Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses - analysis of 93 interventions. World J Surg. 2008;32:1021-1028. [PMID: 18338207 DOI: 10.1007/s00268-008-9492-1]

Predictors of unsuccessful laparoscopic resection of gastric submucosal neoplasms

BACKGROUND

While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome.

METHODS

From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months.

RESULTS

Patients were 62 ± 14 years and 56 % male. Mean tumor size was 5.5 ± 4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p < 0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p < 0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1-1.3; p = 0.13).

CONCLUSIONS

Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.

Modern treatment of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GIST) are rare mesenchymal smooth muscle sarcomas that can arise anywhere within the gastrointestinal tract. Sporadic mutations within the tyrosine kinase receptors of the interstitial cells of Cajal have been identified as the key molecular step in GIST carcinogenesis. Although many patients are asymptomatic, the most common associated symptoms include: abdominal pain, dyspepsia, gastric outlet obstruction, and anorexia. Rarely, GIST can perforate causing life-threatening hemoperitoneum. Most are ultimately diagnosed on cross-sectional imaging studies (i.e., computed tomography and/or magnetic resonance imaging in combination with upper endoscopy. Endoscopic ultrasonographic localization of these tumors within the smooth muscle layer and acquisition of neoplastic spindle cells harboring mutations in the c-KIT gene is pathognomonic. Curative treatment requires a complete gross resection of the tumor. Both open and minimally invasive operations have been shown to reduce recurrence rates and improve long-term survival. While there is considerable debate over whether GIST can be benign neoplasms, we believe that all GIST have malignant potential, but vary in their propensity to recur after resection and metastasize to distant organ sites. Prognostic factors include location, size (i.e., > 5 cm), grade (> 5-10 mitoses per 50 high power fields and specific mutational events that are still being defined. Adjuvant therapy with tyrosine kinase inhibitors, such as imatinib mesylate, has been shown to reduce the risk of recurrence after one year of therapy. Treatment of locally-advanced or borderline resectable gastric GIST with neoadjuvant imatinib has been shown to induce regression in a minority of patients and stabilization in the majority of cases. This treatment strategy potentially reduces the need for more extensive surgical resections and increases the number of patients eligible for curative therapy. The modern surgical treatment of gastric GIST combines the novel use of targeted therapy and aggressive minimally invasive surgical procedures to provide effective treatment for this lethal, but rare gastrointestinal malignancy.

Minimally invasive treatment of gastric gastrointestinal stromal tumors: laparoscopic and endoscopic approach

PURPOSE

This study aimed to verify the long-term outcome of a minimally invasive endoscopic or laparoscopic approach for the treatment of gastric gastrointestinal stromal tumor (GIST).

METHODS

This single-center study involved a retrospective review of gastric tumors that were pathologically confirmed as GIST. A total of 84 patients who underwent minimally invasive endoscopic or laparoscopic resection for gastric GIST were enrolled from February 2002 to June 2007. These demographics, tumor characteristics, and outcomes were analyzed for identification of outcomes and feasibility of endoscopic or laparoscopic resection.

RESULTS

Of 84 patients, 27 and 57 patients underwent endoscopic and laparoscopic resection, respectively. The average tumor size was 3.1 ± 1.7 cm. With a mean follow-up of 40.5 ± 20.7 months, 82 (97.7%) patients were disease free. Two patients, both of whom underwent laparoscopic resection, were alive with peritoneal recurrence. Two (7.4%) and 6 (10.5%) patients, respectively, had postoperative complications after endoscopic resection and laparoscopic resection. There was no significant difference in the operative morbidity according to tumor size. There was no postoperative mortality.

CONCLUSIONS

Laparoscopic surgery for gastric GIST is safe and feasible, even in large (>5 cm) tumors. Because endoscopic resection showed good results without recurrence, this approach can be useful in selected cases with a high operative risk or a need for preservation of organ function.

The role of surgery in the multidisciplinary management of patients with localized gastrointestinal stromal tumors

Surgical resection of localized gastrointestinal stromal tumors (GISTs) is associated with recurrence rates of approximately 50% at 5 years of follow-up. The introduction of tyrosine kinase inhibitors, such as imatinib, improved overall survival rates in advanced disease, while in the adjuvant setting, improved recurrence-free survival following resection of high-risk GIST. The demonstration of the clinical benefit of tyrosine kinase inhibitors in both the metastatic and adjuvant settings generated interest in neoadjuvant approaches for patients with operable locally advanced disease, particularly in difficult anatomic locations. The potential impact of tumor downsizing in areas such as the gastroesophageal junction, the duodenum or the rectum, on the extent of surgical resection and morbidity is real. The ongoing research regarding neoadjuvant therapy, the duration of adjuvant therapy and the optimal means by which to risk stratify patients with GIST continues to keep the treatment of this disease at the forefront of personalized cancer care.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Endoscopy-assisted anastomosis: a modified technique for laparoscopic side-to-side esophagojejunostomy following a total gastrectomy

INTRODUCTION

Esophagojejunostomy with a circular stapling device is sometimes difficult to perform in a laparoscopic setting. On the other hand, a side-to-side anastomosis with a linear stapling device is technically challenging.

METHODS

Between June 2002 and March 2008, 10 consecutive patients underwent a laparoscopy-assisted total gastrectomy using a side-to-side anastomosis technique. Of these patients, four underwent a laparoscopy-assisted total gastrectomy with a modified anastomosis technique. A small wound was created on the antimesenteric side of the jejunum 5 cm distal to the resected portion and then in the lower esophagus. A peroral endoscope was advanced to the hole, and the cartridge fork was introduced into the lower esophagus under endoscopic guidance. The device (45 mm, blue) was fired to create an antiperistaltic side-to-side anastomosis. The common entry hole was closed by transecting the jejunum and the esophagus with another linear stapler and by using an endoscope as a stent.

RESULTS

Four patients underwent the modified procedure and did not require an open procedure. One patient developed a pancreatic fistula, which was treated conservatively. The average operative time, reconstruction time and blood loss were 483 ± 133 minutes, 139 ± 31 minutes, and 199 ± 121 mL, respectively. An introduction of the stapler into the lower esophagus and a closure of the common entry hole were performed safely without any stress.

CONCLUSION

Although several techniques must be compared to determine the ideal procedure for laparoscopic esophagojejunostomy, the modified side-to-side anastomosis technique may be useful in clinical settings.

Local resection by combined laparoendoscopic surgery for duodenal gastrointestinal stromal tumor

Combined laparoendoscopic surgery is a novel surgical method which consists of both endoscopic surgery from inside the gastrointestinal tract and laparoscopic surgery from the outside. We report a case of duodenal GIST, in which combined laparoendoscopic local resection was attempted. The lesion was resected endoscopically using endoscopic submucosal dissection technique under laparoscopic assistance. Laparoscope was used for originating the orientation of the tumor, intra-operative EUS, and monitoring serosal injury from the peritoneal cavity. Postoperative hemorrhage occurred; however, precise orientation of the lesion helped us to manage the patient with minimal invasive reoperation. And thus, the bowel integrity was completely preserved, by avoiding segmental duodenal resection and pancreaticoduodenectomy. This novel, less invasive surgical procedure may become an attractive option for the lesions originating in the anatomically challenging portion of the GI tract for endoscopic or laparoscopic surgery alone.

Endoscopic dissection of large endogenous myogenic tumors in the esophagus and stomach is safe and feasible: a report of 42 cases

OBJECTIVE

Submucosal myogenic tumors, including leiomyoma and stromal tumors, are currently treated primarily by open surgery or laparoscopic excision. The aim of this retrospective study was to evaluate the feasibility of endoscopic dissection (ED) for resecting endogenous esophageal leiomyoma (EL) and gastric stromal tumors (GSTs) with diameters of 5 cm.

METHODS

We enrolled 42 patients with endogenous EL and GST who had undergone endoscopic surgery (endoscopic group). These cases were compared retrospectively with 22 patients who had undergone thoracotomy or laparotomy (control group). Endoscopic group (n = 42) received ED for EL and GST resection, including circumferential removal of superficial mucosa of targeted tumor. Control group (n = 22) received thoracotomy or laparotomy for resection of esophageal and gastric myogenic tumors. Main outcome measures were operative time, intraoperative bleeding and perforation, postoperative complications, and hospital stays and costs were compared between groups.

RESULTS

Endogenous EL and GST were successfully removed from all patients. Bleeding and perforation occurred in seven and five EL and GST patients, respectively. Bleeding was corrected with argon plasma coagulation (APC). Perforation was endoscopically repaired with clips. Mean operative time was 49 min for endoscopic EL and 55 min for GST resection. No major bleeding or perforation occurred postoperatively. Endoscopic treatment had shorter length of stay and lower hospital costs than conventional procedures.

CONCLUSIONS

ED is safe and feasible for resection of endogenous EL and GST in selected cases.

Laser-supported diaphanoscopy: a new technique in laparoscopic-endoscopic rendezvous procedures allowing better and more tissue-sparing tumor resection than wedge resection

BACKGROUND

Locating gastrointestinal stromal tumors (GIST) during laparoscopic surgery continues sometimes to be difficult and inaccurate. In addition, the methods used for tumor mapping often do not lead to precise location of tumors. Also, they are too expensive or too complex for an easy surgical approach. Furthermore, the standard wedge resection often sacrifices too much healthy tissue.

METHODS

The current study introduces an innovative tissue-sparing method using laser-supported diaphanoscopy (Endolight) for exact location of GIST during laparoscopic surgery. The instrument was developed by the authors' group. This study retrospectively evaluated two groups of patients experiencing GIST. The first group of 10 patients was treated by standard wedge resection. The second group of 10 patients was treated by Endolight-guided laparoscopic resection during a laparoscopic-endoscopic rendezvous procedure.

RESULTS

After precise location of GIST using Endolight, all patients could be successfully resected. The largest resection margins using Endolight (9.8±3.8 mm) were significantly smaller than the largest resection margins using wedge resection (stapler) without Endolight (21.5±9.1 mm; p<0.0001). The average surgery time for the group treated by standard wedge resection was 65 min (range, 28-108 min). The surgery time required for the group treated by Endolight-guided resections ranged from 48 to 189 min (average, 123 min). The number of marks used for Endolight resections ranged from four to seven depending on the location and size of the tumor.

CONCLUSION

The reported technique allows the precise location of GIST, leading to exact and tissue-sparing transmural laparoscopic resection of these tumors compared with standard wedge-resection. Laser-supported diaphanoscopy using the newly developed innovative device offers new perspectives and a highly effective technique for resecting GIST that combines an endoscopic with a laparoscopic approach.

[Orientation of endoscopic images: rectification by gravity]

A known problem in endoscopic surgery (especially with flexible video endoscopes) is the absence of a stable horizon in endoscopic images displayed on a monitor. With our "ENDOrientation" approach, image rectification, even in non-rigid endoscopic surgery (particularly NOTES), can be realized with a tiny MEMS tri-axial inertial sensor placed on the tip of an endoscope. This sensor measures the impact of gravity on each of the three orthogonal accelerometer axes in real time. After an initial calibration and temporal filtering of these three data steams, the rotation angle of an endoscope can be estimated directly. The achievable sampling rate of the inertial sensor is above the usual endoscopic video frame rate of 25 Hz; the rotation accuracy is approximately one degree. The image rectification can be performed in real time by digitally rotating the endoscopic video signal. Improvements and benefits have been evaluated in animal studies: coordination and movement of different instruments was rated to be much more intuitive with a stable horizon on endoscopic images. The recorded time stamps and position tracks clearly support this observation.

Full-thickness endoscopic resection of nonintracavitary gastric stromal tumors: a novel approach

BACKGROUND

Until now, the conventional treatment of stromal tumors has been primarily open surgery or laparoscopic excision. The use of combined laparoscopic/endoscopic surgeries has been investigated, but endoscopic therapy alone has been limited to en bloc resection or nucleus removal of intracavitary tumors with diameters<2 cm. Nonintracavitary and intramural gastric stromal tumors preclude the use of endoscopic resection due to the risk of gastric perforation. This study was designed to show the safety and effectiveness of full-thickness endoscopic resection of nonintracavitary stromal tumors based on our direct experience.

METHODS

A total of 109 consecutive patients with nonintracavitary gastric stromal tumors<4 cm in diameter underwent surgical treatment; 66 patients received endoscopic surgery and 43 patients received laparoscopic surgery.

RESULTS

No significant differences existed between the two groups in terms of demographics and clinical characteristics, and no tumor exceeded 3.5 cm in size. Median operation times (endoscopic group, 53.6 min; laparoscopic group, 139 min) and hospitalization fees of the endoscopic group were significantly lower than those of the laparoscopic group with significant median hospital stays (8 days for endoscopic group; 6 days for laparoscopic group). No intraoperative complications occurred in the laparoscopic group and complete removal of tumors was achieved in the endoscopic group. Postoperative complications occurred in 6 patients of 43 who underwent laparoscopic surgery and 17 patients of 66 who underwent endoscopic surgery, representing a significant difference; the size of the lesion correlated positively with the occurrence of complications.

CONCLUSIONS

Endoscopic resection is safe and effective for treating nonintracavitary stromal tumors. The endoscopic natural-cavity technique produced less surgical injury to the patients and preserved the anatomy of intra-abdominal structures. In addition, the endoscopic technique reduced operative times, postoperative bleeding, and costs.

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

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

Role of surgery combined with kinase inhibition in the management of gastrointestinal stromal tumor (GIST)

BACKGROUND

Surgery is the standard treatment for primary, gastrointestinal stromal tumor (GIST); however, surgical resection often is not curative, particularly in large GIST. Five years after complete removal of their tumor, approximately half of treated patients relapse. Imatinib, an oral tyrosine kinase inhibitor (TKI), is first-line treatment in patients with metastatic or unresectable GIST. It has resulted in durable objective responses or stable disease in 84% of patients and is well tolerated. The efficacy of imatinib in advanced GIST has created interest in a variety of potential multimodal approaches to management that combine surgery with systemic therapy.

RESULTS

Recently, a large, randomized, Phase III, US cooperative group trial that compared adjuvant imatinib, for 1 year after primary complete surgical resection, with placebo in primary GIST, reported a significantly shorter time to relapse for those in the placebo group. This led to the approval of imatinib for this new indication in the US and Europe. Several studies evaluating the efficacy of adjuvant imatinib in patients with primary GIST who are at high risk for postoperative relapse are ongoing; in particular two large European studies are expected to yield preliminary results in the near future. Neoadjuvant therapy with imatinib is also being investigated for its effect on surgical outcomes, with first trial results reported.

CONCLUSION

This article provides an update on the rapidly evolving role of surgery, treatment with TKI therapy, and their combination in the management of GIST as well as further reviews pertinent to current clinical research findings.

A Band Lifting Assisted Method for Laparoscopic Resection of Gastrointestinal Stromal Tumors on the Posterior Wall of the Stomach

Laparoscopic surgical techniques are beneficial for the wedge resection of gastrointestinal stromal tumors (GISTs). We have developed a new technique of laparoscopic transgastric resection for GISTs of the posterior wall of the stomach, a band lifting wedge resection method that has been confirmed to ensure sufficient surgical margins around the resected specimen in 21 cases. GISTs located at the posterior wall of the stomach were collected for this study. Laparoscopic anterior gastrotomy was performed and a 9-Fr rubber band was looped around the base of the tumor, allowing it to be lifted up through the anterior gastrotomy. The lesion was transected using a laparoscopic linear cutter and the gastrotomy was then closed by sequential application of the linear cutter. Surgical specimens were examined immunohistochemically All GISTs were successfully and completely resected using the laparoscopic technique. The resected tumors were ellipse-shaped or round. Macroscopic examination of the resected specimens showed complete tumor excision with negative surgical margins in all patients. A band lifting method for transection of GISTs on the posterior wall of the stomach easily allows for sufficient surgical margins of GISTs. The technique is reliable and feasible for laparoscopic treatment of GISTs in the stomach.

[Aspects of surgical treatment for gastro-intestinal stromal tumors]

Gastro-intestinal stromal tumors (GIST) form the commonest subgroup of soft tissue sarcomas. They arise in the muscular layer of the esophagus, stomach, small intestines and rectum. Characteristic and important for the assessment of the extent of tumors is the peripheral rim vascularization of primary tumors and metastases. Indications for resection are given for tumors larger than 2 cm in size. Locally advanced GISTs can be advantageously treated with imatinib/sunitinib as neoadjuvant and it is often possible to select a low level of resection for this size of tumor and when the rim area is not hypervascularized. Even in the metastasizing stage surgical treatment can be used for elimination of resistant metastases or for removal of residual tumor tissue in an attempt to counteract secondary tumor progression. The effect of this treatment is currently being tested in a randomized phase III study.

[Gastrointestinal stroma tumours (GIST) and the gastroenterologist]

Gastrointestinal stromal tumours are frequently incidental findings at gastrointestinal endoscopy. The most common location is the stomach. Larger tumours may cause abdominal pain or obscure or overt bleeding. Diagnosis and distinction from other submucosal tumours is usually done by the means of endoscopic ultrasound with fine needle aspiration. Lesions with a diameter of more than 3 cm at endosonography are associated with a high malignant potential. Today, endoscopic resection of gastrointestinal stromal tumours is not (yet) routinely performed.

Surgical management of gastrointestinal stromal tumours

BACKGROUND

Over the past decade, gastrointestinal stromal tumours (GISTs) have served as a model for the application of tyrosine kinase inhibitors in the treatment of solid neoplasms. Operative and medical management of GISTs is rapidly evolving, but current guidelines appear restricted to basic non-organ-specific recommendations.

METHODS

A PubMed search was made of the English literature from 1998 to 2008 for references containing the terms 'gastrointestinal stromal tumours' and 'surgery'. This paper reviews the various operative strategies so far reported for GISTs within the digestive tract.

RESULTS

Many original procedures tailored to the specific characteristics of these rare sarcomas have been reported. GISTs exhibit distinct features, in particular an absence of metastases within locoregional lymph nodes. Operations requiring extended lymph node dissection, typically designed for adenocarcinomas, such as gastrectomy with extended lymph node dissection, Whipple's procedure and total mesorectum excision, are inappropriate for treating GISTs originating from the stomach, duodenum and rectum respectively.

CONCLUSION

GISTs allow the possibility of performing oncologically adequate but limited (wedge; segmental) resections. Such surgery can be carried out in a variety of ways, such as open, laparoscopic, trans-sacral or endoscopic.

Perioperative and oncological outcome of laparoscopic resection of gastrointestinal stromal tumour (GIST) of the stomach

Background. Surgery remains the only curative treatment for gastrointestinal stromal tumour (GIST). Resection needs to ensure tumour-free margins while lymphadenectomy is not required. Thus, partial gastric resection is the treatment of choice for small gastric GISTs. Evidence on whether performing resection laparoscopically compromises outcome is limited. Methods. We compiled patients undergoing laparoscopic resection of suspected gastric GIST between 2003 and 2007. Follow-up was performed to obtain information on tumour recurrence. Results. Laparoscopic resection with free margins was performed in 21/22 patients. Histology confirmed GIST in 17 cases, 4 tumours were benign neoplasms. Median operation time and postoperative stay for GIST patients were 130 (range 80-201) mins and 7 (range 5-95) days. Two patients experienced stapler line leakage necessitating surgical revision. After median follow-up of 18 (range 1-53) months, no recurrence occurred. Conclusions. Laparoscopic resection of gastric GISTs yields good perioperative outcomes. Oncologic outcome needs to be assessed with longer follow-up. For posterior lesions, special precaution is needed. Laparoscopic resection could become standard for circumscribed gastric GISTs if necessary precautions for oncological procedures are observed.