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

Advancements in Endoscopic Treatment for Gastric Subepithelial Tumors

Peroral flexible endoscopy is a minimally invasive technique that enables the local resection of gastric subepithelial tumors (SETs) with malignant potential. Resection techniques are mainly chosen on the basis of the lesion size. Minute SETs less than 1 cm should be managed through a watch and wait strategy, with the exception of histologically diagnosed superficial lesions, which require endoscopic mucosal resection or endoscopic submucosal dissection. For 1- to 3-cm small SETs, endoscopic enucleation techniques, such as endoscopic submucosal excavation, submucosal tunneling endoscopic resection, and peroral endoscopic tumor resection, can be used. However, endoscopic full-thickness resection is preferred for histologically complete removal with negative surgical margins. When endoscopic full-thickness resection is considered technically difficult, laparoscopic and endoscopic cooperative surgery (LECS) is a safe and dependable alternative. Moderate-sized SETs (3 to 5 cm) require surgical intervention because the lesions must be removed transabdominally. LECS is a less invasive surgical procedure as it reduces the resection area; however, some LECS techniques that require transoral tumor retrieval are not available. Endoscopic intervention for lesions larger than 5 cm should be used with caution for research purposes. With advancements in endoscopic diagnosis, the indications for endoscopic treatment for SETs are expected to improve, thereby enhancing patients' quality of life.

Is laparoscopic approach as treatment of large gastric GIST acceptable?

AIM

Laparoscopic surgery is widely used for small gastric gastrointestinal stromal tumors (GISTs) (≤ 5 cm) but remains a controversial approach for larger gastric GISTs (> 5 cm). This study aims to compare short- and long-term outcomes of laparoscopic resection in comparison with open resection for gastric GISTs measuring over 5 cm.

METHOD

All patients receiving surgery for gastric GIST > 5 cm between 2000 and 2021 in a single tertiary hospital were included. Data were collected from prospectively maintained records. Kaplan-Meier method and log rank test were used to compare survival outcomes.

RESULTS

Among 108 included patients, 59 patients had minimally invasive (MI) surgery (54.6%) whereas 49 patients had open surgery (46.4%). The rate of overall postoperative morbidity was 14.8% and the median length was significantly shorter in the MI group [4 (range 2-30) vs. 7 (range 4-33) days; P = 0.007]. The overall R0 resection rate was 98.2% and the rate of tumor rupture was 13%, not different between the two groups. Recurrence occurred in 24% of the whole population without any difference between groups (20.3% vs. 28.7%, p = 0.31). Minimally invasive surgery was not found as a negative prognostic disease-free survival factor.

CONCLUSION

Laparoscopic surgery could be a safe and feasible alternative to open surgery in large gastric GIST, bringing the benefits of minimally invasive surgery without compromising oncologic results.

The GIST of it all: management of gastrointestinal stromal tumors (GIST) from the first steps to tailored therapy. A bibliometric analysis

PURPOSE

Improvement of patient care is associated with increasing publication numbers in biomedical research. However, such increasing numbers of publications make it challenging for physicians and scientists to screen and process the literature of their respective fields. In this study, we present a comprehensive bibliometric analysis of the evolution of gastrointestinal stromal tumor (GIST) research, analyzing the current state of the field and identifying key open questions going beyond the recent advantages for future studies to assess.

METHODS

Using the Web of Science Core Collection, 5040 GIST-associated publications in the years 1984-2022 were identified and analyzed regarding key bibliometric variables using the Bibliometrix R package and VOSviewer software.

RESULTS

GIST-associated publication numbers substantially increased over time, accentuated from year 2000 onwards, and being characterized by multinational collaborations. The main topic clusters comprise surgical management, tyrosine kinase inhibitor (TKI) development/treatment, diagnostic workup, and molecular pathophysiology. Within all main topic clusters, a significant progress is reflected by the literature over the years. This progress ranges from conventional open surgical techniques over minimally invasive, including robotic and endoscopic, resection techniques to increasing identification of specific functional genetic aberrations sensitizing for newly developed TKIs being extensively investigated in clinical studies and implemented in GIST treatment guidelines. However, especially in locally advanced, recurrent, and metastatic disease stages, surgery-related questions and certain specific questions concerning (further-line) TKI treatment resistance were infrequently addressed.

CONCLUSION

Increasing GIST-related publication numbers reflect a continuous progress in the major topic clusters of the GIST research field. Especially in advanced disease stages, questions related to the interplay between surgical approaches and TKI treatment sensitivity should be addressed in future studies.

LAPAROSCOPIC VERSUS OPEN SURGERY IN GASTRIC GASTROINTESTINAL STROMAL TUMORS LARGER THAN 5 CM: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Surgical resection represents the main treatment for resectable nonmetastatic gastric gastrointestinal stromal tumors. Despite the feasibility and safety of laparoscopic resection, its standard use in gastric tumors larger than 5 cm is yet to be established.

AIMS

This study aimed to compare the current evidence on laparoscopic resection with the classical open surgical approach in terms of perioperative, postoperative, and oncological outcomes.

METHODS

The PubMed, Scopus, and Web of Science databases were consulted. Articles comparing the approach to gastric gastric gastrointestinal stromal tumors larger than 5 cm by open and laparoscopic surgery were eligible. A post hoc subgroup analysis based on the extent of the surgery was performed to evaluate the operative time, blood loss, and length of hospital stay.

RESULTS

A total of nine studies met the eligibility criteria. In the study, 246 patients undergoing laparoscopic surgery and 301 patients undergoing open surgery were included. The laparoscopic approach had statistically significant lower intraoperative blood loss (p=0.01) and time to oral intake (p<0.01), time to first flatus (p<0.01), and length of hospital stay (0.01), compared to the open surgery approach. No significant differences were found when operative time (0.25), postoperative complications (0.08), R0 resection (0.76), and recurrence rate (0.09) were evaluated. The comparative subgroup analysis between studies could not explain the substantial heterogeneity obtained in the respective outcomes.

CONCLUSION

The laparoscopic approach in gastric gastrointestinal stromal tumors larger than 5 cm compared to the open surgical approach is a technically safe and feasible surgical method with similar oncological results.

Laparoscopic partial gastrectomy for a giant bleeding GIST of the stomach: A case report

Introduction

Gastrointestinal stromal tumors (GIST) are rare neoplasms often located in the stomach. Elective laparoscopic surgery is the well-established treatment. Often these tumors have a presentation with acute gastrointestinal bleeding and/or as large masses that challenge mini invasive laparoscopic approach. This article describes the case of a patient with large gastric GIST with bleeding onset and discusses the feasibility and safety of emergency laparoscopy.

Presentation of case

A 36-year-old man presented with melena and severe anaemia. An upper endoscopy and abdominal CT scan showed a large gastric fundal submucosal mass of more than 10 cm of diameter close to the superior splenic pole. Because of relapsing bleeding he was submitted to emergency laparoscopy with complete resection of the gastric mass by partial gastrectomy.

Discussion

Laparoscopic approach to GIST larger than 10 cm is still a challenging surgical task and the feasibility depends on multiple factors including the location and size of the lesions. Few series of patients have been described in the literature. This case described a giant GIST with major and relapsing gastrointestinal bleeding that induced an emergency surgically approach with a minimally invasive laparoscopic partial gastric resection.

Conclusions

This report described a case of giant gastric GIST that presented with repeated and severe gastrointestinal bleeding and was treated by emergency laparoscopic gastric resection. The feasibility and advantages of the surgical technique are discussed. The best surgical approach in these rare cases has still to be evaluated on individual basis.

•

Laparoscopic surgical approach for giant gastric GIST is still challenging

•

Emergency surgery for bleeding GIST has not been frequently described

•

Laparoscopic surgical resection of giant gist is feasible but has to be evaluated on an individual basis

A propensity score-matched analysis of laparoscopic versus open surgical radical resection for gastric gastrointestinal stromal tumor

Background

Surgery is the mainstay of treatment for gastric gastrointestinal stromal tumours (GIST). However, the choice of surgical approach for gastric GIST remains controversial.

Aims and Objectives

To evaluate the short- and long-term efficacies of laparoscopic surgery versus conventional open surgery for gastric GIST.

Materials and Methods

We retrospectively reviewed 148 patients with gastric GIST at our hospital between January 2013 and January 2020. The patients were categorised into the following two groups based on the surgery performed: The laparoscopic surgery group (LG) and the open surgery group (OG). Differences in the tumour size, surgical procedures and modified National Institutes of Health classification were statistically significant. To balance the intergroup confounders, we performed 1:1 propensity score matching (PSM).

Results

A total of 104 patients were selected after PSM (52 in each group). We focused on the short- and long- term outcomes of patients. The baseline information was balanced between the two groups after PSM. The LG benefited from the advantages of a minimally invasive surgery (faster gastrointestinal function recovery, shorter time to drainage tube removal, less blood loss and shorter hospitalisation period), however, it also had high treatment costs. Moreover, both laparoscopic and open surgeries resulted in similar intra-operative and post-operative complications rates, overall survival time and disease-free survival time.

Conclusion

Laparoscopic resection is feasible and oncologically safe for GIST. However, more prospective studies are required to confirm the findings.

Is minimally invasive surgery for large gastric GIST actually safe? A comparative analysis of short- and long-term outcomes

INTRODUCTION

While minimally invasive surgery (MIS) is frequently utilized to remove small gastric gastrointestinal stromal tumors (GIST), MIS surgery for tumors ≥ 5 cm is currently not endorsed by national guidelines as standard of care due to concerns of safety and inferior oncologic outcomes. Hence this study investigates the perioperative and long-term outcomes of MIS for T3 gastric GIST measuring 5-10 cm.

METHODS

The National Cancer Database (NCDB) 2017 was queried for gastric GIST measuring 5-10 cm or T3 category. Inclusion criteria were known: stage, size, comorbidities, grade, lymphovascular invasion, type of surgery, approach, conversion info, margin status, mitotic rate, neoadjuvant and adjuvant treatment, hospital stay, readmission, 30- and 90-day mortality, complete follow-up, type of institution, and hospital gastric surgery case volume. Binary logistic regression, linear regression models, and Kaplan-Meier survival analysis were used.

RESULTS

In 3765 patients, mean tumor size was 67.3 mm; 26.3% MIS; and 73.8% open. Median hospital stay was shorter for MIS (4.77 vs 7.04 days, p < 0.001). There was no significant difference in incidence of R1 margins [2.9% MIS vs. 3.1% open (p = 0.143)], unplanned readmission [2.9% MIS and 4.1% open (OR 0.474 p = 0.025)], 30-day mortality [0.5% MIS vs 1.2% open (OR 0.325, p = 0.031)], and 90-day mortality [0.9% MIS vs 2.1% open (OR 0.478 p = 0.036)]. Cox regression models for OS showed no difference in survival (p = 0.137, HR 0.808).

CONCLUSION

This analysis provides substantial evidence that MIS for gastric GIST ≥ 5-10 cm may not only offer improved postoperative morbidity but also oncologic safety. Moreover, as both approaches lead to similar long-term survival, national guidelines may need to incorporate this new information.

Safety and feasibility of laparoscopy-assisted surgery for gastrointestinal stromal tumors larger than 5 cm: Results of a retrospective, single-center series of 1,802 consecutive patients

BACKGROUND

The role of laparoscopy-assisted resection for treating gastrointestinal stromal tumors >5 cm is still disputed. We aimed to assess the advantages of laparoscopy-assisted resection for treating gastrointestinal stromal tumors >5 cm.

METHODS

In total, 1,802 patients with primary gastrointestinal stromal tumors who underwent laparoscopy-assisted surgery or open surgery were retrospectively evaluated. Propensity score matching was performed to reduce confounders.

RESULTS

In total, 518 patients with tumor size >5 cm were enrolled in this study (males: 292, 56.4%; females: 226, 43.6%; median age: 58 years, range: 23-85 years). One hundred and twenty-three (23.7%) patients underwent laparoscopy-assisted resection, and 395 (76.3%) patients underwent open resection. After propensity score matching, 190 patients were included (95 in each group). The laparoscopy-assisted surgery group was superior to the open surgery group considering the blood loss (>200 mL: 6.3% vs 22.1%, P = .005), length of midline incision (6.0 ± 0.9 cm vs 9.6 ± 2.1 cm, P < .001), time to first flatus (49.7 ± 10.5 hours vs 63.9 ± 7.4 hours, P < .001), and shorter hospital stay (10.3 ± 3.2 days vs 11.9 ± 2.9 days, P < .001). The difference in relapse-free survival or overall survival between the laparoscopy-assisted surgery and open surgery groups after matching was not significant (all P > .05). On subgroup analysis, the relapse-free survival and overall survival of the laparoscopy-assisted surgery group were comparable to those of the open surgery group, irrespective of tumor location (gastric or nongastric locations) (all P > .05).

CONCLUSION

When performed by experienced surgeons, laparoscopy-assisted resection is feasible and safe for gastrointestinal stromal tumors >5 cm, which showed improved short-term outcomes and comparable oncological outcomes, regardless of whether the tumor had a gastric or nongastric location.

Hand-assisted laparoscopic resection versus total laparoscopic gastric surgery for primary gastric gastrointestinal stromal tumors (GISTs): an analysis from a high-volume institution

Background

Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) is technically feasible and associated with favorable outcomes. We compared the clinical efficacy of hand-assisted laparoscopic surgery (HLS) and total laparoscopic surgery (TLS) for gastric GISTs.

Methods

We retrospectively analyzed the clinical data of 69 consecutive patients diagnosed with a gastric GIST in a tertiary referral teaching hospital from December 2016 to December 2020. Surgical outcomes were compared between two groups.

Results

Fifty-three patients (TLS group: n = 36; HLS group: n = 17) were included. The mean age was 56.9 and 58.1 years in the TLS and HLS groups, respectively. The maximum tumor margin was significantly shorter in the HLS group than in the TLS group (2.3 ± 0.9. vs. 3.0 ± 0.8 cm; P = 0.004). The operative time of the HLS group was significantly shorter than that of the TLS group (70.6 ± 19.1 min vs. 134.4 ± 53.7 min; P < 0.001). The HLS group had less intraoperative blood loss, a shorter time to first flatus, and a shorter time to fluid diet than the TLS group (P < 0.05). No significant difference was found between the groups in the incidence or severity of complications within 30 days after surgery. Recurrence or metastasis occurred in four cases (HLS group; n = 1; TLS group; n = 3).

Conclusions

This study demonstrated that compared with TLS, HLS for gastric GISTs has the advantages of simpler operation, shorter operative time, and faster postoperative recovery.

Early experience of laparoscopic resection and comparison with open surgery for gastric gastrointestinal stromal tumor: a multicenter retrospective study

The advantages of laparoscopic resection over open surgery in the treatment of gastric gastrointestinal stromal tumor (GIST) are not conclusive. This study aimed to evaluate the postoperative and oncologic outcome of laparoscopic resection for gastric GIST, compared to open surgery. We retrospectively reviewed the prospectively collected database of 1019 patients with gastric GIST after surgical resection at 13 Korean and 2 Japanese institutions. The surgical and oncologic outcomes were compared between laparoscopic and open group, through 1:1 propensity score matching (PSM). The laparoscopic group (N = 318) had a lower rate of overall complications (3.5% vs. 7.9%, P = 0.024) and wound complications (0.6% vs. 3.1%, P = 0.037), shorter hospitalization days (6.68 ± 4.99 vs. 8.79 ± 6.50, P < 0.001) than the open group (N = 318). The superiority of the laparoscopic approach was also demonstrated in patients with tumors larger than 5 cm, and at unfavorable locations. The recurrence-free survival was not different between the two groups, regardless of tumor size, locational favorableness, and risk classifications. Cox regression analysis revealed that tumor size larger than 5 cm, higher mitotic count, R1 resection, and tumor rupture during surgery were independent risk factors for recurrence. Laparoscopic surgery provides lower rates of complications and shorter hospitalizations for patients with gastric GIST than open surgery.

Complete laparoscopic wedge resection of a giant locally advanced gastric GIST with near pathological complete response after preoperative treatment with imatinib mesylate: A case report

Introduction and importance

Surgical resection is the only curative treatment for gastrointestinal stromal tumor (GIST). Laparoscopic approach for large (>5 cm) and giant (>10 cm) gastric GIST remains under controversy. What's more, whether laparoscopic surgery could be performed after preoperative imatinib treatment of giant gastric GIST is still unknown.

Case presentation

We report a 68-year-old man with a giant (almost 30 cm) locally advanced gastric GIST which required resection of contiguous organs initially. After received 12 months imatinib therapy, the tumor became resectable and he finally achieved a complete laparoscopic wedge resection. Pathological evaluation of the resected specimen revealed a near pathological complete response was obtained. The imatinib treatment was ongoing after surgical resection and there was no radiological or clinical evidence of disease recurrence until to October 2021.

Clinical discussion

Laparoscopic approach is safe and effective for gastric GIST. Even for lesions greater for 5 cm. However, there are few reports for the application of laparoscopic wedge resection for gastric GIST larger than 10 cm. Preoperative use of imatinib can decrease the tumor size, so that may increase the chance of laparoscopic approach.

Conclusion

Preoperative imatinib therapy was effective for reducing the gastric GIST, which may increase the chance of minimally invasive approach and organ preservation. Patients with locally advanced GIST could benefit from the multidisciplinary approach.

•

A man with a giant (almost 30 cm) locally advanced gastric GIST achieved a complete laparoscopic wedge resection with preoperative imatinib therapy.

•

Pathological evaluation of the resected specimen revealed a near pathological complete response was obtained.

•

Preoperative imatinib therapy may facilitate R0 resection, organ preservation and increase the chance of minimally invasive approach.

•

Multidisciplinary approach is the optimal treatment for patients with locally advanced GIST.

Minimally Invasive Approach to Gastric GISTs: Analysis of a Multicenter Robotic and Laparoscopic Experience with Literature Review

Simple Summary

Gastrointestinal stromal tumors (GISTs) represent about 1–3% of all gastrointestinal malignancies, of which 50–60% are gastric GISTs (GGs). To the date, surgery represents the best therapeutic option, and the robotic gastric surgery could gain an important role, overcoming many laparoscopic drawbacks. The aim of this study is to evaluate safety and effectiveness of minimally invasive surgery (MIS) for GGs, reporting 10-year experience of three different centers. We included a population of 81 patients who underwent MIS approaches (36 laparoscopy vs. 45 robotic surgery). Seventy-two (72) patients were enrolled in a follow-up program to evaluate the long-term oncological outcomes. Furthermore, we discussed some technical notes and also we analyzed the operative and peri-operative outcomes. In conclusion, our results suggest that the robotic approach might be a suitable treatment, especially for GISTs >5 cm, even located in unfavorable places, despite longer operative time and costs than laparoscopic approach.

Abstract

Background: Gastrointestinal stromal tumors (GISTs) are most frequently located in the stomach. In the setting of a multidisciplinary approach, surgery represents the best therapeutic option, consisting mainly in a wedge gastric resection. (1) Materials and methods: Between January 2010 to September 2020, 105 patients with a primary gastrointestinal stromal tumor (GISTs) located in the stomach, underwent surgery at three surgical units. (2) Results: A multi-institutional analysis of minimally invasive series including 81 cases (36 laparoscopic and 45 robotic) from 3 referral centers was performed. Males were 35 (43.2%), the average age was 66.64 years old. ASA score ≥3 was 6 (13.3%) in the RS and 4 (11.1%) in the LS and the average tumor size was 4.4 cm. Most of the procedures were wedge resections (N = 76; 93.8%) and the main operative time was 151 min in the RS and 97 min in the LS. Conversion was necessary in five cases (6.2%). (3) Conclusions: Minimal invasive approaches for gastric GISTs performed in selected patients and experienced centers are safe. A robotic approach represents a useful option, especially for GISTs that are more than 5 cm, even located in unfavorable places.

Laparoscopic Partial Gastrectomy for Large Gastric GISTs

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are considered the most common mesenchymal tumors in the gastrointestinal tract and the stomach is the most frequently site affected (50-60%). The safety and feasibility of laparoscopic surgery for gastric GISTs of sizes larger than 5 cm remains unclear. It depends on the surgical skills, tumor location, and the learning curve of the surgeons.

METHODS

Between December 2013 and January 2021, 30 patients diagnosed with gastric GISTs underwent laparoscopic partial gastrectomy. This is a retrospective study done in Surgical Oncology unit, Oncology Center, Mansoura University, Egypt.

RESULTS

The most common tumor location was in the greater curvature in (46.7%). The mean tumor size was 9.5 cm (range 5-17 cm). All of the patients underwent laparoscopic partial gastrectomy. Associated splenectomy was done for only one patient. The mean operative time was 152.67 min and the estimated blood loss (EBL) was 139.33 ml. The mean hospital stay was 3.53 days. The mean follow-up period was 32.4 months.

CONCLUSION

Laparoscopic resection for gastric GISTs has become a feasible method. Patients with large tumors have the same favorable outcomes as small tumors. Large-sized GISTs may receive neoadjuvant therapy to downstage the disease and make it amenable for laparoscopic resection.

Giant Gastrointestinal Stromal Tumors of the Stomach Successfully Treated With Laparoscopic Resection: Case Report and Literature Review

The stomach is the most common site of gastrointestinal stromal tumors (GISTs), representing 60% to 70% of all GIST tumors of the gastrointestinal tract. Gastric GISTs are usually asymptomatic discovered incidentally during endoscopic or radiological investigations. A small percentage may present with melena, hematemesis, and anemia due to recurrent bleeding. We report a case of a giant gastric GIST presented with anemia, that successfully treated with laparoscopic resection.

An Unexpected Finding of Gastrointestinal Stromal Tumors During Laparoscopic Sleeve Gastrectomy; How to Deal? How Much Safety Margin Needed?

Background: There is an increasing incidence of coincidental gastric gastrointestinal stromal tumors (GIST) during a laparoscopic sleeve gastrectomy (LSG). Resection with negative margin R0 is the safest and most proper treatment. Objectives: The incidence of GIST in patients undergoing LSG and resection with a 1- to 2-cm safety margin was validated and analyzed. The primary endpoint is that can simultaneous excision be oncologically adequate or not? How much GIST is supposed to be far from a staple line? Methods: The present prospective study included 338 patients with body mass index (BMI) ≥ 35. All patients underwent LSG without known history or imaging reveal GIST. Resection was done with a safety margin of 1 to 2 cm away from the stapled margin and, then, sent for histopathology and immunohistochemically staining. Results: A total of 17 patients (5%) had coincidental GIST. The size was T1 in 88.2% of patients; 16 patients were staged as IA according to the American Joint Committee on Cancer (AJCC TNM). Safety margin was ≤ 1 cm for 3 patients to avoid incorporation in staple line and 14 patients (82.3%) had 2 cm safety margin. Resection margin in biopsy revealed positive resection margin R1 for 2 patients, whose safety margin was only 1 cm or less. A total of 15 patients had a negative margin (R0), whose safety margin was 2 cm. Conclusions: Any incidental GIST can be removed safely during LSG as long as it is far from the staple line with at least a 2-cm safety margin and negative resection margins without changing the procedure. Margins less than 1 cm are associated with adverse prognostic factors.

Meta-Analysis on the Efficacy and Safety of Laparoscopic Surgery for Large Gastric Gastrointestinal Stromal Tumors

BACKGROUND

The aim of this study was to conduct a meta-analysis comparing the safety and feasibility of laparoscopic versus open resection for gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm.

METHOD

We searched the Cochrane Library, PubMed, and Embase for relevant articles. Randomized and nonrandomized clinical trials were identified and included in this study. Searching for related articles on large GIST (>5 cm) for laparoscopic resection (laparoscopic group [LAPG]) and open resection (open group [OG]), RevMan 5.3 was used for data analysis, comparing 2 groups of operation time, intraoperative blood loss, complications, length of hospital stay, recurrence rate, disease-free survival, and overall survival.

RESULTS

Seven studies including 440 patients were identified for the meta-analysis. Meta-analysis revealed that LAPG had less bleeding, shorter postoperative hospital stay, and a better 5-year disease-free survival. There was no significant difference between LAPG and OG in operation time, postoperative complications, recurrence rate, and overall survival.

CONCLUSION

Laparoscopic resection of large (>5 cm) GIST is safe and feasible and has the advantages of less intraoperative blood loss and fast postoperative recovery, with a good outcome in the recent oncology.

Combined endo-laparoscopic treatment of large gastrointestinal stromal tumor of the stomach: Report of a case and literature review

•

We report a case of 75-year-old Caucasian men with unknown voluminous gastric GIST, who came to our attention complaining melena. We decided to perform a laparoscopic-endoscopic combined surgical approach.

•

Intraoperative endoscopy identified gastric GIST and confirmed the submucosal origin and the integrity of the capsule. A 10 cm laparoscopic gastrotomy was carried out along the gastric found in order to realize a laparo-endoscopic rendez-vous technique.

•

Laparoscopy has rapidly become a preferable approach for gastric GISTs surgical treatment. The magnified view and the lesser invasiveness of laparoscopic technique allow the surgeon to perform a more meticulous dissection, preventing unexpected bleeding and causing less muscular trauma and less bowel manipulation. All these favourable short-term outcomes associated with laparoscopy do not compromise oncologic results.

Introduction

Gastrointestinal stromal tumours (GISTs) are the most common malignant subepithelial lesions of gastrointestinal tract, originating from Cajal’s cells and characterized by the over expression of tyrosine kinase receptor C-KIT. The prognosis of this disease is associated with tumour size and mitotic index. Standard treatment of a GIST with no metastasis is surgical resection.

Presentation of case

We report a case of a 75-year-old Caucasian man with unknown voluminous gastric GIST, who came to our attention complaining black stool. We decided to perform a laparoscopic-endoscopic combined surgical approach. Intraoperative gastroscopy identified the gastric GIST and confirmed the submucosal origin and the integrity of the tumor capsule. A 10 cm laparoscopic gastrotomy was carried out along the gastric fundus in order to realize a laparo-endoscopic rendez-vous procedure.

Discussion

Laparoscopic approach is feasible and safe for Gastric GIST both in elective and urgent settings. Even for lesions greater than 5 cm, laparoscopy shows a recurrence rate similar to open surgery when radical resection are performed. An important point to take in consideration is surgical team experience, which seems to be one of the most important factors reducing the incidence of operative complications with better long-term outcomes, both postoperative and oncological.

Conclusion

Mini-invasive approaches for gastric GIST are safe and feasible. The combined approach both laparoscopic and endoscopic has shown to be an effective technique and it may allow a better exposure of the tumour which ensure a radical resection.

Factors Associated with Operation Time of Laparoscopic Gastric Wedge Resection for Gastric Subepithelial Tumors

Purpose

Gastric subepithelial tumor (GST) is a disease entity that includes all gastric subepithelial lesions. The oncologically safe surgical technique is complete resection with adequate resection margins. Most of the studies about laparoscopic gastric wedge rsection (LGWR) in GST focus on oncologic curability or surgical effectiveness. However, studies on the factors associated with the operation time are rare. Therefore, this study was conducted to analyze and compare the factors associated with the operation time of LGWR.

Methods

From 2010 to 2019, 145 consecutive patients undergoing LGWR were reviewed retrospectively. Clinical characteristics of GST and operation time were analyzed and compared.

Results

A total of 145 patients was enrolled and reviewed. There were 59 males (40.7%) and 86 females (59.3%) with a mean age of 53.6 years and mean body mass index (BMI) of 23.9 kg/m2. Mean tumor size was 2.9 cm and mean operation time was 66.0 minutes. In statistically, the mean operation time showed significant association with tumor size, BMI, longitudinal tumor location and tumor location between lesser and greater curvature. In multivariate analysis, tumor size, BMI and longitudinal classification of tumor location are statistically significant.

Conclusion

A shorter operation time is expected when there is a small tumor, low BMI and mid portion of the stomach GST. Preoperative evaluation for tumor size and body weight is important. In patients with large GST, obesity and both end stomach GST, we think that pre-operative preparation for long operation time should be considered.

Laparoscopic Versus Open Surgery for Gastric Gastrointestinal Stromal Tumors: a Propensity Score Matching Analysis

BACKGROUND

Surgery is the first choice for the treatment of gastric gastrointestinal stromal tumors (GISTs). With the development of new instruments and techniques, the popularity of laparoscopic resection of GISTs has increased rapidly. Previous studies on the advantages of laparoscopic resection over open surgery are generally limited by methodology or data capacity. This study evaluated the efficacy of laparoscopic resection and open surgery in gastric GISTs using the propensity score matching (PSM) method.

METHODS

Between January 2005 and December 2017, 1027 patients were diagnosed with primary GIST at our institution. Among them, 548 patients were enrolled in this study. Standard demographic and clinicopathological data were collected from our database. Selection bias was eliminated using the PSM methods.

RESULTS

After PSM, 256 cases involved in the comparison (128 laparoscopic (LAP) vs. 128 open surgery (OPEN)) were randomly matched (1:1) by age, sex, body mass index, hypertension, diabetes, heart disease, year of surgery, tumor location, tumor size, mitotic rate, and treatment with adjuvant tyrosine kinase inhibitors. The LAP group was superior to the OPEN group in blood loss (χ² = 6.048, P = 0.049), time to first flatus (49.41 ± 7.56 vs. 71.31 ± 4.87 h, P < 0.001), and hospital stay (10.21 ± 6.05 vs. 12.56 ± 5.43 days, P = 0.001). No significant differences were seen in either the relapse-free survival or overall survival between the LAP and OPEN groups. In tumors located in favorable locations, the LAP group showed less blood loss (P = 0.008) and less multivisceral resection (17.8% vs. 5.5%, P = 0.02).

CONCLUSIONS

Laparoscopic resection for gastric GISTs is associated with improved surgical outcomes and postoperative courses and comparable oncological outcomes, regardless of favorable or unfavorable tumor location.

Efficacy and safety of endoscopic submucosal dissection for large gastric stromal tumors

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) of gastric stromal tumors is becoming increasingly common. However, there have been few studies analyzing the therapeutic efficacy and safety of this technique on large (≥ 3 cm) gastric stromal tumors (LGSTs). The aim of this study was to determine the feasibility of ESD for the removal of LGSTs and to investigate the clinical safety and efficacy of ESD for this indication.

METHODS

A retrospective analysis was carried out on 82 patients with LGSTs who underwent an ESD. Data on therapeutic outcomes and follow-up were collected for an analysis of the rates of en block resection and complete resection. A logistic regression model was used to identify potential risk factors for ESD-related complications, and a receiver operating characteristic (ROC) curve was generated for qualifying independent risk factors.

RESULTS

En bloc resection was achieved in 81 lesions (98.8%), and complete resection was achieved in 80 lesions (97.6%). The rates of intraoperative and postoperative bleeding were 6.1% and 3.7%, respectively. The accidental perforation rate was 12.2%, the postoperative perforation rate was 3.7%, the intentional perforation rate was 28.0%, and the postoperative infection rate was 12.2%. There was no postoperative mortality. LGSTs originating from the deep muscularis propria (MP) layer (OR = 4.905, 95% CI: 1.362-17.658, P = 0.015), located at the gastric fundus (OR = 4.927, 95% CI:1.308-18.558, P = 0.018) and with an irregular shape (OR = 4.842, 95% CI: 1.242-18.870, P = 0.023) increased the rate of complications. The prediction model that incorporated these factors demonstrated an area under the ROC curve of 0.77 (95% CI: 0.66-0.89). No tumor recurrence or distant metastasis was observed during the follow-up period, which ranged from 6-36 months.

CONCLUSIONS

ESD is a feasible, safe, effective and minimally invasive approach for the resection of LGSTs. Tumors originating from the deep MP layer, located at the fundus and with an irregular shape were identified as risk factors for the development of complications.

[Laparoscopic surgery in the treatment of patients with gastric gastrointestinal stromal tumors]

OBJECTIVE

To compare safety and efficiency of conventional open and laparoscopic surgery in patients with gastrointestinal stromal tumors (GIST) of the stomach.

MATERIAL AND METHODS

A retrospective analysis included 42 patients with gastric GIST who were treated at the Moscow City Oncological Hospital #62 for the period from 2006 to 2018. All patients were divided into two groups depending on surgical approach.

RESULTS

Laparoscopic surgery is safe and effective in patients with gastric GIST. Short-term results of traditional open and laparoscopic operations in patients with gastric GISTs were compared.

CONCLUSION

Laparoscopic resection of gastric GIST is justified for tumors less than 5 cm. Laparoscopic procedure for tumors over 5 cm must be done only in high-volume hospitals.

Laparoscopic Treatment of Gastric Subepithelial Tumor: Finding Ways to Manage with Shorter Hospitalization Days

Purpose

The standard treatment for gastric subepithelial tumor (SET) is surgical resection, which is primarily performed via laparoscopy. The aims of this study were firstly to evaluate factors influencing morbidity and hospitalization after treatment of gastric SET, and secondly, to figure out the factors how to make shorter hospitalization with equal safety.

Methods

We retrospectively enrolled 229 consecutive patients who underwent laparoscopic gastric wedge resection (LGWR) for gastric SET between August 2003 and December 2015. Patients were divided into two groups: the 3 days or less hospitalization group (N=82, group A) and the greater than 3 days hospitalization group (N=147, group B).

Results

Median tumor size was 3.0 cm (range, 0.2~13.0 cm) and mean postoperative hospitalization was 4.27±2.15 days. There were 6 complications (2.6%), with no cases of mortality. In group A, tumors were smaller (3.0±1.1 cm vs. 3.6±1.9 cm, p<0.01) and more likely to be located on the greater curvature (28% vs. 15%, p<0.01) compared with group B. The tumor growth pattern (exophytic tumor: 72% in group A vs. 65% in group B, p=0.25) was not different between the two groups. Multivariate analysis showed that tumor size larger than 5 cm and posterior wall tumor location were risk factors for longer hospital stay.

Conclusion

We could reduce the hospitalization of patients with gastric SET less than 5cm sized and located on other than the posterior wall within 3days. Those patients could be a candidate for day surgery.

Laparoscopic treatment of large gastrointestinal stromal tumors (> 5 cm)

INTRODUCTION

Although laparoscopic techniques are currently a recognized type of treatment of small stromal tumors (GISTs) of the stomach, their application in the case of larger tumors has been the subject of debate.

AIM

To evaluate the technical feasibility, safety and early results of the laparoscopic treatment of large GISTs with a diameter of more than 5 cm.

MATERIAL AND METHODS

A retrospective analysis was performed using data on patients who underwent laparoscopic surgery for gastric GIST in the period from 2009 to 2016. The patients selected for the study were divided into two groups based on the diameter of the tumor: patients who developed a tumor with a diameter smaller than or equal to 5 cm (group 1), and those whose tumors exceeded 5 cm in diameter (group 2). The following factors were established and compared for the two groups: duration of surgery, amount of intra-operative blood loss, length of hospital stay, and the number and nature of post-operative complications.

RESULTS

No deaths occurred in the 30-day post-operative period, and no statistically significant differences regarding complications in the post-operative period were observed. In group 2, statistically significantly more pronounced blood loss and longer hospital length of stay were observed. No difference in the duration of surgery between the investigated groups was observed.

CONCLUSIONS

It appears that the surgical treatment of GISTs with a diameter of more than 5 cm by means of minimally invasive procedures is a viable and safe alternative.

Large incidental gastrointestinal stromal tumors in a patient presenting with acutely symptomatic nephrolithiasis: A case report

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms, representing approximately 1%-2% of all primary gastrointestinal malignancies. Incidental GISTs are often less than 1 cm when discovered and have been reported predominantly in obese patients undergoing surgery for other medical indications. We present the rare case of a large incidental GIST in a nonobese patient with acutely symptomatic nephrolithiasis. Large GISTs may be treated with neoadjuvant imatinib mesylate to reduce tumor size prior to surgery, though some tumors may experience little change in size despite effective treatment. Treatment response for GISTs can be monitored via imaging studies, such as computed tomography or magnetic resonance imaging, but computed tomography is generally preferred over magnetic resonance imaging.

Clinicopathological and morphological spectrum of gastrointestinal stromal tumours on multi-detector computed tomography

PURPOSE

To describe the clinicopathological and morphological features of gastrointestinal stromal tumours (GISTs) on multi-detector computed tomography (MDCT).

MATERIAL AND METHODS

MDCT (plain and post contrast) images of 25 confirmed cases of GISTs were retrospectively evaluated from our hospital database. The images were analysed for the location, size, growth pattern, attenuation pattern, relation to adjacent structures, presence or absence of ulceration, calcification, metastases, lymphadenopathy, and for any complications such as haemorrhage, intestinal obstruction, etc. Institutional Ethics Committee clearance was obtained prior to the commencement of the study. Statistics used included percentage frequency.

RESULTS

Our study group comprised 14 males and 11 females. The mean age of our study population was 60 years (age range: 40 to 82 years). The mean tumour size was 11.7 cm. The stomach and small bowel accounted for 76% of the primary tumour site. The commonest imaging appearance of GIST observed in our study was that of an exophytic mass (76%) with a heterogenous pattern of enhancement (96%) with intratumoural necrosis (76%). MDCT demonstrated complications in three patients (12%). Six patients presented with metastatic foci (five to the liver and one to the lung), while lymphadenopathy was observed in five patients (20%). Associated complications included intestinal obstruction (8%) and retrogastric haematoma (4%). Incidental findings included uterine fibroid (n = 1), ovarian dermoid (n = 1), and chronic pancreatitis (n = 1).

CONCLUSIONS

GISTs are predominantly large tumours with a well circumscribed and exophytic pattern on MDCT, with or without cystic/necrotic areas, and they mostly show a heterogenous pattern of enhancement on post-contrast administration.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Laparoscopic Surgery for Large Gastric Submucosal Tumors

BACKGROUND

In general, laparoscopic resection for gastric gastrointestinal stromal tumors (GISTs) >5 cm is not recommended. However, there is a lack of evidence to support this recommendation.

PATIENTS AND METHODS

This study included 108 patients who underwent laparoscopic surgery for gastric GISTs. Of the 108 patients, 23 had GISTs>5 cm. The aim of this study is to evaluate the oncological safety of laparoscopic surgery for large gastric GISTs. In addition, we performed a rapid systematic review of laparoscopic surgery for large gastric GISTs.

RESULTS

In our cases, all patients were performed R0 resection without capsular rupture and surgical margins were negative on pathologic examination. In all studies, en bloc resection was achieved without capsular rupture in all patients. The average positive surgical margins rate was 1.6% in total reports.

CONCLUSIONS

The laparoscopic approach for large gastric GISTs>5 cm has been proposed as safe when performed by experienced surgeons.

Surgical and oncological long term outcomes of gastrointestinal stromal tumors (GIST) resection- retrospective cohort study

PURPOSE

Surgery remains the mainstay of gastrointestinal stromal tumors (GISTs) treatment. The aim of our study was to compare postoperative outcomes and long term oncologic results of GISTs resection. An analysis of laparoscopic versus open surgery for GISTs and a subgroup analysis of lesions larger than 5 cm were realized.

MATERIALS AND METHODS

Between January 2005 and December 2014, 143 patients with primary GISTs were treated with radical resection in two tertiary centers. Eight patients with metastatic disease were excluded. The remaining patients were assigned to 2 groups: laparoscopy and open surgery. A separate analysis of tumors larger than 5 cm was realized for the laparoscopy group. Long-term follow-up was used to analyze the oncologic and surgical results. Relevant clinical variables were evaluated using univariate and multivariate analyses.

RESULTS

With similar oncological outcomes(p = 0.09) and morbidity(p = 0.56), laparoscopy compared to open surgery significantly reduced length of hospitalization (p = 0.01). For lesions >5 cm laparoscopic resection is associated with similar short-term outcomes with resection for small tumors without compromising oncological outcomes (p = 0.89). For all patients, the probability of remaining disease free at 3 years, and 5 years was 97, 6% and 95%, respectively.

CONCLUSION

Laparoscopic resection is a technically and oncologically safe and feasible approach for GISTs compared with open resection. Resection of lesions superior of 5 cm by laparoscopy has efficacy and recurrence rates similar to open surgical controls. Large tumor resection should only be attempted by surgeons with a large experience with minimally invasive surgery in order to avoid operative complications and unfavorable long term outcome.

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.

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.

Short- and Long-Term Outcomes of Endoscope-Assisted Laparoscopic Wedge Resection for Gastric Submucosal Tumors Adjacent to Esophagogastric Junction

BACKGROUND

Laparoscopic wedge resection (LWR) is used to treat gastric submucosal tumors (SMTs). However, LWR can injure the cardia if tumors are near the esophagogastric junction (EGJ), resulting in gastric stenosis. This study's purpose was to summarize our experience with endoscope-assisted LWR for gastric SMTs within 3 cm of the EGJ and to verify the procedure's feasibility and safety.

METHODS

Data from 91 consecutive patients with gastric SMTs within 3 cm of the EGJ who underwent endoscope-assisted LWR at our hospital from 2007 to 2017 were obtained from a prospectively maintained database. The clinicopathological results, perioperative data, and long-term follow-up data were analyzed.

RESULTS

All patients successfully underwent endoscope-assisted LWR. The mean distance from tumor to EGJ was 2.43 ± 0.80 cm. Eighty-two patients underwent laparoscopic exogastric wedge resection (LEWR) and nine underwent laparoscopic transgastric wedge resection (LTWR). Mean operative time was 112.4 ± 48.8 min; mean blood loss was 36.8 ± 53.5 ml. Mean time to first flatus was 2.04 ± 0.68 days. Mean time to liquid intake was 2.53 ± 0.85 days. Mean postoperative hospital stay was 4.97 ± 1.80 days. Three patients (3.3%) had postoperative complications, all Clavien-Dindo grade I. The mean maximum tumor diameter was 3.00 ± 1.96 cm (range 0.5-10). LTWR was used more often than LEWR for SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ. The mean follow-up time was 36.86 ± 29.73 months (range 3-126). There was no stenosis of EGJ or tumor recurrence. Sixteen patients (17.6%) complained of upper gastrointestinal symptoms during the follow-up, which were all relieved by usage of acid suppressive medications.

CONCLUSIONS

Endoscope-assisted LWR is safe, feasible, and effective for gastric SMTs near the EGJ. LTWR is preferable to LEWR for gastric SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ.

Comparison between laparoscopic and open surgery for large gastrointestinal stromal tumors: A meta-analysis

AIM

To investigate whether laparoscopic surgery is as safe and feasible as open resection for patients with larger gastrointestinal stromal tumors (GISTs) (≥ 5 cm).

METHODS

A systematic search of PubMed, EMBASE, Web of Science and the Cochrane Library database was performed. Relevant studies of laparoscopic and open surgery for GISTs of > 5 cm published before December 2016 were identified from these databases. The quality of the studies was assessed by the Newcastle-Ottawa Quality Assessment Scale. The tumor size, operation time, blood loss, postoperative hospital stay, complication rate, and disease-free survival rate were assessed. The software Stata (version 12.0) was used for the meta-analysis.

RESULTS

Five clinical trials comprising 209 patients with GISTs of similar larger sizes were evaluated. The pooled analysis of 100 patients in the laparoscopic resection group and 109 patients in the open resection group demonstrated that laparoscopic surgery was significantly associated with a shorter postoperative hospital stay (P < 0.001) and less blood loss (P = 0.002). Moreover, there were no statistically significant differences in the operation time (P = 0.38), postoperative complication rate (P = 0.88), or disease-free survival rate (P = 0.20) between two groups.

CONCLUSION

Our findings revealed that for patients with large GISTs of comparable sizes, laparoscopic surgery did not significantly influence the operation factors or clinical outcomes compared with open surgery. This suggests that laparoscopic resection is as acceptable as open surgery for treatment of large gastric GISTs.

Minimally invasive surgery for gastric gastrointestinal stromal tumors

Minimally invasive surgery has been increasingly performed for gastric gastrointestinal stromal tumors (GIST). In this review we discuss and summarize the current evidence on minimally invasive surgery for gastric GISTs. Laparoscopic resection for gastric GIST has been consistently shown to be associated with superior perioperative outcomes with no compromise in oncological outcomes when compared to open resection in numerous retrospective case-control studies. It has also been shown to be safe and feasible for large tumors or tumors located in unfavorable sites. However, to date, there remains a lack of level 1 evidence from prospective randomized control trials in support of laparoscopic resection.

Meta-analysis comparing laparoscopic versus open resection for gastric gastrointestinal stromal tumors larger than 5 cm

BACKGROUND

Data on the safety and feasibility of laparoscopic versus open resection for gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm are limited. Therefore, the aim of this meta-analysis was to compared laparoscopic and open resection for gastric GISTs larger than 5 cm.

METHODS

We perform a literature search on PubMed, the Cochrane Library, and Embase. Review Manage version 5.1 (RevMan 5.1) was used for data analysis. The GRADE profiler software (version 3.6) was used to estimate the level of evidence.

RESULTS

A total of 6 observational studies and one unpublished retrospective cohort study met the inclusion criteria for the meta-analysis: 203 patients in LAP and 214 patients in OPEN group. The pooled result revealed that laparoscopic resection was associated with a same operative time (WMD = -0.87 min; 95% CI: -47.50 to 47.75; P = 0.97), intraoperative blood loss (WMD = -34.38 ml; 95% CI: -79.60 to 10.84; P = 0.14), overall complications (RR = 0.65; 95% CI: 0.38 to 1.12; P = 0.12), better 5-year disease-free survival (HR = 0.40; 95% CI: 0.17 to 0.91; P = 0.03) and overall survival (HR = 0.09; 95% CI: 0.02 to 0.40; P = 0.002) compared with open resection.

CONCLUSION

Laparoscopic resection is a technically and oncologically safe and feasible approach for large-sized gastric GISTs (≥ 5 cm) compared to open resection.

Laparoscopic Versus Open Resection of Gastric Gastrointestinal Stromal Tumors Larger Than 5 cm: A Single-Center, Retrospective Study

BACKGROUND

The technical feasibility and oncological safety of laparoscopic surgery for gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm has not been adequately studied. Therefore, we performed this retrospective study to investigate the clinical outcomes of gastric GIST patients treated with laparoscopic surgery compared with those who underwent open surgery.

METHODS

We retrospectively evaluated the outcomes of 48 consecutive patients who underwent gastric resection for gastric GISTs larger than 5 cm. The patients were divided into 2 groups based on the surgery performed: the laparoscopic resection group (LAPG) and the open resection group (OG). We assessed all available patient data, including baseline information, tumor characteristics, surgical outcomes, pathological results, postoperative complications, and long-term patient survival.

RESULTS

The 2 groups had similar baseline data. No differences were found in tumor size, location, mitotic count, and risk grade according to Fletcher's risk classification. The LAPG was superior to the OG in blood loss, time to first flatus, time to oral intake, and length of postoperative hospital stay. Perioperative complications, recurrence rate, and long-term survival, however, did not differ significantly between the groups. The mean operation time in the LAPG was 28 minutes longer than that in the OG.

CONCLUSIONS

In patients with primary gastric GISTs larger than 5 cm, laparoscopic resection is a technically feasible and oncologically safe surgery when performed by experienced surgeons.

Comparison of short- and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors

AIM

To compare the short- and long-term outcomes of laparoscopic (LR) vs open resection (OR) for gastric gastrointestinal stromal tumors (gGISTs).

METHODS

In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed gGISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled (122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups.

RESULTS

After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. The LR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay (P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups (P > 0.05). No significant difference was found in postoperative adjuvant therapy (P = 0.587). The mean follow-up time was 35.30 ± 26.02 (range, 4-102) mo in the LR group and 40.99 ± 25.07 (range, 4-122) mo in the OR group with no significant difference (P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups (P > 0.05).

CONCLUSION

Laparoscopic surgery for gGISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising long-term oncological outcomes.

Robotic Versus Laparoscopic Gastric Resection for Primary Gastrointestinal Stromal Tumors >5 cm: A Size-Matched and Location-Matched Comparison

This study compared robotic (RR) and laparoscopic resection (LR) for primary gastrointestinal stromal tumors (GISTs) of the stomach >5 cm. Twelve consecutive patients who underwent RR from 2012 to 2015 were matched for tumor size and location with 24 patients who underwent LR from 2000 to 2012. The median tumor size was 7.1 cm (range, 5.5 to 11.5). GISTs were resected by wedge resection (91.7%) or distal gastrectomy. The median RR operative time was longer than that of LR (162.5 vs. 130 min, respectively; P=0.004). Only 1 LR patient required conversion. The time to flatus and hospital stay were similar between groups. Overall, 3 patients developed minor postoperative complications that were medically treated. Mortality was nil. All resections were R0. No difference was observed in the incidence of recurrence. RR was significantly more expensive (+21.6%) than LR. RR appears to be safe and feasible for GISTs>5 cm, but is associated with longer operative times and greater costs.

Technical success and short-term results of surgical treatment of gastrointestinal stromal tumors: an experience of three centers

BACKGROUND

Gastrointestinal stromal tumors (GIST) comprise about 80% of gastrointestinal sarcomas. In patients with localized disease, surgery is considered as "Gold Standard" treatment. Organ-sparing radical en-block resection is widely accepted practice. Since lymph node dissection is not routinely indicated, minimally invasive approach is of particular interest. The aim of this study is to investigate the short-term outcomes of different surgical treatment of GISTs.

METHODS

We analyzed data of 116 patients who received surgical treatment for localized forms of GIST. Tumors were located in the stomach in 87 (75%) cases, in the small intestine in 26 (22.4%) cases, and extragastrointestinal GISTs were found in 3 (2.6%) patients. Four different approaches were used-open surgery (OpS, n=48), laparoscopic surgery (LS, n=40), endoscopic procedures (EP, n=22) and hybrid rendezvous (HR, n=6). Patient demographics, clinical presentation of tumors, characteristics of operation procedures (duration, intraoperative blood loss, frequency of R0-resection and fragmentation of tumor), postoperative complications and length of hospital stay were examined in all these groups.

RESULTS

Radical treatment (R0-resection) was performed in all patients. There were no cases of tumor ruptures during surgical procedure. Mean size of GIST in OpS was 9.1±2.0 [2-35] cm; in LS: 4.9±0.8 (1.5-15) cm; in HR: 3.5±0.8 (2-4.5) cm and in EP: 2.3±0.3 (0.4-3.5) cm. Intraoperative blood loss in OpS was 369.7±209.5 [0-4,000] mL; LS: 63.9±16.0 [0-150] mL; in HR: 96.7±44.3 [50-200] mL; in EP: 33.3±11.0 [0-150] mL. Duration of operation in OpS was 160±20.4 [50-310] min; in LS: 104.7±12.7 [50-185]; in HR: 176.7±44.0 [110-260] min and in EP: 89.8±15.5 [25-190] min. Complication rate in OpS was 5 (10.4%); in LS: 3 (7.5%); in HR: 0% and in EP: 3 (13.6%). Length of hospital stay in OpS was 13.8±2.2 [7-52] days; in LS: 11, 4±2.2 [4-21] days; in HR: 11±3.2 [7-15] days and in EP: 11, 9±2.1 [5-22] days. There were no postoperative deaths.

CONCLUSIONS

There is a diversity of surgical approaches for GISTs treatment. From our point of view, the main selection criteria for certain procedure are size, localization, growth type of the tumor and status of overlying mucosa. Nevertheless, due to relative rarity and heterogeneity of this pathology, individualization is necessary in each specific case. Laparoscopic and endoscopic surgery is proved to be safe and feasible for resection of the gastric GISTs, with a reasonable operation time, low blood loss, and an acceptable complication rate. Immediate results indicate that all interventions were performed radically without mortality or serious morbidity.

Meta-analysis of laparoscopic vs. open resection of gastric gastrointestinal stromal tumors

Background

This meta-analysis compared laparoscopic surgery (LAP) and open resection (OPEN) for the treatment of gastric gastrointestinal stromal tumors (GISTs) with regard to feasibility and safety.

Methods

We searched PubMed, Embase, and Web of Science for studies published before March 2016 comparing the LAP and OPEN procedures for GISTs. RevMan 5.1 software was used for the meta-analysis.

Results

In total, 28 studies met the inclusion criteria for the meta-analysis. The mean tumor sizes in the OPEN and LAP groups were 4.54 and 5.67 cm. Compared with the OPEN patients, the LAP patients experienced shorter surgical times (P = 0.05), less blood loss (P<0.01), earlier time to flatus (P<0.01) and an oral diet (P<0.01), and shorter hospital stays (P<0.01). The LAP patients also exhibited a decrease in overall complications (P<0.01). In addition, regarding the subgroup of larger GISTs (>5 cm), the present study did not report significant differences in operation time (P = 0.93), postoperative complications (P = 0.30), or recurrence rate (P = 0.61) between the two groups, though LAP was associated with favorable results regarding blood loss (P = 0.03) and hospital stay (P<0.01).

Conclusions

Compared with the OPEN procedure, the LAP procedure is associated with preferable short-term postoperative outcomes and does not compromise long-term oncological outcomes. For gastric GISTs >5 cm, no significant difference was detected between LAP and OPEN if patient selection and intraoperative decisions were carefully considered.

Management of Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal tract. The stomach is the most common site of origin. Management of GISTs changed after the introduction of molecularly targeted therapies. Although the only potentially curative treatment of resectable primary GISTs is surgery, recurrence is common. Patients with primary GISTs at intermediate or high risk of recurrence should receive imatinib postoperatively. Imatinib is also first-line therapy for advanced disease. Cytoreductive surgery might be considered in advanced GIST for patients with stable/responding disease or limited focal progression on tyrosine kinase inhibitor therapy. GIST requires multidisciplinary management.

Laparoscopic surgery versus open resection in patients with gastrointestinal stromal tumors: An updated systematic review and meta-analysis

PURPOSES

The contemporary surgery has reported the safety of laparoscopic surgery (LAP) for patients with gastrointestinal stromal tumors (GISTs). However, its use is still debated due to suspicion of the oncologic equivalence to open surgery (OPEN). We conducted a systematic review and meta-analysis of updated original articles to investigate the short- and long-term clinical outcomes of LAP compared with OPEN for GISTs.

METHODS

A systematic search was performed in PubMed, Embase, Web of Science, Cochrane Library and CNKI. Comparative studies of laparoscopic and open surgery for GISTs were published before November 2016. The Newcastle-Ottawa scale was utilized to conduct quality assessment. The Review Manager (RevMan) software version 5.0 was used for meta-analysis.

RESULTS

Twenty-four studies involving 2140 patients were included for the meta-analysis. The meta-analysis results showed that, compared with OPEN, LAP indicated potentially favorable outcomes in terms of operative time (WMD, -30.71; 95% CI, -58.48 to -2.95; P = 0.03); intraoperative blood loss (WMD, -60.90; 95% CI, -91.53 to -30.28; P < 0.0001); time to flatus (WMD, -1.10; 95% CI, -1.41 to -0.79; P < 0.00001); time to oral intake (WMD, -1.25; 95% CI, -1.64 to -0.86; P < 0.00001); length of hospital stay (WMD, -3.42; 95% CI, -4.37 to -2.46; P < 0.00001); overall complications (OR, 0.38; 95% CI, 0.27 to 0.54; P < 0.00001); and recurrence (OR, 0.45; 95% CI, 0.30 to 0.66; P < 0.0001).

CONCLUSIONS

Laparoscopic surgery is safe and feasible for the treatment of GISTs including less operative time and intraoperative blood loss, earlier postoperative recovery, shorter hospital stay, and lower rate of overall complications and recurrence.

Can laparoscopic surgery be applied in gastric gastrointestinal stromal tumors located in unfavorable sites?: A study based on the NCCN guidelines

This article investigated the feasibility of laparoscopic surgery in unfavorable site gastric gastrointestinal stromal tumors (GISTs).We identified 214 patients who underwent primary gastric GIST resection at our institution (January 2006-December 2014) from a prospectively collected database. These patients were divided into a Favorable group (140 cases) and an Unfavorable group (74 cases) according to the 2014 version of the National Comprehensive Cancer Network Clinical Guidelines (NCCN guidelines).The wedge resection rate of the Favorable group was higher than that of the Unfavorable group, and most procedures were performed laparoscopically (P < 0.05). In addition, there were no differences in the other clinicopathological features between these groups (P > 0.05). The postoperative stay of the Unfavorable group was longer than that of the Favorable group (P = 0.02). Laparoscopic surgery in both groups resulted in a shorter operative time, lower blood loss, faster time to first flatus, faster time to first fluid diet, and shorter postoperative stay than open surgery (P < 0.05). Although the difference was not significant (P = 0.09), the postoperative complication incidence of the Favorable group was less than that of the Unfavorable group (10% vs 17.6%). Furthermore, in the Unfavorable group, the incidence of postoperative complications from laparoscopic surgery was significantly lower than that of open surgery (P = 0.001). There were no differences in the 5-year overall survival (OS) and recurrence-free survival (RFS) of these groups (P > 0.05). Furthermore, in the Unfavorable group, the 5-year OS and RFS were similar for both laparoscopic and open procedures. Multivariate Cox regression analysis showed that imatinib (IM) treatment was an independent risk factor for poor prognosis.Laparoscopic operation for gastric GISTs located in unfavorable sites can yield similar long-term outcomes compared with an open operation. However, laparoscopic surgery has the obvious advantage of being minimally invasive, and the incidence of postoperative complications was low. Laparoscopic surgery is thus an option for the treatment of localized gastric GISTs.

Safety and efficacy of laparoscopic wedge gastrectomy for large gastrointestinal stromal tumors

BACKGROUND

Although the feasibility of minimally invasive resection of small gastric GISTs is well established, less is known about safety and efficacy of laparoscopic surgery for large tumors.

METHODS

A retrospective analysis was performed, using a prospectively maintained comprehensive database. Patients were divided into two groups according to tumor size: Case group with tumors > 5 cm and control group with tumors <5 cm. Hospital charts were reviewed, and various outcome measures recorded, including operative time, estimated operative blood loss, post-operative leak, stasis, infection and recurrence.

RESULTS

No tumors were ruptured during surgical manipulation and no major morbidity or mortality occurred in either group. Operative time (75,8 ± 33,1 min in large cases vs 75,8 ± 33,1 min in small cases) was similar in both groups (p = 0,61). The incidence of post-operative complications did not differ between the two groups. In details there were 21 out of 25 (84%) uncomplicated cases among small GISTs versus 17 out of 24 (70,8%) uncomplicated cases among large GISTs (p = 0,32).

CONCLUSION

This matched-pair case control study demonstrates that laparoscopic wedge resection for large gastric GISTs is safe and effective, as demonstrated for small tumors.

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.

Clinicopathologic features and prognosis of primary gastrointestinal stromal tumor patients under 35 years of age: A 10-year retrospective study

OBJECTIVES

To investigate gastrointestinal stromal tumor (GIST) clinicopathologic characteristics in young adults.

METHODS

Clinicopathologic data from GIST patients under 35 years diagnosed at our hospital from January 2005 to December 2014 were retrospectively collected.

RESULTS

Thirty-one (5.3%, 31/585) patients were included; 17 (54.8%) were female. The most common presentation and primary tumor site were gastrointestinal bleeding (n = 18, 58.1%) and the small intestine (n = 13, 41.9%), respectively. Fifteen (48.4%) GISTs were classified as having a high relapse risk; two (6.4%), intermediate; nine (29.0%), low; and five (16.1%), very low. All patients underwent tumor resection. With a median follow-up of 51 months for 20 (64.5%) patients, 12 (60%) were given imatinib methylate as adjuvant therapy. One (5%) patient died of peritoneal GIST dissemination, four (20%) developed abdominal recurrences, two (10%) had hepatic metastasis, and thirteen (65%) were disease free. The 5-year disease-free survival rate was 51.2%.

CONCLUSIONS

GISTs rarely occur in young adults. The most common location is the small intestine. A slight female predominance was observed in the current study. Adjuvant therapy longer than the recommended duration may be beneficial for GISTs with a high relapse risk. Combined targeted therapy and surgery is appropriate for recurrent and metastatic GISTs in select patients. J. Surg. Oncol. 2016;114:977-981. © 2016 Wiley Periodicals, Inc.

Laparoscopic wedge resection for suspected large (≥5 cm) gastric gastrointestinal stromal tumors

BACKGROUND

Laparoscopic wedge resection (LWR) for small gastric gastrointestinal stromal tumors (GIST) is now widely accepted, but its application for large GISTs remains controversial. This study aims to evaluate the feasibility and safety of LWR for suspected large (≥5 cm) gastric GISTs.

METHODS

Retrospective review of 82 consecutive patients who underwent attempted LWR for suspected gastric GIST. LWR for large (≥5 cm) (n = 23) tumors was compared with LWR for small (<5 cm) tumors (n = 59). The 23 patients with LWR for large tumors were also compared to 36 consecutive patients who underwent open wedge resection (OWR) for large tumors.

RESULTS

Comparison between patients who underwent LWR for large versus small tumors demonstrated that resection of large tumors was associated with a longer operating time. There was no difference in other perioperative outcomes, and oncological outcomes such as frequency of close margins (≤1 mm) and recurrence-free survival. Comparison between patients who underwent LWR versus OWR for large tumors showed that LWR was associated with decreased median time to fluid or solid diet, shorter postoperative stay but longer operating times. There was no difference in oncological outcomes.

CONCLUSION

LWR for suspected large gastric GIST is feasible and safe. It is associated with similar short-term outcomes with LWR for small tumors and favorable short-term outcomes over OWR for large tumors without compromising on oncological outcomes.

Retrospective study of laparoscopic versus open gastric resection for gastric gastrointestinal stromal tumors based on the propensity score matching method

BACKGROUND

Surgical resection with a free margin is considered the gold standard for the treatment of gastric gastrointestinal stromal tumors (GISTs). Previous studies about the advantages of laparoscopic resection versus open surgery have generally been non-randomized and retrospective and have some obvious shortcomings that could influence the veracity and reliability of the results. Therefore, the aim of this study was to evaluate the efficacy of laparoscopic resection in the treatment of gastric GISTs using the propensity score matching (PSM) method.

METHODS

Between 2005 and 2014, 217 consecutive patients undergoing laparoscopic or open resection for gastric GISTs were enrolled in a retrospective, single-center study. Patient and tumor characteristics, intraoperative and postoperative characteristics, and oncologic outcomes were collected from a database. The efficacy of the laparoscopic approach was analyzed using the PSM method by comparing the clinical parameters of patients who underwent laparoscopic (LAP) and open resection (OPEN) procedures.

RESULTS

After PSM, 88 patients involved in the analysis (44 LAP vs. 44 OPEN) were randomly matched (1:1) by tumor size, localization, disease course, body mass index, age, and gender. The LAP group was clearly superior to the open group in terms of intraoperative indicators and postoperative short-term efficacy. The incidence of postoperative complications in the LAP group was lower than in the OPEN group (4.5 vs. 18.2 %, P = 0.044). A survival analysis showed that there was no significant difference in the disease-free survival time between the two groups (χ ² = 0.211, P = 0.646).

CONCLUSION

These data should be processed using the PSM method in a non-randomized controlled trial (non-RCT) study. It is safe and feasible for patients with gastric GISTs up to 5 cm in size or located in the gastroesophageal junction to be treated with laparoscopic surgery.