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

Analysis of 151 consecutive gastric submucosal tumors according to tumor location

BACKGROUND

The aim of the present study was to evaluate the histopathological characteristics of gastric submucosal tumors (SMTs) according to their location.

METHODS

A retrospective analysis of a prospective database of 151 consecutive patients who underwent surgery for gastric SMTs between 2001 and 2009 was performed.

RESULTS

Of 151 gastric SMTs, 100 (66.2%) were gastrointestinal stromal tumors, 21 (13.9%) were leiomyomas, and 30 (19.9%) were other benign tumors. Leiomyoma was the most common neoplasm at the cardia (55.2%; P < 0.05), and the incidence of endophytic cardia tumors was higher compared with other locations (65.5%; P < 0.05). SMTs located at the cardia were significantly smaller than those found in the upper third (2.6 ± 1.0 vs. 4.1 ± 3.0; P < 0.05) and middle third (2.6 ± 1.0 vs. 3.9 ± 3.3; P < 0.05) of the stomach.

CONCLUSIONS

The characteristics of gastric SMTs located at the cardia differ significantly from those of gastric SMTs located in other regions of the stomach. These findings suggest that treatment strategy should be tailored by the location of tumors.

Laparoscopic gastric wedge resection and prophylactic antireflux surgery for a submucosal tumor of gastroesophageal junction

A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

Single-Port Laparoscopic Subtotal Gastrectomy With DIα Lymphadenectomy

Background. “Conventional multiport” laparoscopic gastrectomy for early stage gastric cancer is an increasingly frequently performed procedure. The authors describe their experience of the first reported single-port laparoscopic subtotal gastrectomy in an 88-year-old lady with early antral gastric adenocarcinoma. Method. Single-port laparoscopic subtotal gastrectomy with D1α lymphadenectomy was successfully performed using a transumbilical multichannel single port. Straight and flexible tipped laparoscopes were used to obtain off-axis views of the operative field. A flexible tipped stapler and curved instruments were used to reconstruct the Polya-type gastrojejunostomy. The procedure was performed without compromising standard, oncological principles. Results. Specimen histology revealed moderately to poorly differentiated adenocarcinoma infiltrating the submucosa. Proximal and distal resection margins were tumor free. Furthermore, 41 tumor-free lymph nodes were harvested. The patient was discharged on postoperative day 6. Conclusions. Single-port gastrectomy for cancer is technically and oncologically feasible when performed by experienced minimally invasive surgical oncologists with extensive experience of benign single-port laparoscopic procedures. The advantages to the patient in terms of cosmesis and shorter hospital stay are clear. However, further studies are required to assess this technique when treating gastric and other malignancies.

Laparoscopic wedge resection for gastric submucosal tumors: a size-location matched case-control study

BACKGROUND

Laparoscopic local resection for gastric submucosal tumors (SMTs) has become accepted as a standard treatment because it offers less postoperative pain and faster recovery. However, until recently, the laparoscopic approach has been limited by tumor location and size. The aim of this study was to examine the efficacy and safety of laparoscopic wedge resection (LWR) in comparison to open wedge resection (OWR), based on tumor size and location.

STUDY DESIGN

In this case-control study, 50 patients who received LWR for gastric SMTs were carefully matched by size and location of the tumor; 50 patients underwent OWR during the same period. Patient demographics, clinicopathologic characteristics, and postoperative courses were compared.

RESULTS

After matching for tumor size and location, the LWR group showed more favorable results than the OWR group in terms of the starting time of soft meals (mean days, 3.4 vs 4.8, respectively; p < 0.001) and length of hospital stay (mean days, 5.7 vs 7.8, respectively; p < 0.001), but not in terms of operative time (mean minutes, 153 vs 127, respectively; p < 0.05). The rate of postoperative complications did not differ between the groups.

CONCLUSIONS

This case-control study suggests that laparoscopic surgery can be safely performed for gastric SMTs and results in a better postoperative recovery, regardless of tumor size or location.

Tailored laparoscopic resection for suspected gastric gastrointestinal stromal tumors

BACKGROUND

The aim of the present study was to evaluate the long-term outcomes of tailored laparoscopic resections for suspected gastric gastrointestinal stromal tumors (GISTs) based on the tumor size, location, and growth morphology.

METHODS

Between February 1994 and April 2009, 64 patients undergoing gastric resections of suspected gastric GISTs were identified in a prospectively collected database. Medical records were reviewed for patient demographics, perioperative outcomes, and follow-up.

RESULTS

Forty-five patients underwent attempted laparoscopic resections, with 44 completed laparoscopically. Twenty-eight neoplasms were located in the upper third of the stomach (including 6 neoplasms at the esophagogastric junction), 9 in the middle third, and 8 in the lower third (including 4 prepyloric neoplasms). Laparoscopic approaches included 35 exogastric (3 single incision access) and 10 transgastric approaches. Median operating time was 100min (range, 30-240), and blood loss was 5ml (range, 1-80). Median tumor size and operative margin were 32mm (range, 16-74) and 7mm (range, 1-20), respectively. One patient was converted to an open, pylorus-preserving gastrectomy. One patient developed a complication. The histopathologic risk assessment classifications of 37 GISTs were 2 very low, 26 low, 7 intermediate, and 2 high risk. Although 1 patient developed a local recurrence after intragastric resection, all 45 patients were disease free at a median follow-up of 74 months (range, 1-181).

CONCLUSION

Although technically demanding, tailored laparoscopic resection based on tumor characteristics in most patients with suspected gastric GIST is safe and feasible and resultis in good both surgical and oncologic outcomes.