor recurrence at a mean follow-up of 40 months.

CONCLUSIONS

Combined laparoscopic-endoscopic "rendez-vous" procedures are easy to perform and offer a curative approach for almost all gastric submucosal lesions. The technique is associated with low morbidity and short hospitalization. Though even patients with large GISTs of intermediate and high risk were treated, no tumor recurrence has been observed to date.

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.

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

Little is known about the outcomes of laparoscopic wedge resection (LWR) in comparison with conventional open wedge resection (OWR) for gastric submucosal tumor. Outcomes of 21 patients who underwent LWR (n = 14) or OWR (n = 7) for gastric submucosal tumor between 1993 and 2004 were investigated. We compared the short-term and long-term operative results between the 2 groups. LWR showed several advantages over OWR for gastric submucosal tumor: less blood loss, lower fever on day 1, lower analgesic usage rate, earlier first postoperative flatus and oral intake, lower leukocyte count on days 1 and 7, and lower C-reactive protein level on days 1 and 3. All patients, except 2 with histologically diagnosed high-risk gastrointestinal stromal tumor, survived during the mean follow-up period of 60 months. LWR is feasible for the management of patients with gastric submucosal tumor.

Laparoscopic wedge resection for gastrointestinal stromal tumors of the stomach: initial experience

PURPOSE

Surgery for gastrointestinal stromal tumors (GIST) of the stomach is now frequently performed using a laparoscopic approach. We investigated the feasibility and effectiveness of laparoscopy in the management of GIST of the stomach.

METHODS

We reviewed the records of 12 consecutive patients who underwent laparoscopic surgery for GIST between April 2000 and April 2004, and compared their short-term outcomes with those of patients who underwent open surgery. All laparoscopic wedge resections were done using stapling devices and 3-4 trocars, often with the aid of intraoperative gastroscopy. We examined all patients preoperatively using various diagnostic modalities, including endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA). A laparoscopic approach was not indicated if the tumor was located near the cardia or pylorus or if it was >=5 cm in diameter.

RESULTS

A specific diagnosis of GIST was obtained preoperatively by EUS-FNA in 10 of the 12 patients. The median diameter of the lesion was 2.7 cm (range, 1.5-4.8 cm). Although intraoperative complications were encountered in two patients, conversion to open surgery was not required, and we were able to perform complete tumor excision with negative surgical margins in all patients. The median operative time was 100 min (range, 65-180 min), similar to that for open surgery. First flatus was passed earlier, and the interval to resuming oral intake was shorter than after open surgery. No major postoperative complications such as leakage developed, and the median postoperative hospital stay was 7 days (range, 5-12 days). All diagnoses made by EUS-FNA were confirmed by immunohisto-pathological evaluation of resected specimens.

CONCLUSION

Laparoscopic wedge resection is a feasible treatment option for GISTs of the stomach if the lesion is <5 cm in diameter.

CDH1 associated gastric cancer: a report of a family and review of the literature

AIMS

Hereditary diffuse gastric cancer (HDGC) is an autosomal-dominant inherited form of gastric cancer associated with inactivating germline mutations in the CDH1 gene. We set out to outline the role of CDH1 in HDGC. Investigation of a family suspected as having HDGC is discussed. The role of surgery in the management of affected individuals is then examined.

METHODS

A search was conducted of Medline and the National Library of Medicine to identify key articles concerning CDH1 gene mutations, familial gastric cancer and gastrectomy. Further, relevant articles were obtained by manual scanning of the reference lists of identified papers. Mutation-specific CDH1 genetic testing was performed on six living family members and on gastric tissue obtained from two deceased members.

RESULTS

CDH1 mutations cause inactivation of the cell adhesion protein E-cadherin. Carriers of the CDH1 germline gene mutation develop an aggressive, diffuse, submucosal gastric cancer at an early age. Current endoscopic screening is ineffective at detecting HDGC. The presence of a CDH1 germline gene mutation was confirmed in both deceased family members and also in four of the six living members tested.

CONCLUSION

Genetic counselling and CDH1 gene mutation testing is indicated in families with suspected HDGC. In the absence of a satisfactory surveillance mechanism, prophylactic total gastrectomy would appear to be an appropriate therapeutic option in mutation carriers.

Laparoscopic wedge resection with handsewn closure for gastroduodenal tumors

PURPOSE

To evaluate the feasibility and efficacy of laparoscopic wedge resection with handsewn closure in gastroduodenal tumors.

METHODS

Laparoscopic wedge resection was performed in 16 patients with gastroduodenal tumor between May 2000 and December 2002. Every case, except one, was performed via an extragastric approach; a transgastric approach was adopted in a single case. Excision of the lesion was performed manually by means of electrocautery or ultrasonic coagulating shears and closed by manual intracorporeal running suture.

RESULTS

Among the 16 cases, two cases were treated using a laparoscope-assisted method, but there was no case of conversion to open surgery. Mean size of lesions was 27.9 mm in diameter and the mean operation time was 219 minutes. In all cases, a complete tumor excision with negative surgical margins was obtained. The final pathologic diagnoses were ectopic pancreas (4 cases), gastrointestinal stromal tumor (3 cases), leiomyoma (2 cases), adenomyoma (2 cases), tubular adenoma (1 case), Brunner's gland hyperplasia (1 case), carcinoid tumor (1 case), eosinophilic granuloma (1 case), and post-endoscopic mucosectomy state for early gastric cancer (1 case). The average numbers of days to first postoperative oral food intake and hospital stay were 3.1 days and 6.0 days, respectively. There were no postoperative complications.

CONCLUSIONS

Laparoscopic wedge resection with handsewn closure should be considered as a valid treatment option for selected gastroduodenal tumors in terms of feasibility, safety, and cost. A more efficient surgical instrument and technique should be developed in future.

Endoscopic diagnosis and treatment of submucosal tumors of gastrointestinal tract

AIM: To improve the diagnoses and treatment for submucosal tumors of gastrointestinal tract.

METHODS: Endoscopic ultrasonograpy (EUS) was conducted in 136 patients with submucosal tumors (SMT) in gastrointestinal tract. Endoscopic therapy or surgical operation was taken according to the different layers of SMT.

RESULTS: A total of 33 cases of stromal tumors derived from mucosa; 2 cysts, 8 lipomas, 12 etopic pancreases in stomach and 5 varics in gastric fundus from submucosa; 60 benign stromal tumors and 16 malignant stromal tumors from muscularis; 24 benign stromal tumors from mucosa, 6 benign stromal tumors from muscularis, 4 gastric lipomas, 2 cysts, 6 etopic pancreas in stomach were resected by endoscopy; 28 cases of benign stromal tumors derived from muscularis, 15 malignant stromal tumors, 2 lipoma and 2 etopic pancreas were removed by surgery. 97.7% of SMTs diagnosed by EUS were confirmed further by pathology.

CONCLUSION: Different layers of gastrointestinal tract with SMTs can be distinguished clearly by EUS, leading to definite diagnosis of SMTs. EUS is important to select treating methods of SMTs in gastrointestinal tract. Endoscopic therapy is an effective method for submucosal tumor of gastrointestinal tract.

Laparoscopic gastric surgery in a Japanese institution: analysis of the initial 100 procedures

BACKGROUND

Although endoscopic surgical procedures are popular in various fields, reports on its use in gastric surgical procedures are limited. This study was designed to review our initial experience with laparoscopic gastric surgical techniques to evaluate indications and surgical results.

STUDY DESIGN

We undertook a retrospective analysis of 100 patients (66 men and 34 women, mean age 63 years) who underwent laparoscopic gastric surgical procedures between 1995 and 2001. Procedures performed were distal gastrectomy (n = 76), wedge resection (n = 20), and intragastric surgical procedures (n = 4). Patients were divided into two groups according to the date of the procedure, from the earliest to the most recent.

RESULTS

There were 85 patients with gastric cancers, 14 submucosal tumors, and 1 duodenal ulcer. In 8 cases conversion was made to an open surgical procedure. Operation times required for distal gastrectomy, wedge resection, and intragastric surgical procedures were 330 +/- 69, 144 +/- 34, and 298 +/- 106 min, and blood loss was 354 +/- 251, 56 +/- 94, and 33 +/- 58 g, respectively. Complications included transient anastomotic stenosis (n = 5), leakage (n = 4), and bleeding (n = 1) after distal gastrectomy, and bleeding (n = 1) after intragastric surgical procedures. There were no complications after wedge resection. Comparing the first and second halves of the series, the percentage of distal gastrectomy significantly increased from 66% to 86% (p = 0.02) and the number of dissected lymph nodes at this procedure increased from 20 +/- 13 to 33 +/- 17 (p < 0.01).

CONCLUSIONS

Laparoscopic gastric surgical procedures are safe and feasible for early gastric cancers and submucosal tumors. Technical advances in lymph node dissection have made distal gastrectomy a leading and increasingly popular laparoscopic procedure for early gastric cancer.