Surgical treatment of gastric gastrointestinal stromal tumor

A subepithelial lesion algorithm for endoscopic (SAFE) resection in the upper gastrointestinal tract

BACKGROUND

Complete excision of upper gastrointestinal subepithelial lesions (U-SELs) eliminates diagnostic uncertainty, obviates the need for surveillance, and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. We describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection.

METHODS

U-SELs were enrolled prospectively over 115 months until March 2023. All subjects underwent axial (computed tomography) imaging and endoscopic ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria (MP) involvement.

RESULTS

106 U-SELs (41 esophageal, 65 gastric) were resected (mean patient age 60.6 [SD 13.4]; 51.9% male). Esophageal U-SELs underwent endoscopic submucosal dissection (ESD; n = 22) or submucosal tunneling endoscopic resection (STER) if MP involvement was suspected (n = 19). Gastric U-SELs underwent STER (n = 6 at cardia), ESD (n = 47), or exposing endoscopic full-thickness resection (e-EFTR; n = 12). Technical success rates were 97.6% and 92.3%, respectively. Among the noncardiac gastric U-SELs, five resections (9.6%) were completed laparoscopically owing to deep and broad full-thickness involvement; five (9.6%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure owing to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation, or recurrence at 13 months.

CONCLUSION

U-SELs may be effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Esophageal U-SELs suspected of involving the MP should undergo STER. Gastric SELs are best managed by ESD, with a view to proceeding to e-EFTR. A laparoscopic upper gastrointestinal surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

Exploring nanotechnology solutions for improved outcomes in gastrointestinal stromal tumors

Objectives

Gastrointestinal stromal tumors, the most prevalent mesenchymal tumors (80 %) of the gastrointestinal tract, comprise less than 1 % of all gastrointestinal neoplasms and about 5 % of all sarcomas. Despite their rarity, Gastrointestinal stromal tumors present diverse clinical manifestations, anatomic locations, histological subtypes, and prognostic outcomes.

Methods

This scoping review comprehensively explores the epidemiology, clinical characteristics, diagnostic and prognostic modalities, as well as new therapeutic options for Gastrointestinal stromal tumors.

Results

A particular focus is placed on the promising role of bio-nanomaterials as multifunctional agents for drug delivery and 3D tumor microenvironment modeling. Bio-nanomaterials offer promising opportunities for targeted drug delivery, overcoming treatment resistance, and improving therapeutic efficacy.

Conclusion

Despite significant advancements, Gastrointestinal stromal tumors remain a complex clinical entity with ongoing challenges. The integration of nanotechnology into Gastrointestinal stromal tumors management offers the potential to enhance patient outcomes. Future studies should prioritize the development and evaluation of nanomaterial-based therapies in clinical trials to facilitate the translation of laboratory discoveries into real-world clinical applications.

Gastrointestinal Stromal Tumors of the Stomach: Is There Any Advantage of Robotic Resections? A Systematic Review and Meta-Analysis

Background: The role of robotic surgery for gastrointestinal stromal tumor (GIST) resection remains unclear. This systematic review and meta-analysis aimed to investigate the outcomes of robotic versus laparoscopic surgery in patients requiring surgery for gastric GISTs. Methods: MEDLINE, EMBASE, and the Cochrane databases were searched from inception to September 4, 2023. Two independent reviewers conducted a systematic review of the literature to select all types of analytic studies comparing robotic versus laparoscopic surgery for GISTs and reporting intraoperative, postoperative, and/or pathological outcomes. Results: Overall, 4 retrospective studies were selected, including a total of 264 patients, specifically 111 (42%) in the robotic and 153 (58%) in the laparoscopic group. Robotic surgery was associated with longer operating time (+42.46 min; 95% confidence interval [CI]: 9.34, 75.58; P=0.01; I2: 85%) and reduced use of mechanical staplers (odds ratio [OR]: 0.05; 95%CI: 0.02, 0.11; P<0.00001; I2: 92%;) compared with laparoscopy. Although nonsignificant, conversion to open surgery was less frequently reported for robotic surgery (2.7%) than laparoscopy (5.2%) (OR: 0.59; 95%CI: 0.17, 2.03; P=0.4; I2: 0%). No difference was found for postoperative and oncological outcomes. Conclusions: Robotic surgery for gastric GISTs provides similar intraoperative, postoperative, and pathological outcomes to laparoscopy, despite longer operative time.

Digestive bleeding due to jejunal stromal tumor: A train can hide another-A case report

Gastrointestinal mesenchymal tumors (GIST) are the most prevalent sarcoma tumors affecting the digestive tract. GIST originates from Cajal cells located within the digestive tract's wall. These cells play a crucial role in regulating digestive peristaltism as they are considered pacemaker cells. These tumors are especially located in the stomach (60%) but can also be seen in the small bowel (30%), in which jejunal stromal tumors are estimated to reach (40%). In this case report, we describe a jejunal GIST, which was initially discovered due to active bleeding, serving as the primary symptom, along with an underlying small loop intussusception. In our knowledge, GIST causing an intussusception is a rare entity in literature as well as GIST causing active bleeding. For that aim, we present a 36-year-old male patient, presented to our department with melena. An abdominal computed tomography scan was performed, revealing a small bowel intussusception associated with a 2 cm tumor. Despite the imprecise cause of the bleeding, due to the ongoing active hemorrhage, we decided to proceed with an emergency laparotomy, suspecting a tumorous origin of the bleeding. During the surgery, the tumor was located in the jejunum. The affected jejunal segment containing the tumor was resected, and an anastomosis was performed. Pathology examination confirmed a stromal tumor. The postoperative follow-up was uneventful.

A Case Report of an Unusual Presentation of a Pedunculated Gastrointestinal Stromal Tumor: Acute Upper Gastrointestinal Bleeding in a 57-Year-Old Female

Gastrointestinal stromal tumors (GISTs) are rare tumors accounting for 0.1-3% of gastrointestinal (GI) neoplasms. ‏In the past, GIST was classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas. However, now it is evident that GIST is a separate tumor entity, and it is the most frequent sarcoma of the GI tract. We report a case of a 57-year-old female with a five-day history of black tarry stools, two episodes of vomiting of dark-colored blood, dizziness, abdominal pain, night sweats, and palpitation, provoked by a change of position. After a computerized tomography (CT) of the abdomen and pelvis, a GIST was suspected, which was confirmed with histopathology. Acute upper GI bleeding is a rare presentation of GIST. Clear guidelines should be developed for GIST. An early diagnosis is crucial for a better prognosis.

Long-term outcomes of a phase II study of neoadjuvant imatinib in large gastrointestinal stromal tumors of the stomach

BACKGROUND

Neoadjuvant treatment is recommended for large GISTs due to their friability and risk of extensive operations; however, studies on the indications and long-term results of this approach are lacking.

METHODS

Patients with large (≥ 10 cm) gastric GISTs were enrolled from multiple centers in Korea and Japan after a pathologic confirmation of c-KIT ( +) GISTs. Imatinib (400 mg/d) was given for 6-9 months preoperatively, and R0 resection was intended. Postoperative imatinib was given for at least 12 months and recommended for 3 years.

RESULTS

A total of 56 patients were enrolled in this study, with 53 patients receiving imatinib treatment at least once and 48 patients undergoing R0 resection. The 5-year overall survival and progression-free survival rates were 94.3% and 61.6%, respectively. Even patients with stable disease by RECIST criteria responded well to preoperative imatinib treatment and could undergo R0 resection, with most being evaluated as partial response by CHOI criteria. The optimal reduction in tumor size was achieved with preoperative imatinib treatment for 24 weeks or more. No resumption of imatinib treatment was identified as an independent prognostic factor for recurrence after R0 resection. No additional size criteria for a higher risk of recurrence were identified in this cohort with a size of 10 cm or more.

CONCLUSIONS

Neoadjuvant imatinib treatment is an effective treatment option for gastric GISTs 10 cm or larger. Postoperative imatinib treatment is recommended even after R0 resection to minimize recurrence.

Radiologic Review of Small Bowel Malignancies and Their Mimicking Lesions

Because of their small size, small bowel malignancies are often easily missed when radiologists read CT images, which can lead to errors in the normal small bowel due to their similar enhancement to the small bowel or non-specific enhancement. In addition, small bowel malignancies are sometimes mistaken for masses of other origins, such as the uterus, rectum, or omentum. In this article, we describe various small-bowel malignancies, their mimicking lesions and the typical and atypical features on CT imaging along with their clinical manifestations.

Safety, efficacy, and selection strategy of laparoscopic local gastrectomy for gastrointestinal stromal tumors in the esophagogastric junction

Objective

To investigate the safety, efficacy, and selection strategy of laparoscopic local gastrectomy for stromal tumors in the esophagogastric junction.

Methods

Thirty-eight patients with mesenchymal tumors in the esophagogastric junction were retrospectively enrolled from April 2018 to July 2021 in which the upper edge of the tumor is less than 2 cm from the Z-line or has invaded the Z-line <1/2 circumference. Surgical outcomes, complications, recover, and postoperative gastroesophageal reflux of both groups were compared.

Results

27 patients underwent wedge resection, and 11 underwent resection by opening all of the layers of the stomach wall. Operative time (90.0 vs. 181.8 min, respectively, P = 0.001) was shorter for the WR group vs. RASW. Blood loss (20 vs. 50 ml, respectively, P = 0.012) was less for the WR group vs. RASW. Recovery of the RASW group was slower in terms of time to pass gas (2 vs. 3 days, P = 0.034), time to oral intake (2 vs. 4 days, P = 0.007), time to semi-liquid food intake (4 vs. 8 days, P = 0.003), and postoperative hospitalization (5 vs. 8 days, P = 0.001) vs. WR. In terms of short-term complications (≤30 days), no significant between-group differences were observed. Cardia stenosis did not occur in either group. In the WR group, one patient experienced mild reflux at 6 months and recovered 1 year after surgery. In the RASW group, one patient experienced severe gastroesophageal reflux at 6 months and 1 year after surgery, which was not entirely relieved by taking antacids. No other patients have gastroesophageal reflux.

Conclusion

Laparoscopic local gastrectomy is safe and feasible for mesenchymal tumors in the esophagogastric junction in which the upper edge of the tumor is less than 2 cm from the Z-line or has invaded the Z-line <1/2 circumference, and has achieved an excellent short-term effect. The choice of surgery is based on the relationship between the tumor and the position of the cardia.

A Huge Malignant Gastric Gastrointestinal Stromal Tumor in a Young Patient

Malignant gastrointestinal stromal tumors (GISTs) are rare neoplasms originating from the gastrointestinal tract that rarely occur in patients below 40 years of age. To our knowledge, there have been no previous reports of satellite and metastatic nodules in GIST. We present a case of a young patient with a huge malignant gastric GIST accompanied by spontaneous bleeding and satellite and metastatic nodules, successfully treated surgically, without preoperative chemotherapy administration. A 28-year-old man was admitted to Haeundae Paik Hospital with melena. A huge bulging gastric mass with ulceration and bleeding was observed on endoscopy. A subepithelial lesion on the stomach body, abutting the pancreatic body and tail, with regional lymph node enlargement was confirmed by EUS and CT. Radical total gastrectomy was performed, the invasion surrounding the pancreatic tail and spleen were surgically dissected, and enlarged lymph nodes around the celiac trunk and the common hepatic artery were removed. The pathology results showed a malignant GIST with two satellite nodules and a metastatic tumor nodule at the left paracardial lymph node site. After complete resection of the malignant GIST, adjuvant chemotherapy with imatinib was initiated. Follow-up CT and endoscopy performed 6 months after surgery confirmed no recurrence of the disease.

Safety of laparoscopic local resection for gastrointestinal stromal tumors near the esophagogastric junction

PURPOSE

Laparoscopic local resection for gastrointestinal stromal tumors (GISTs) near the esophagogastric junction (EGJ) increases the risk of injuring the EGJ. We investigated the safety of laparoscopic local resection for GISTs near the EGJ according to the distance from the EGJ to the tumor edge.

METHODS

We retrospectively evaluated 40 patients who had undergone laparoscopic local resection for GISTs near the EGJ between January 2009 and December 2019. After excluding 1 patient who had undergone right colectomy at the same time, 39 patients were classified according to distance of the GIST from the EGJ in the Near group (0-2.0 cm; n = 16) and the Far group (2.1-5.0 cm; n = 23).

RESULTS

We found no marked differences in the operation time, blood loss, length of postoperative hospital stay, or postoperative complication rate in the two groups. Anastomotic leakage occurred with a tumor located on the EGJ. Three tumors recurred in the Near group, and all of them were located on the EGJ.

CONCLUSION

Except for GISTs located on the EGJ, laparoscopic local resection for GISTs near the EGJ can be performed safely with few postoperative complications and a low risk of recurrence.

Feasibility of Non-Exposure Simple Suturing Endoscopic Full-Thickness Resection in Comparison with Laparoscopic Endoscopic Cooperative Surgery for Gastric Subepithelial Tumors: Results of Two Independent Prospective Trials

Simple Summary

Nonexposure simple suturing endoscopic full-thickness resection (NESS-EFTR) is a recently developed method to prevent the exposure of tumor cells, and we performed a small prospective trial of NESS-EFTR for gastric subepithelial tumors (SETs). In this study, we compared the results of NESS-EFTR trial with those of another small prospective trial of laparoscopic and endoscopic cooperative surgery which was performed in different time period. The results of this study show the feasibility of NESS-EFTR for gastric SETs and provide evidence for the clinical application of the NESS-EFTR procedure.

Abstract

Recently, nonexposure simple suturing endoscopic full-thickness resection (NESS-EFTR) method was developed to avoid tumor exposure to the peritoneal cavity. The aim of this study is to compare the short-term outcomes of the NESS-EFTR method with those of laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumors (SETs). A prospective single-center trial of LECS for gastric SETs was performed from March 2012 to October 2013 with a separate prospective trial of NESS-EFTR performed from August 2015 to June 2017, enrolling 15 patients each. Among the 30 enrolled patients, 14 who underwent LECS and 11 who underwent NESS-EFTR were finally included in the analysis. The rate of complete resection and successful closure was 100% in both groups. The operating time was longer for NESS-EFTR group than for LECS (110 vs. 189 min; p < 0.0001). There were no postoperative complications except one case of transient fever in the NESS-EFTR group. One patient in the LECS group had peritoneal seeding of gastrointestinal stromal tumor at 17 months postoperatively, and there was no other recurrence. Although NESS-EFTR had long operating and procedure times, it was feasible for patients with gastric SETs requiring a nonexposure technique.

Robotic surgery for gastric gastrointestinal stromal tumors: A single center case series

BACKGROUND AND OBJECTIVES

The aim of surgical treatment of gastrointestinal stromal tumors (GIST) is a microscopically complete resection. Initial indications for laparoscopic surgery were limited to smaller tumors, in favorable locations. Over time, indications for minimal invasive surgery (MIS) have expanded, however concerns remain when considering resection of larger GISTs. Our aims were to assess the utility of robotic resection of gastric GISTs for challenging tumors.

METHODS

GIST resections, in this study were performed using the Intuitive Da Vinci Surgical Xi System. GIST's were considered challenging if tumor size was >50 mm at the time of surgery and/or the location of the tumor was type II, III, or IV using Privette/Al-Thanai classification.

RESULTS

Robotic resections were performed on 12 consecutive patients, 83% were considered challenging cases, 6 out of 12 for location and 5 out of 12 for size. Initial median tumor size on imaging was 53.7 mm, and post-imatinib was 45.8 mm. All tumors were removed with clear margins (R0) via wedge resections, with no complications. Median operative time was 192 minutes (95-250). Length of hospital stay was 2 days (2-6).

CONCLUSIONS

Robotic resection of gastric GIST's appears oncologically safe, and may expand the benefits of MIS to a greater cohort of complex cases.

Recent advances in the management of gastrointestinal stromal tumor

Gastrointestinal stromal tumor (GIST) is a rare but an important clinical entity seen in our clinical practice. It is the most common mesenchymal tumor of the gastrointestinal tract and most common malignancy of the small intestine. Although the exact prevalence of GIST is not known, the incidence of GIST has been increasing. GISTs arise from interstitial cells of Cajal. Most of the GISTs occur due to mutation in c-kit gene or platelet derived growth factor receptor alpha gene. 15% of GISTs do not have these mutations and they are called wild-type GISTs. Almost all GISTs express KIT receptor tyrosine kinase. Histologically, GISTs look like spindle cell tumors most of the time but they can be epitheloid or mixed type. The median size of GISTs varies from 2.7 cm to 8.9 cm. Clinically, patients with small GISTs remain asymptomatic but as the GIST size increases, patients present with various symptoms depending on the location of the GIST. Most of GISTs are located in the stomach or small bowel. Diagnosis is suspected on imaging and endoscopic studies, and confirmed by tissue acquisition with immunohistochemical staining. The aggressiveness of GISTs depends on the size, mitotic index and location. Surgical resection is the treatment of choice. But various endoscopic modalities of resection are increasingly being tried. Tyrosine kinase inhibitors are extremely useful in the management of large GISTs, unresectable GISTs and metastatic GISTs. Treatment options for metastatic GISTs also include radiotherapy, chemotherapy, hepatic artery embolization, chemoembolization and radiofrequency ablation.

Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients' tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection

Background and aims

Endoscopic full-thickness resection (EFTR) has been increasingly applied in the treatment of gastric submucosal tumors (G-SMTs) with explorative intention. This study aimed to compare the efficacy, tolerability, and clinical outcomes of EFTR and surgical intervention for the management of muscularis propria (MP)-derived G-SMTs.

Methods

Between September 2011 and May 2019, the clinical records of patients with MP-derived G-SMTs undergoing EFTR at our endoscopic unit were collected. A cohort of people with primary MP-derived G-SMTs treated by surgery was matched in a 1:1 ratio to EFTR group with regard to patients’ baseline characteristics, clinicopathologic features of the tumor and the procedure date. The perioperative outcomes and follow-up data were analyzed.

Results

In total, 62 and 62 patients were enrolled into the surgery and EFTR group, respectively, with median follow-up of 786 days. The size of G-SMTs (with ulceration) ranged from 10 to 90 mm. For patients with tumor smaller than 30 mm, surgery and EFTR group presented comparable procedural success rate (both were 100%), en bloc resection rate (100% vs. 94.7%), tumor capsule rupture rate (0% vs. 5.3%), and pathological R0 resection rate (both were 100%). EFTR had a statistically significant advantage over surgery for estimated blood loss (3.12 ± 5.20 vs. 46.97 ± 60.73 ml, p ≤ 0.001), discrepancy between the pre- and postprocedural hemoglobin level (5.18 ± 5.43 vs. 9.84 ± 8.25 g/L, p = 0.005), bowel function restoration [1 (0–5) vs. 3 (1–5) days, p ≤ 0.001], and hospital cost (28,617.09 ± 6720.78 vs. 33,963.10 ± 13,454.52 Yuan, p = 0.033). The patients with tumor larger than 30 mm showed roughly the same outcomes after comparison analysis of the two groups. However, the clinical data revealed lower en bloc resection rate (75.0% vs. 100%, p = 0.022) and higher tumor capsule rupture rate (25.0% vs. 0%, p = 0.022) for EFTR when compared to surgery. The procedure time, duration of postprocedural fasting and antibiotics usage, and hospital stay of the two groups were equivalent. The occurrence rate of adverse events within postoperative day 7 were 74.2% and 72.6% after EFTR and surgery, respectively (p = 1.000). No complications occurred during the follow-up.

Conclusion

For treatment of MP-derived G-SMTs (with or without ulceration), our study showed the feasibility and safety of EFTR, which also provided better results in terms of procedural blood loss, the postoperative bowel function restoration and cost-effectiveness when compared to surgery, whereas the surgery was superior in en bloc resection rate for G-SMTs larger than 30 mm. The postprocedural clinical outcomes seemed to be equivalent in these two resection methods.

Microscopically Positive Resection Margins in Laparoscopic Gastric GIST Resection May Not Confer a Poorer Prognosis

Laparoscopic resection of gastrointestinal stromal tumor (GIST) has increased popularity with studies showing good outcomes for patients with tumors <5 cm, with a shorter hospital stay, lower blood loss, and morbidity. Our study aims to audit the clinical profile and surgical outcomes of GISTs, with an evaluation of laparoscopic versus open surgery and the prognostic role of positive R1 margins. In our retrospective study, 62 GIST patients who underwent surgery were included and further analysis was made for the 48 gastric GISTs patients. In total, 33 patients underwent laparoscopic gastric GIST resection, whereas the rest underwent open resection. There was no difference in operative duration but the blood loss was lesser and length of stay shorter in the laparoscopic group. The laparoscopic group had a higher incidence of R1 resection but none developed recurrence or metastasis during follow-up. Laparoscopic resection in the management of gastric GISTs resulted in higher R1 resection rates but this did not affect recurrence rates or overall survival.

A novel technique for removing large gastric subepithelial tumors with ESD method in the subcardia region

Previously, patients with tumors larger than 4 cm in sub-cardia region usually received open gastrectomy. Due to its anatomic features, the cardia is often considered as a contraindicated area for endoscopic resection. Herein, we report a novel technique of endoscopic submucosal dissection (ESD) which facilitates the removal of gastric subepithelial tumors (SMTs) larger than 4 cm in the subcardia and fundus region. This is a retrospective case series of patients with SMTs larger than 4 cm in the subcardia and fundus regions who received the novel procedure of ESD between October 2015 and October 2016. The novel procedure of ESD involved a median linear incision of the mucosa being made in the central area of the tumor, followed by the submucosal dissection. The residual defect was finally closed using titanium endoclips. The endoscopical outcomes, histopathological findings as well as other complications were assessed. Eight patients fulfilled the entry criteria. The mean lesion size was 45.6±7.5 mm (range: 40.0-65.0 mm), and the mean operating time was 83±13 min (range: 60-100 min). The en bloc resection rate was 100%. Although perforations occurred in 5 out of 8 patients, they were successfully closed with endoclips. The median length of inpatient hospital stay was 6 days (range: 5-8 days). No patients needed further gastrectomy. The median follow-up was 36 months and none of the patients developed local recurrence or distant metastasis. The advanced procedure of ESD is feasible and safe for tumors more than 4 cm in the subcardia region. It could be applied as a novel technique for treating patient without surgical interventions.

Magnetically Actuated Soft Capsule Endoscope for Fine-Needle Biopsy

Wireless capsule endoscopes have revolutionized diagnostic procedures in the gastrointestinal (GI) tract by minimizing discomfort and trauma. Biopsy procedures, which are often necessary for a confirmed diagnosis of an illness, have been incorporated recently into robotic capsule endoscopes to improve their diagnostic functionality beyond only imaging. However, capsule robots to date have only been able to acquire biopsy samples of superficial tissues of the GI tract, which could generate false-negative diagnostic results if the diseased tissue is under the surface of the GI tract. To improve their diagnostic accuracy for submucosal tumors/diseases, we propose a magnetically actuated soft robotic capsule robot, which takes biopsy samples in a deep tissue of a stomach using the fine-needle biopsy technique. We present the design, control, and human-machine interfacing methods for the fine-needle biopsy capsule robot. Ex vivo experiments in a porcine stomach show 85% yield for the biopsy of phantom tumors located underneath the first layers of the stomach wall.

Multifocal gastrointestinal stromal tumor: A case report with CT, surgical, and histopathologic correlation

Mutifocal gatrointestinal stromal tumors (GISTs) are rare conditions that are usually associated with other syndromes or reported in pediatric cases. The sporadic form represents only 11% of GISTs. The imaging features on a contrast-enhanced computed tomography examination, surgery and histopathology of a rare case of a sporadic multifocal small bowel GISTs in an emergency setting are described. This case highlights how GISTs appearances on an imaging computed tomography may vary. Radiologists can have difficulty in defining the point of origin of large lesions. In our case, laparotomy open surgery was mandatory to figuring out the correct diagnosis.

Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site

AIMS

The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi).

SUBJECTS AND METHODS

Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification.

RESULTS

Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications.

CONCLUSION

Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.

5-Year Survival in Gastric Adenocarcinoma with Epithelial and Stromal Versican Expression

Background & Objective

Gastric cancer is the second most frequent cause of cancer death worldwide, despite dif- ferences in incidence around the world. The majority of gastric cancer cases concern gastric adenocarcinoma, which has a fairly high 5-year survival rate when coupled with early-stage diagnosis. Versican, a member of the aggregating chondroitin sulfate proteoglycans family, is accumulated predominantly in the tumor stroma. The aim of our study was to investigate versican expression in gastric adenocarcinoma.

Methods

In this study we investigated 80 patients with gastric adenocarcinoma who underwent gastrectomy. Each sample was obtained from paraffin-embedded resected specimens of the stomach after histopathological diagnosis. Patient follow-up was performed every 3 months after the beginning of data collection. Survival analysis was calcu- lated using the Kaplan-Meier method for univariate analysis.

Results

Out of 80 patients with gastric adenocarcinoma, 76 cases (76.3%males and 23.7% females) completed the follow-up period. Positive versican expression in tumor epithelial and stromal cells was found in 39.5% and 22.4% of tumors, respectively. Shorter survival was observed among patients whose gastric adenocarcinoma expressed epithelial or stromal versican.

Conclusion

In summary, the present study suggests that versican is likely a prognostic biomarker that predicts a poor outcome in patients with gastric adenocarcinoma. Comprehensive studies with larger sample sizes are needed.

Importance of Early Diagnosis of Gastrointestinal Stromal Tumors of the Stomach: Our 5-Year, Single-Center Experience

Objective:

The aim of this study was to investigate clinicopathologic characteristics, diagnosis, treatment, and prognosis of patients who underwent surgery with a diagnosis of a gastrointestinal stromal tumor (GIST) of the stomach.

Methods:

In this single center study, the data of a total of 42 patients diagnosed with a GIST of the stomach in our center between 2010 and 2015 were retrospectively analyzed. The mean age was 60.6 years, with a male-to-female ratio of 1.47/1. Patients presented with various complaints (21 patients had stomach pain,14 patients were asymptomatic, 3 patients had hemorrhage, 2 patients had heartburn and acidity,1 patient had intumescence,1 patient had nausea and vomiting), and all patients underwent surgery. The initial diagnosis was made with endoscopy in 19 patients, with computed tomography in 21 patients, and with magnetic resonance imaging in 2 patients. Local excision or wedge resection was performed in 27 patients, whereas subtotal gastrectomy was performed in 15 patients.

Results:

The mean tumor diameter was 5.66 cm. Pathologically, 25 patients had very low, 5 patients had low, 6 patients had moderate, and 6 patients had high-grade malignancy. The patients with moderate- to high-grade malignancy received imatinib. Liver metastasis occurred in 2 patients. The mean follow-up was 33 months. The mean disease-free survival time was 31.72 months, and the mean disease-specific (n = 2) survival time was 31.25 months. All patients including metastatic ones were still alive.

Conclusions:

Our study results show that frequent use of imaging studies and increased use of endoscopic scans for various reasons may increase the rate of incidentally detected gastric stromal tumors. High rates of disease-free survival can be achieved in GIST patients who are in the low-risk group due to the early diagnosis.

Evaluation for therapeutic measures to small gastric stromal tumor: A retrospective study of 90 cases

Surgery and regular follow-up are two main measures for small gastric stromal tumors (sGST) less than 2cm in diameter, while there is no sound evidence to prove which treatment is more beneficial to sGST patients. In this study, we reviewed the clinical and pathological features of patients with sGST receiving surgery and discussed the value of surgical intervention. In all, 90 patients who were diagnosed as sGST(less than 2cm) and accepted surgical treatment were enrolled, correspondently, another 104 patients with GSTs between 2-5cm and 74 patients with GSTs >5cm were collected as Control groups 1 and 2, respectively, and all of them received surgical treatment. Results showed that there were no significant difference among 3 groups in terms of gender, age, clinical features, tumor locations, and mutations of the exon 9 or 11 in C-kit gene, and immunohistochemical results of CD117, CD34, and DOG-1 proteins (P > 0.05). However, we observed growing percentage of medium-/high-risk GSTs and nucleus mitotic counts >5/50 HPF in Control groups (P < 0.05). Patients with sGST were more suitable for minimally invasive procedures than the other 2 groups, with shorter hospital stay (P < 0.05). During the follow-up period (medium 45.4 months), the recurrence rate was also associated with tumor size, which surged from 1.11% in sGST group to 7.69% and 17.56% in Control groups 1 and 2, respectively. In all, we concluded that patients with sGST experienced low proportions of medium-/high-risk tumors; however, they still suffered from potential risk of tumor progression. Due to satisfied surgical outcome, surgical treatment could be suggested for sGST.

Laparoscopic Versus Open Resection for Gastric Gastrointestinal Stromal Tumors (GISTs): A Size-Location-Matched Case-Control Study

BACKGROUND

Laparoscopic resection for gastric gastrointestinal stromal tumors (GISTs) is technically feasible, but the long-term effect remains uncertain. This study aims to compare the long-term oncologic outcomes of laparoscopic versus open resection of GISTs by larger cases based on tumor size-location-matched study.

METHODS

Between 2006 and 2015, 63 consecutive patients with a primary gastric GIST undergoing laparoscopic resection were enrolled in and matched (1:1) to patients undergoing open resection by tumor size and location. Clinical and pathologic parameters and surgical outcomes associated with each surgical type were collected and compared.

RESULTS

The operation time, intraoperative blood loss, return of bowel function and oral intake, nasogastric tube retention time and postoperative stay were all shorter/faster in laparoscopic group than those in open group (P < 0.001). Postoperative complications were comparable except for the higher incidence of abdominal/incision pain in open group (9.52 vs 27%, P = 0.01). There was no statistical difference in recurrence rate (9.52 vs 15.87%, P = 0.29) and long-term recurrence-free survival between the two groups (P = 0.39).

CONCLUSIONS

The long-term oncologic outcome of laparoscopic resection of primary gastric GISTs is comparable to that of open procedure, but laparoscopic procedure has the advantage of minimal invasion and is superior in postoperative recovery.

Laparoscopic resection for gastrointestinal stromal tumors in esophagogastric junction (EGJ): how to protect the EGJ

BACKGROUND

Laparoscopic surgery for gastric gastrointestinal stromal tumors (GISTs) is now widely performed. However, laparoscopic resection of GIST in the esophagogastric junction (EGJ) is technically difficult and rarely reported. Herein, we introduce four fashions of laparoscopic resection for EGJ-GIST.

METHODS

A retrospective review of 42 consecutive patients with EGJ-GIST who underwent attempted laparoscopic surgery was conducted. EGJ-GIST was defined as GIST with an upper border of less than 5 cm from the esophagogastric line. Four fashions of laparoscopic resection were performed: fashion A, laparoscopic wedge resection using linear stapler; fashion B, laparoscopic complete resection by opening the stomach wall and closing with suture or linear stapler; fashion C, laparoscopic mucosa-preserving resection; and fashion D, laparoscopic proximal gastrectomy with pyloroplasty and gastric plication. Clinicopathologic characteristics, operative course, and short-term and long-term outcomes were analyzed.

RESULTS

All procedures were completed successfully without operative complications. In 24 of 42 (57.1%) patients, tumors were located in the fundus or greater curvature. Out of those, 70.8% (17/24) received fashion A and 29.2% (7/24) received fashion B. Tumors in 16 of 42 (38.1%) patients were located in the lesser curvature. Of those, 81.3% (13/16) underwent fashion B and 18.7% (3/16) underwent fashion D. One tumor in the anterior stomach wall and one in the posterior wall received fashion C. The mean operative time was 103.8 ± 22.1 min and the mean estimated blood loss was 22.4 ± 13.5 ml. The mean time to flatus was 40.3 ± 12.9 h and the time to fluid intake was 43.2 ± 14.3 h. The mean hospital stay was 4.8 ± 2.1 days.

CONCLUSIONS

Laparoscopic surgery for EGJ-GIST is safe and feasible. The selection of various laparoscopic resection fashions should be chosen based on tumor location and the surgeon's experience.

Effectiveness and safety of endoscopic resection for gastric GISTs: a systematic review

AIMS

To evaluate the effectiveness and safety of endoscopic resection for gastric gastrointestinal stromal tumors (GISTs).

MATERIAL AND METHODS

The effectiveness and safety of endoscopic resection were mainly assessed by complete resection rate, postoperative adverse event rate, and recurrence rate. Moreover, a comparison of endoscopic with laparoscopic resection for gastric GISTs was made through weighted mean difference by STATA 12.0 with regard to operation time, blood loss, and length of stay after including patients who underwent endoscopic or laparoscopic resection for gastric GISTs in the comparative studies.

RESULTS

Eleven studies investigating endoscopic resection for GISTs were included. For stromal tumors <2 cm in average diameters the pooled rates of complete resection, postoperative adverse events and recurrence were 0.97, 0.08, and 0.03, respectively. Only five retrospective studies directly compared endoscopic with laparoscopic resection for gastric GISTs with average diameters from 1.1 cm to 3.8 cm, and endoscopic resection had a shorter operation time than laparoscopic resection, but there were no significant differences in intraoperative blood loss, length of stay, postoperative complications, and postoperative recurrence rates between the two approaches.

CONCLUSIONS

Endoscopic resection is predominantly tried for gastric GISTs of relatively small size. It seems effective and safe for gastric GISTs <2 cm in average diameter, with relatively short operation times.

Laparoscopic techniques and strategies for gastrointestinal GISTs

The laparoscopic approach is widely accepted surgical treatment for gastrointestinal submucosal tumors (SMTs). In this chapter, we will introduce laparoscopic techniques and strategy for gastrointestinal SMTs, in accordance with those for gastrointestinal stromal tumors (GISTs). The indication for a laparoscopic approach has been related to tumor size. The upper limit of tumor size has increased, according to recent trends, and there is no established guideline for a lower limit. All patients undergoing laparoscopic surgery receive preoperative examinations including gastrofiberscopy, upper gastrointestinal radiography, computed tomography (CT), and endoscopic ultrasonography (EUS). Gastric tumors <20 mm in diameter measured by EUS or CT are preoperatively localized by gastrofiberscopic clipping of the mucosa covering the SMT. While maintaining the principle of local resection with a negative resection margin, different surgical techniques are required depending on the location and configuration of the tumor. A single dose of a second-generation cephalosporin is administered to patients as a prophylactic antibiotic before or immediately after operation. If a patient undergoes wedge resection, a semi-bland diet will be provided within 48-72 hours. However, in cases of proximal or distal gastrectomy, the diet will be restricted for several days. A "no-touch" technique, by which the risk of tumor dissemination can be minimized, includes grasping the surrounding tissues, holding the threads sutured at the normal serosa around the tumor, and using a laparoscopic stapler or bag during laparoscopic resection.

Our experience with laparoscopic partial gastrectomy by the 'lift-and-cut method' for gastric gastrointestinal stromal tumor with maximal preservation of the remnant stomach

BACKGROUND

Wedge resection is the most commonly used method in laparoscopic partial gastrectomy for gastric gastrointestinal stromal tumor (GIST). However, this method can involve inadvertent resection of additional gastric tissue and cause gastric deformation. To minimize the volume of resected gastric tissue, we have developed a laparoscopic partial gastrectomy with seromyotomy which we call the 'lift-and-cut method' for gastric GIST. Here, we report a case series of this surgery.

METHOD

First, the seromuscular layer around the tumor is cut. Because the mucosa and submucosa are extensible, the tumor is lifted toward the abdominal cavity. After sufficient lifting, the gastric tissue under the tumor is cut at the submucosal layer with a linear stapler (thus 'lift-and-cut method'). Finally, the defect in the seromuscular layer is closed with a hand-sewn suture.

RESULTS

From April 2011 to December 2015, 28 patients underwent laparoscopic partial gastrectomy by this method at Osaka Red Cross Hospital. Average operation time was 126 min (range 65-302 min) and average blood loss was 10 ml (range 0-200 ml). No intraoperative complications including tumor rupture or postoperative complications regarded as Clavien-Dindo Grade II or higher occurred. All patients took sufficient solid diet at discharge. Median postoperative hospital stay was 7 days (range 5-21 days). On median follow-up of 26.6 months (range 6-54 months), no recurrence was reported.

CONCLUSION

Laparoscopic partial gastrectomy by the lift-and-cut method is safe and simple, and widely applicable for gastric GIST.

Application of novel endoloops to close the defects resulted from endoscopic full-thickness resection with single-channel gastroscope: a multicenter study

BACKGROUND

The key step of the endoscopic full-thickness resection (EFTR) procedure is the successful closure of any gastric wall defect which ultimately avoids surgical intervention. This report presents a new method of closing large gastric defects left after EFTR, using metallic clips and novel endoloops by means of single-channel endoscope.

METHODS

We retrospectively analyzed 68 patients who were treated for gastric fundus gastrointestinal stromal tumors originating from the muscularis propria layer at four institutes between April 2014 and February 2015 and consequently underwent EFTR. The large gastric post-EFTR defects were completely closed with metallic clips and novel endoloops using single-channel endoscope, and all the patients were discharged with subsequent endoscopic and clinical follow-up. Patient characteristics, tumor size, en bloc resection rate, closure operation time, and postoperative adverse events were evaluated.

RESULTS

EFTR was successfully performed on 68 patients [41 male (60 %), 27 female (40 %); median age 61 years, range 38-73], and the en bloc resection rate was 100 %. Complete closure of all the gastric post-EFTR defects was achieved (success rate 100 %). The mean closure operation time was 13 min (range 9-21 min). The mean maximum size of the lesions was 2.6 cm (range 2.0-3.5 cm). One Mallory-Weiss syndrome and one delayed bleeding were resolved with nonsurgical treatment. The wounds were healed in all cases 1 month after the procedure.

CONCLUSIONS

The use of metallic clips and novel endoloops with single-channel endoscope is a relatively safe, easy, and feasible method for repairing large gastric post-EFTR defects.

Small EUS-suspected gastrointestinal stromal tumors of the stomach: An overview for the current state of management

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors found in the gastrointestinal (GI) tract, with the stomach being the most common site. They represent a distinct group of GI tumors originating from the interstitial cells of Cajal and are characterized by gain-of-function mutations of KIT. KIT oncoprotein serves as both diagnostic and therapeutic targets. Prognosis is related to size, mitotic activity, and site of the tumor. Asymptomatic, small endoscopic ultrasonography (EUS)-suspected GISTs are increasingly encountered with the wide availability of endoscopic/endosonographic examination. The majority of small GISTs are biologically indolent, albeit possibly harboring c-KIT gene mutations. An ongoing controversy exists regarding the management and surveillance policy for small gastric GISTs. A number of reports on the management of GISTs have been published, not confidently addressing the issue of gastric GISTs of small size. This work provides an overview on the current state of management considerations, specifically focusing on small EUS-suspected gastric GISTs, which are increasingly encountered by clinicians.

Comparison of minilaparoscopy and single-incision intragastric surgery for gastric submucosal tumor resection in a porcine model

BACKGROUND

The aim of this study was to develop an easy-to-induce and reproducible model of gastric submucosal tumor in swine to compare minilaparoscopy (ML) with single-incision (SI) intragastric surgery.

METHODS

Twelve healthy female pigs (weight 30.94 ± 2.49 kg) underwent a transparietal injection of sterile alginate at the level of Z-line (n = 6) and at the pre-pyloric area (n = 6) creating a model of gastric submucosal pseudotumor. The operative procedures included intragastric resection with ML and SI approaches of cardiac and pre-pyloric lesions, with gastroscopic assistance. After resection, the gastric mucosal layer was closed using intracorporeal sutures. The operative time, complication rate and clinical evolution after 1 month were compared in the four groups that the pigs were arranged.

RESULTS

The pseudotumors ranged in size from 3 to 6 cm in diameter. The access of the gastric cavity and resection of the experimental SMP and suturing of the mucosa were performed successfully in 12 animals using both approaches. Mean time to perform the exeresis of gastric cardia tumors was significantly higher in single-incision approach. No significant differences were observed in the surgical time during pyloric surgery. Minilaparoscopic approach reduced significantly the mucosa closure time in esophagogastric and pyloric pseudotumors. One month after, no alterations were shown in the abdominal cavity using exploratory laparotomy.

CONCLUSIONS

The technical feasibility of performing safe and efficient intragastric approach of submucosal pseudotumors in swine model was verified in this study. Intragastric ML has advantages over SI, namely regarding the reduction in total surgical times and the fewer technical difficulties.

Cap-aspiration lumpectomy for small submucosal tumors originating from the muscularis propria of the gastric fundus: a preliminary study (with videos)

OBJECTIVE

Small fundal submucosal tumors (SMTs) originated from the muscularis propria pose great difficulties to conventional therapies. We aimed to evaluate the feasibility and safety of endoscopic cap-aspiration lumpectomy (CASL) as a new and simple full-thickness resection for the treatment of small fundal SMTs.

METHODS

From July 2013 to February 2014, patients with small fundal SMTs of ≤10 mm in diameter that were originated from muscularis propria were included in the study. CASL was performed by suctioning SMTs into a transparent cap, ligating with a metal snare and resecting the tumors. The wall deficit was closed by using endoclips.

RESULTS

Altogether 28 patients were included in the study. CASL achieved an en bloc resection rate of 100%, with a mean total procedure time of 23.9 min. Active perforation was found in 20 (71.4%) patients, and endoclips closed the wall defect in all 20 cases. One patient developed pneumoperitoneum and self-limited peritonitis was found in two patients, all of whom were managed successfully. Pathological examination showed that 71.4% (20/28) of the tumors were gastrointestinal stromal tumors. No tumor recurrence was observed during the follow-up.

CONCLUSIONS

CASL may be a feasible and safe full-thickness resection modality for the treatment of small fundal SMTs arising from the muscularis propria. Further randomized studies are needed to confirm the results.

Novel method for hybrid endo-laparoscopic full-thickness gastric resection using laparoscopic transgastric suture passer device

BACKGROUND

Current surgical methods for partial gastric full-thickness resections (FTRs) are limited by long operative times and risk of gastric content spillage, especially for lesions located at the posterior wall. We propose a simplified hybrid approach to FTR with reduced risk of spillage.

METHODS

Resection margins were marked by endoscopic electrocautery to simulate a gastric lesion in the upper third of the posterior wall in eight pigs. A custom-made laparoscopic "suture passer" was made of a sharpened bendable dissecting forceps. Full-thickness sutures were alternatively passed from the serosa side with the suture passer through the gastric wall and grabbed endoluminally using an endoscopic grasper and vice versa. These transgastric sutures formed either a purse string (PS; n = 4) or a continuous horizontal mattress (HM; n = 4). Sutures were then fastened from the laparoscopic side, resulting in external outpouching of the lesion. The pouch was transected using 45-mm linear staplers. Operative time, resection margins, and number of staplers were evaluated.

RESULTS

The combined approach allowed one to precisely place the sutures around the pseudo lesions, despite the inflated stomach, and it included all target markings. PS and HM methods were similar regarding time for transgastric suture (780 s ± 219.1 s vs. 765 s ± 179.2 s, p = .885), resection margins (1.3 ± 1.0 cm vs. 0.8 ± 0.6 cm, p = .248), and number of staplers (3.8 ± 1.0 vs 3.3 ± 0.5, p = .405). Stapling time (600 s ± 189.7 s vs. 330 s ± 24.5 s, p = .028) was significantly shorter in the HM technique.

CONCLUSION

FTR with laparo-endoscopic transgastric suture application was feasible in the animal model. This technique allows one to achieve accurate resection margins with minimal risk of spillage.

Incidental gastrointestinal stromal tumor at a gastroscopic polypectomy specimen: A case report and review of literature

Although gastrointestinal stromal tumors (GISTs) comprise less than 1% of all gastrointestinal (GI) tract tumors, they are the most common mesenchymal tumors of the GI tract. Gastrointestinal stromal tumors can occur anywhere along the GI tract, but the stomach and small intestine are the most frequently involved sites. Gastrointestinal stromal tumors are frequently asymptomatic, and one-third of all cases are found incidentally. Endoscopy, endoscopic ultrasonography, and computed tomography are useful tools in the diagnosis. Endoscopic mucosal resection, endoscopic submucosal dissection, laparoscopic endoscopic cooperative surgery, and surgery with either laparoscopic or open approaches are treatment modalities for GISTs. An R0 resection is the principle surgery. Imatinib is the main medical agent used in the adjuvant or neoadjuvant treatment of GIST. We present a 65-year-old woman with an asymptomatic GIST that arose from a gastric polyp treated via endoscopic polypectomy.

Giant gastrointestinal stromal tumour of rare sarcomatoid epithelioid subtype: Case study and literature review

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract, but they represent less than 3% of all gastrointestinal tract malignancies. This is a detailed case study of a 52-year-old male patient treated for very uncommon histological subtype of gastric GIST with atypical clinical presentation, asymptomatic progress and late diagnosis. The resected tumour, giant in diameters, was confirmed to represent the most rare histopathologic subtype of GISTs - sarcomatoid epithelioid GIST. We report this case and review the literature with a special focus on pathomorphological evaluation, biological aggressiveness and prognostic factors. To our knowledge this is the first report of giant GIST of very uncommon sarcomatoid epithelioid subtype. It is concluded that clinicians should pay attention to the fact that initial diagnosis may be delayed due to mildly asymptomatic and non-specific clinical presentation. Asymptomatic tumours diagnosed at a late stage, which is often the case, can be large on presentation. Prognosis for patients diagnosed with GIST depend on tumour size, mitotic rate, histopathologic subtype and tumour location. That is why early diagnosis and R0 resection, which is usually feasible and safe even in giant gastric sarcomatoid epithelioid subtype of GISTs, are the key factors for further treatment and good prognosis.

Minimally invasive surgeries for submucosal tumors of the stomach

Submucosal tumors (SMTs) of the gastrointestinal tract, which may be an occasional finding on routine upper gastrointestinal (GI) endoscopy, represent a diagnostic and therapeutic challenge. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract and have the potential to progress to malignancy. The primary treatment goal for localized GISTs is surgical resection with achievement of a negative margin (R0 resection). This is the effective way to achieve complete treatment. Minimally invasive surgery has become common in the surgical resection of gastrointestinal SMTs. Recent advances in endoscopic technology provide various treatment modalities for gastric SMTs. Moreover, investigators have developed laparoscopic and endoscopic cooperative procedures. In addition, robotic surgery for SMTs is another choice. The purpose of this article is to review recent trends in minimally invasive surgery for gastric SMTs.

Minimally invasive surgery for submucosal (subepithelial) tumors of the stomach

Minimally invasive surgery has become common in the surgical resection of gastrointestinal submucosal tumors (SMTs). The purpose of this article is to review recent trends in minimally invasive surgery for gastric SMTs. Although laparoscopic resection has been main stream of minimally invasive surgery for gastrointestinal SMTs, recent advances in endoscopic procedures now provide various treatment modalities for gastric SMTs. Moreover, investigators have developed several hybrid techniques that include the advantages of both laparoscopic and endoscopic procedure. In addition, several types of reduced port surgeries, modification of conventional laparoscopic procedures, have been recently applied to the surgical resection of SMTs. Meanwhile, robotic surgery for SMTs requires further evidence and improvement.

Higher incidence of gastroesophageal reflux disease after gastric wedge resections of gastric submucosal tumors located close to the gastroesophageal junction

Purpose

We hypothesized that gastroesophageal reflux disease (GERD) would be more prevalent after a gastric wedge resection of a submucosal tumor (SMT) located close to the gastroesophageal junction (GEJ) than after a gastric wedge resection of an SMT at other locations because of the damage to the lower esophageal sphincter during surgery.

Methods

Fifty-eight patients with gastric SMT who underwent open or laparoscopic gastric wedge resection between January 2000 and August 2012 at the Department of Surgery, Incheon St. Mary's Hospital were enrolled into this study. The patients were divided into 2 groups according to the location of the tumor, upper or lateral border of the tumor within 5 cm of the GEJ (GEJ ≤ 5 cm group) and upper or lateral border of the tumor greater than 5 cm distal to the GEJ (GEJ > 5 cm group). The surgical records, clinicopathologic findings, postoperative GERD symptoms, postoperative use of acid suppressive medications and preoperative and postoperative endoscopic findings were retrospectively reviewed and compared between the 2 groups.

Results

There was no difference in the frequency of the preoperative GERD symptoms between the 2 groups, whereas postoperative GERD symptoms and postoperative use of acid suppressive medications were more frequent in the GEJ ≤ 5 cm group (P = 0.045 and P = 0.031). However, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and Hill's grade between the 2 groups.

Conclusion

The incidence of GERD was higher after gastric wedge resection of SMTs located close to the GEJ. Hence, adequate care should be taken during the follow-up of these patients.

Laparoscopic versus open gastric resection for larger than 5 cm primary gastric gastrointestinal stromal tumors (GIST): a size-matched comparison

BACKGROUND

Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) appears technically feasible and associated with favorable outcomes. Tumor size plays an important role in surgical approach, with laparotomy tending to be used to treat larger tumors. This study evaluated the technical feasibility, safety, and oncologic efficacy of laparoscopic surgery for GISTs ≥5 cm in diameter.

METHODS

One hundred forty patients who underwent resection of primary gastric GIST at our institution from January 2007 to December 2012 were identified. Twenty-three patients with tumor larger than 5 cm in diameter treated by laparoscopic resection and were randomly matched (1:1) by tumor size (±1 cm) to patients with open resection. Clinical and pathologic variables and surgical outcomes for each surgical type were identified and compared.

RESULTS

There were no significant differences in clinicopathologic characteristics between the two groups. Laparoscopic group was superior to open group in operation time, blood loss, time to ground activities, time to first flatus, times to liquid diet, and postoperative stay (P < 0.05). Number of transfusions and time to semi-liquid diet, however, did not differ between groups. There was no operative mortality, and the postoperative complications were similar. Fifteen patients in the laparoscopic group and 17 patients in the open group received adjuvant treatment with imatinib. Recurrence or metastasis occurred in eight cases (three in the laparoscopic group and five in the open group). No significant difference in long-term disease-free survival was found between the two groups (P > 0.05).

CONCLUSION

When performed by experienced surgeons, laparoscopic resection for gastric GISTs larger than 5 cm is a safe and effective minimally invasive surgery.

Laparoscopic surgery for double gastrointestinal stromal tumor of the stomach: a report of two cases

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that originate from interstitial cells of Cajal or their stem cell-like precursors. Generally, GISTs have specific c-KIT gene mutations. The incidence of GISTs is estimated to be 10 to 20 cases/one million individuals, and GISTs typically affect people over 50 years of age. The majority of GISTs are solitary. However, multifocal GISTs have been observed, especially in children. We report on two unusual adult cases of double GISTs that were treated by laparoscopic surgery. The first patient presented a polypoid mass of the fundus and a second isolated smaller tumor in the posterior wall of the lesser curvature of the stomach. A histopathological examination confirmed that both tumors were GISTs and were c-KIT-positive. A total laparoscopic gastrectomy was performed. In the second patient, GISTs were identified at the level of the fundus and the greater curvature of the stomach. A laparoscopic partial sleeve gastrectomy was performed. Both surgeries were successful with no complications or relapses at three to five years following surgery.