Totally laparoscopic resection of a very large gastric GIST

Total inverse transgastric resection with transoral specimen removal

BACKGROUND

Laparoscopic local excision is accepted for gastrointestinal stromal tumors (GIST) and benign lesions of the stomach. Yet, tumors at the gastroesophageal junction, on the posterior wall, or in the distal antrum are difficult to approach. Such tumors often must be exposed via gastrotomy or using a rendezvous maneuver. Our method of total intragastric laparoscopic resection using 'pneumogastrum', rigid laparoscope, and conventional laparoscopic instruments is described in an intuitive video.

METHODS

Two cases of total inverse transgastric resection involved resection of a submucosal GIST, one at the front wall of the cardia and the other on the posterior wall of the antrum. The third case required excision of a large prepyloric cystic lesion leading to a gastric outlet stenosis. After insertion of three trocars under laparoscopic control, a further trocar was introduced into the stomach and 'pneumogastrum' was established. Two additional 5-mm trocars were intragastrally placed. Intragastric endoscopy with a rigid optic provided an excellent view. The tumor was exposed resected with a linear stapler. The specimen was inserted into an Endo Pouch™ which was sutured to an orally inserted gastric tube. The Endo Pouch™ was gently pulled transorally. After removal of the intragastric trocars, the entrance points were laparoscopically closed.

RESULTS

From the first and second cases, we retrieved GIST tumors. In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful.

CONCLUSIONS

Gastric GIST should be resected laparoscopically if negative margins are safely achieved regardless of its size. Tumors at the frontwall and exophytic backwall GIST are addressed by laparoscopic wedge resection. Tumors at the gastrojejunal junction, in the prepyloric region, and fundus as well as submucous GIST of the gastric backwall are best approached by intragastric laparoscopic resection. Transoral specimen retrieval is an interesting option in smaller tumors.

Laparoscopic resection for large gastric gastrointestinal stromal tumor (GIST): intermediate follow-up results

BACKGROUND

Laparoscopic wedge resection has become a widely accepted treatment for small gastrointestinal stromal tumor (GIST) of the stomach. However, its feasibility as treatment for large gastric GIST is not known. In this retrospective study, the perioperative and oncologic outcomes of laparoscopic wedge resection for gastric GIST (5-8 cm) were reviewed.

METHODS

Between November 2002 and December 2012, a total of 39 patients with primary gastric GIST sized 5-8 cm underwent surgery at a tertiary care center, including 18 patients who underwent laparoscopic wedge resection of the stomach (Lap group) and 21 patients who underwent open wedge resection of the stomach (Open group). Clinicopathological parameters were reviewed and compared between the groups.

RESULTS

The demographics including age, gender, and body weight were similar between groups. The operative outcomes including blood loss, hospital stay, and surgical complications were also similar, except that operative time was longer in the Lap group (146.6 ± 50.2 vs. 113.3 ± 42.9 min in the Open group, p = 0.03). There was no tumor rupture, conversion of procedures, or major surgical morbidity in either group. The overall median follow-up time was 3.6 years (1.0-11.1). Only one patient in the Lap group had liver metastasis (4 months postoperatively). This patient remains alive 5 years later under imatinib treatment. One patient in the Open group and three patients in the Lap group have died of GIST-unrelated diseases.

CONCLUSIONS

Laparoscopic wedge resection of the stomach for primary gastric GIST (5-8 cm) appears to be safe and feasible, with operative and oncological outcomes comparable to those of the open method.