Comparison of the post-operative outcomes and survival of laparoscopic versus open resections for gastric gastrointestinal stromal tumors: A multi-center prospective cohort study

Outcomes of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors: A retrospective multicenter study at 21 Japanese institutions

Aim

We conducted a multicenter study on classical laparoscopic and endoscopic cooperative surgery (LECS) and LECS-related procedures to retrospectively clarify the safety, problems, and mid-term outcomes of these methods after their coverage by the national health insurance.

Methods

A total of 201 patients who underwent classical LECS/LECS-related procedures for gastric submucosal tumors (G-SMTs) in 21 institutions affiliated with the Laparoscopy Endoscopy Cooperative Surgery Study Group from April 2014 to March 2016 were included. Data was retrospectively obtained from the patients' charts.

Results

The most common surgical procedure was classical LECS (155 patients, 77.1%), non-exposed endoscopic wall inversion surgery (22 patients, 11.4%), a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (16 patients, 8%), and closed LECS (two patients, 1%). Only six (3%) patients underwent LECS with gastrostomy. The mean operative time and blood loss were 188.4 (70-462) minutes and 23.3 (0-793) g, respectively. Ten (5%) patients developed postoperative complications (Clavien-Dindo classification grade II or higher). Two patients needed reoperation due to postoperative bleeding or anastomotic leakage. All tumors were resected with negative margins. A total of 127 (63.2%) patients underwent follow-up observations for over 36 months, one of whom had a recurrence of peritoneal dissemination and one had poor oral intake.

Conclusion

Classical LECS and LECS-related procedures for G-SMTs have favorable short/mid-term outcomes.

Improvement of perioperative outcomes of gastric gastrointestinal stromal tumour (GIST) resections and the influence of minimal invasive surgery

BACKGROUND

Safety of minimally invasive surgery (MIS) for gastrointestinal stromal tumours (GISTs) is still under debate since it might increase the risk of tumour rupture, especially in larger tumours. The aim of this study was to investigate trends in treatment and perioperative outcomes of patients undergoing resections of gastric GISTs over time.

METHODS

This was a multicentre retrospective study of consecutive patients who underwent wedge resection or partial gastrectomy for localized gastric GIST at five GIST reference centres between January 2009 and January 2022. To evaluate changes in treatment and perioperative outcomes over time, patients were divided into four equal periods. Perioperative outcomes were analysed separately and as a novel composite measure textbook outcome (TO).

RESULTS

In total 385 patients were included. Patient and tumour characteristics did not change over time, except for median age (62-65-68-68 years, p = 0.002). The proportion of MIS increased (4.0%-9.8%-37.4%-53.0 %, p < 0.001). Postoperative complications (Clavien Dindo ≥2; 22%-15%-11%-10 %, p = 0.146), duration of admission (6-6-5-4 days, p < 0.001) and operating time (92-94-77-73 min, p = 0.007) decreased over time while TO increased (54.0%- 52.7%-65.9%-76.0 %, p < 0.001). No change was seen in perioperative ruptures (6.0%- 3.6%-1.6%-3.0 %, p = 0.499). MIS was correlated with less CD ≥ 2 complications (p = 0.006), shorter duration of admission (p < 0.001) and more TO (p < 0.001). Similar results were observed in tumours ≤5 cm and >5 cm.

CONCLUSION

A larger percentage of gastric GIST were treated with MIS over time. MIS was correlated with less complications, shorter duration of admission and more TO. Tumour rupture rates remained low over time.

Oncologic outcomes and survival of modern surgical approaches for gastric gastrointestinal stromal tumor (GIST)

BACKGROUND

Studies have demonstrated comparable outcomes between laparoscopic and open resection of gastrointestinal stromal tumor (GIST). We sought to compare outcomes among robotic, laparoscopic, and open resection of gastric GIST in the era of expanding minimally invasive surgery.

METHODS

A retrospective analysis was performed of adult patients with gastric GIST undergoing definitive surgery using the National Cancer Database from 2010 to 2020, excluding cases converted to open. Patients were stratified into minimally invasive surgery (MIS), (combined robotic (R) and laparoscopic (L)), and open (O). Hospital length of stay (LOS), 30-day mortality, 90-day mortality, and margin status were assessed. Subgroup analysis was performed to evaluate outcomes between R and L cohorts. Entropy balancing was used to adjust for intergroup differences. Kaplan-Meier survival estimates were used to compare unadjusted 5-year survival.

RESULTS

Of the 15,022 patients (R = 10.4%, L = 44.3%, O = 45.3%), 63.2% were stage I and 70.6% underwent partial gastrectomy. MIS approach was associated with shorter hospital LOS (β: - 2.58; 95% CI: - 2.82 to - 2.33) and lower odds of 30-day (OR 0.45; 95% CI: 0.30-0.68) and 90-day mortality (OR 0.54; 95% CI: 0.39-0.74) compared to O. Likelihood of R0 resection similar between groups (OR 1.00; 95% CI: 0.88-1.14). Hospital LOS (β: + 0.25; 95% CI: - 0.14-0.64), odds of 30-day (OR 0.99; 95% CI: 0.40-2.46) and 90-day mortality (OR 0.89; 95% CI: 0.47-1.70), and rate of R0 resection (OR 1.02; 95% CI: 0.82-1.27) were comparable between R and L cohorts. Compared to O, MIS approach was associated with improved 5-year OS (log rank p < 0.001). Overall survival was not significantly different between R and L (log rank p = 0.44).

CONCLUSION

These findings suggest that MIS approach may be considered for resection of gastric GIST in select patients. Among patients receiving an MIS approach, the robotic technique can be considered an oncologically safe alternative to laparoscopic surgery.

Understanding Gastric GIST: From Pathophysiology to Personalized Treatment

Background: Gastric gastrointestinal stromal tumors (GISTs) represent a subset of gastrointestinal tumors predominantly found in the stomach. Despite their rarity, these tumors carry significant implications for patient health and management. GISTs are potentially malignant tumors with unpredictable progression. They originate from the interstitial cells of Cajal, which are positioned between the intramural neurons and the smooth muscle cells of the digestive tract. These tumors are characterized primarily by mutations in the c-Kit gene, as well as other mutations such as those in the platelet-derived growth factor receptor alpha (PDGFRA) gene. Methods: Our comprehensive search across five databases initially yielded 2976 articles. After eliminating 197 duplicates, we screened the titles and abstracts of 2779 articles, excluding 2692 for not meeting the inclusion criteria. During the full-text screening, 16 more articles were excluded. Ultimately, 71 papers met the inclusion criteria and were included in our analysis. Results: Due to differences in study designs, inclusion criteria for patients, and reported outcomes, a meta-analysis was not conducted. The accurate diagnosis of GIST is established through histopathological examination and immunohistochemistry. Histopathologically, GISTs are classified into three main types: spindle cell, epithelioid, and mixed. The therapeutic management of GIST involves surgery, endoscopic treatment, and chemotherapy. Conclusions: The prognosis for GIST patients depends on various factors, including risk category, disease stage, applied treatments, and recurrence post-treatment. A significant recent advancement comes from artificial intelligence, which can be increasingly involved in both the diagnosis and treatment of this tumor.

Non-exposed endoscopic wall-inversion surgery with one-step nucleic acid amplification for early gastrointestinal tumors: Personal experience and literature review

BACKGROUND

Laparoscopic and endoscopic cooperative surgery is a safe, organ-sparing surgery that achieves full-thickness resection with adequate margins. Recent studies have demonstrated the safety and efficacy of these procedures. However, these techniques are limited by the exposure of the tumor and mucosa to the peritoneal cavity, which could lead to viable cancer cell seeding and the spillage of gastric juice or enteric liquids into the peritoneal cavity. Non-exposed endoscopic wall-inversion surgery (NEWS) is highly accurate in determining the resection margins to prevent intraperitoneal contamination because the tumor is inverted into the visceral lumen instead of the peritoneal cavity. Accurate intraoperative assessment of the nodal status could allow stratification of the extent of resection. One-step nucleic acid amplification (OSNA) can provide a rapid method of evaluating nodal tissue, whilst near-infrared laparoscopy together with indocyanine green can identify relevant nodal tissue intraoperatively.

AIM

To determine the safety and feasibility of NEWS in early gastric and colon cancers and of adding rapid intraoperative lymph node (LN) assessment with OSNA.

METHODS

The patient-based experiential portion of our investigations was conducted at the General and Oncological Surgery Unit of the St. Giuseppe Moscati Hospital (Avellino, Italy). Patients with early-stage gastric or colon cancer (diagnosed via endoscopy, endoscopic ultrasound, and computed tomography) were included. All lesions were treated by NEWS procedure with intraoperative OSNA assay between January 2022 and October 2022. LNs were examined intraoperatively with OSNA and postoperatively with conventional histology. We analyzed patient demographics, lesion features, histopathological diagnoses, R0 resection (negative margins) status, adverse events, and follow-up results. Data were collected prospectively and analyzed retrospectively.

RESULTS

A total of 10 patients (5 males and 5 females) with an average age of 70.4 ± 4.5 years (range: 62-78 years) were enrolled in this study. Five patients were diagnosed with gastric cancer. The remaining 5 patients were diagnosed with early-stage colon cancer. The mean tumor diameter was 23.8 ± 11.6 mm (range: 15-36 mm). The NEWS procedure was successful in all cases. The mean procedure time was 111.5 ± 10.7 min (range: 80-145 min). The OSNA assay revealed no LN metastases in any patients. Histologically complete resection (R0) was achieved in 9 patients (90.0%). There was no recurrence during the follow-up period.

CONCLUSION

NEWS combined with sentinel LN biopsy and OSNA assay is an effective and safe technique for the removal of selected early gastric and colon cancers in which it is not possible to adopt conventional endoscopic resection techniques. This procedure allows clinicians to acquire additional information on the LN status intraoperatively.

Novel combined endoscopic and laparoscopic surgery for advanced T2 gastric cancer: Two case reports

BACKGROUND

The standard treatment for advanced T2 gastric cancer (GC) is laparoscopic or surgical gastrectomy (either partial or total) and D2 lymphadenectomy. A novel combined endoscopic and laparoscopic surgery (NCELS) has recently been proposed as a better option for T2 GC. Here we describe two case studies demonstrating the efficacy and safety of NCELS.

CASE SUMMARY

Two T2 GC cases were both resected by endoscopic submucosal dissection and full-thickness resection and laparoscopic lymph nodes dissection. This method has the advantage of being more precise and minimally invasive compared to current methods. The treatment of these 2 patients was safe and effective with no complications. These cases were followed up for nearly 4 years without recurrence or metastasis.

CONCLUSION

This novel method provides a minimally invasive treatment option for T2 GC, and its potential indications, effectiveness and safety needs to be further evaluated in controlled studies.

Detection of paradoxical carbon dioxide gas embolism with opening of patent foramen ovale by perioperative transesophageal echocardiography during laparoscopic hepatectomy - A case report -

Background: Due to its various advantages, laparoscopic surgery is preferred over laparotomy in patients who require hepatic resection. Carbon dioxide embolism —which occurs approximately ten times more often in laparoscopic hepatectomy than in general laparoscopic surgery—presents with insignificant symptoms and may be overlooked.Case: A 70-year-old male with hepatic cell carcinoma underwent laparoscopic hepatectomy. Though his vital signs were stable during the initiation of surgery, they became unstable during the procedure. The surgeon detected portal vein rupture, and transesophageal echocardiography was subsequently performed. A large amount of gas in the heart chamber and paradoxical embolism through a patent foramen ovale due to a right-to-left shunt were observed. We treated the symptoms, and the surgery was completed without any further issues.Conclusions: Active use of transesophageal echocardiography to identify and monitor heart functions during a suspected carbon dioxide embolism can significantly reduce morbidity and mortality associated with that embolism.

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.

Current evidence on laparoscopic vs. open resection for gastric stromal tumours

Although the use of laparoscopic surgery is increasing, controversy still surrounds its application for malignant conditions. Gastrointestinal stromal tumours (GISTs) are less demanding in terms of lymphadenectomy, meaning that laparoscopic resection might have a more defined benefit when compared with open resection. To the best of our knowledge, no randomized study exists that compares the laparoscopic and open resection of GISTs. The current study aimed to examine the relevant literature by means of a systematic review. A systematic literature search was performed individually by two authors, in which three independent databases were searched using specific search-terms. Titles, abstracts and full texts were screened, as well as references to relevant articles, in order to comprise a comprehensive list of studies. Data were extracted using a detailed pre-agreed spreadsheet. Studies were evaluated according to the modified MINORS criteria. A total of 10 studies were included in the present review, yielding a total of 14 entries. The majority of studies reported significantly improved perioperative outcomes for the laparoscopic approach, including improved duration of operation, blood loss and length of hospital stay. Only four studies reported long-term outcomes and findings that were controversial, with some studies detecting no statistically significant differences, one reporting improved and one reporting worse disease-free and overall survival for the laparoscopic group. Three studies were deemed to be good quality, two of which had not reported significantly different long-term outcomes, while the third had reported significantly improved outcomes in the open resection group. While there is a clear benefit for performing laparoscopic surgery in patients with GIST with regards to perioperative outcomes, when it comes to long-term oncological outcomes, uncertainty over its application remains. The lack of randomized trials, as well as the poor reporting of retrospective studies, limits the amount of evidence that is currently available. Laparoscopic surgery for GIST is certainly safe, feasible and likely cost-effective; however, further studies are required to inform on whether this technique is superior to open resection.

Is laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumor at the esophagogastric junction safe?

INTRODUCTION

With technique improvements, indications for laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumor (SET) are gradually expanding for tumors technically difficult to resect. However, surgical outcomes of LECS, including for esophagogastric junction (EGJ) tumors requiring advanced skills, remain unknown.

METHODS

We reviewed patients in whom LECS had initially been attempted for gastric SET at the Cancer Institute Hospital in Tokyo from June 2006 to May 2018. Indications for LECS at the EGJ have gradually expanded during the study period to include tumors with esophageal invasion up to 2 cm, or less than half the EJG circumference, preoperatively. Surgical outcomes and risk factors for conversion to other procedures were investigated.

RESULTS

Twenty (9.3%) of the 214 total patients had EGJ tumors. Four patients (20%) with EGJ tumors developed postoperative complications (Clavien-Dindo grade ≥ II). Among 12 patients in whom LECS could be completed for EGJ tumors, only one non-serious complication occurred. Eight patients required conversion to another operation for EGJ tumors (two laparotomy, six proximal gastrectomy). Among conversion cases with EGJ tumors, anastomotic leakage occurred in both patients undergoing laparotomy after LECS, necessitating additional defect closure. There was only one non-serious complication in six proximal gastrectomy patients. On multivariate analysis, EGJ tumor was an independent risk factor for conversion to another operation.

CONCLUSION

LECS at the EGJ may be a risk factor for conversion operation, and when performing LECS at the EGJ is difficult, conversion to proximal gastrectomy, which can be performed safely, should be considered.

Robotic Wedge Resection for Unfavorably Located Gastric Gastrointestinal Stromal Tumors: Perioperative and Long-Term Oncological Outcomes

Background and Objectives: Robotic wedge resection for gastrointestinal stromal tumors (GISTs) located in the stomach offers remarkable advantages, especially for lesions in unfavorable places. Although promising, long-term oncological results associated with this surgical procedure are poorly represented in literature. We present our experience of robotic wedge resection with gastrotomy for challenging gastric GISTs, in terms of both surgical outcomes and long-term oncological results. Methods: From April 2014 to February 2020, all consecutive patients affected by unfavorably located gastric GISTs (based on the Privette/Al-Thani classification system) underwent robotic wedge resection. Clinicopathological, surgical, and long-term oncological results were retrospectively analyzed. Results: Seventeen patients underwent full-thickness gastric wedge resection with primary robot-sewn closure of the defect. In 64.7% of cases, the lesion was ≥5 cm in diameter. No conversion nor tumor rupture were recorded and complete R0 resection was achieved in all cases. Median hospital stay was 5 days (range 3-18). At a median follow-up of 46 months (range 7-67), the disease-free survival rate and the overall survival rate were 94.1% and 82.3%, respectively. Conclusions: Robotic wedge resection with gastrotomy and robotic-sewn suture is a safe and feasible procedure for GISTs located in unfavorable anatomic positions, without compromising oncological outcomes.

Gastrointestinal Stromal Tumor – An Overview

Gastrointestinal stromal tumors (GISTs) are rare tumors but are most common mesenchymal tumors of the digestive tract. They are commonly seen in the stomach (60%) and small intestine (30%). GISTs are likely derived from the interstitial cells of Cajal or their stem cell precursors. They are best characterized by computerized tomography and have a specific staining pattern on immunohistochemistry, i.e., C-Kit and DOG-1. The treatment of GIST is based on the risk assessment for relapse, and patients with localized GIST require resection with or without adjuvant imatinib mesylate (IM). Advanced unresectable tumors are usually treated with IM, with a number of further options available for patients post progression on IM. There is an increasing emphasis on identifying C-Kit and platelet-derived growth factor receptor alpha mutations in all patients with GIST, as these are driver mutations with current and future therapeutic implications.

Minimally invasive options for gastrointestinal stromal tumors of the stomach

BACKGROUND

Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors, most commonly arising in the stomach. Surgical resection remains the mainstay of cure, and can often be accomplished laparoscopically. Tumor size and location guide selection of appropriate resection technique.

METHODS

A retrospective review of all patients undergoing surgery at a single academic center between 2000 and 2018. Comparisons and descriptive statistics performed using student's t test and χ² test.

RESULTS

77 patients underwent resection for gastric GIST, 53 (68%) laparoscopic. Patients undergoing open operations had significantly larger tumors (4 cm vs 7 cm, p < 0.001). Operative time was not significantly different between the two groups (117 min vs 104 min, p = 0.26). Median length of stay was significantly shorter for laparoscopic resection, and postoperative complication rate was lower. A review of the operative notes revealed four types of resection: non-anatomic stapled wedge resection, resection of a full-thickness "disk" of stomach around the tumor with primary closure, formal partial gastrectomy with reconstruction, and laparoscopic transgastric (endoluminal) resection.

CONCLUSION

Non-anatomic resection (wedge or disk) is most feasible for tumors on the greater curve or gastric body, far enough from the pylorus and gastroesophageal junction to avoid narrowing inflow or outflow. A partial gastrectomy may be required for large tumors or those encroaching on the esophagus or pylorus. For small intraluminal tumors, a laparoscopic transgastric approach is ideal. This review of the technical details of each type of resection can aid in selecting the ideal approach for difficult tumors.

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.

Clinical outcomes of non-exposed endoscopic wall-inversion surgery for gastric submucosal tumors: long-term follow-up and functional results

BACKGROUND AND AIMS

To avoid the risk of iatrogenic dissemination during procedures, we have developed a combined laparoscopic and endoscopic surgery with a nonexposure technique for resection of gastric tumors. The study aim was to evaluate the feasibility and safety of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric submucosal tumors (SMTs).

METHODS

Between August 2013 and February 2018, NEWS was performed for 42 patients with gastric SMTs ≤ 3 cm in diameter at our institution. We retrospectively investigated the patients' backgrounds, operative and perioperative outcomes, tumor pathological characteristics, and follow-up data.

RESULTS

All tumors were resected with negative margins by NEWS. The median operation time was 198 min, and the median estimated blood loss was 5.0 mL. Adverse events occurred in one patient with pneumonia. All patients were alive without recurrence within the median follow-up period of 29.2 months. The average body weight loss rate was 0.3 ± 4.0%. No food residue was observed at endoscopic follow-up.

CONCLUSIONS

On the basis of slight body weight loss and the absence of food residue observed in the postoperative endoscopy, NEWS appeared to be safe and feasible for gastric SMTs and to preserve function of the remnant stomach.

Laparoscopic endoscopic cooperative surgery (LECS) for the gastrointestinal tract: Updated indications

Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure combining laparoscopic gastric resection with endoscopic submucosal dissection for local resection of gastric tumors with appropriate, minimal surgical resection margins. The LECS concept was initially developed from the classical LECS procedure for gastric submucosal tumor resection. Many researchers reported that classical LECS was a safe and feasible technique for resection of gastric submucosal tumors, regardless of tumor location, including the esophagogastric junction. Recently, LECS was approved for insurance coverage by Japan's National Health Insurance plan and widely applied for gastric submucosal tumor resection. However, the limitations of classical LECS are the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and tumor cell seeding in the peritoneum. The development of modified LECS procedures, such as inverted-LECS, non-exposed endoscopic wall-inversion surgery, a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique, and closed-LECS, has almost resolved these drawbacks. This has led to a recent increase in the indication of modified LECS to include patients with gastric epithelial neoplasms. The LECS concept is also beginning to be applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future. Sentinel lymph node mapping could also be combined with LECS, resulting in a portion of early gastric cancers being treated by LECS with sentinel node mapping.

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.

Endoscopic Full-thickness Resection for Gastric Subepithelial Tumors Originating From the Muscularis Propria: A 69-Case Series

OBJECTIVE

This report describes a mini-invasive technique called endoscopic full-thickness resection (EFR) for the treatment of gastric subepithelial tumors (SETs) originating from the muscularis propria (MP).

MATERIALS AND METHODS

We retrospectively analyzed 69 patients with gastric SETs originating from the MP at our hospital between September 2009 and July 2016. The data from each patient were reviewed, including patient information, tumor characteristics, procedure-related data, and recurrence rates.

RESULTS

Successful complete resection by EFR was achieved in 69 cases. The complete resection rate was 100%, and the mean resected tumor size was 2.25±1.40 (range, 0.6 to 6) cm. No residual tumor recurrence was detected during the follow-up period in 57 patients. The other 12 patients were lost to follow-up.

CONCLUSIONS

EFR seems to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP.

Robotic Gastrotomy With Intracorporeal Suture for Patients With Gastric Gastrointestinal Stromal Tumors Located at Cardia and Subcardiac Region

PURPOSE

Few studies of robotic gastric gastrointestinal stromal tumors (GISTs) resection have been conducted. This study was aimed to evaluate the robotic gastrotomy with intracorporeal suture for patients with GISTs located at cardia and subcardiac region.

MATERIALS AND METHODS

From January 2014 to August 2016, 11 patients with GISTs located at cardia and subcardiac region underwent robotic gastrotomy with intracorporeal suture. Data of these patients were collected.

RESULTS

The mean operative time was 82.7 minutes and the mean blood loss was 30.0 mL. No complication was reported. The postoperative length of stay was 3.3 days. On postoperative day 14, inflammation recovered to preoperative level. On postoperative month 6, the nutritional status was similar to that before the surgery. After 25.5 months follow-up, all patients survived with no recurrence or metastasis.

CONCLUSIONS

Robotic gastrotomy with intracorporeal suture for patients with GISTs located at cardia and subcardiac region is safe and feasible.

Is the Surgical Margin in Gastrointestinal Stromal Tumors Different?

Background

Radical surgical excision is the mainstay of therapy of primary, nonmetastatic gastrointestinal stromal tumors (GIST) and margin status after surgery is a significant prognostic factor.

Methods and Results

The aim of this paper is to review principles in primary GIST surgery, i.e. differences between R0, R1, and R2 resection, to describe how surgical margin status and tumor intraperitoneal rupture influence the patients' outcome, and how this may be effected by neoadjuvant and adjuvant treatment in locally advanced tumors. A systematic search of literature published between 2000 and 2018 was performed regarding this topic.

Conclusion

Correct interpretation of margin status after surgery can be affected by many factors during operation and preparation of tissue.

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.

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.

Laparoscopic total gastrectomy for a giant gastrointestinal stromal tumor (GIST) with acute massive gastrointestinal bleeding: a case report

Gastrointestinal stromal tumors (GISTs) include 80% of gastrointestinal mesenchymal tumors that originate from interstitial Cajal cells and include 0.1–3% of GI malignancies, and the stomach is the most commonly involved organ. The only potentially curative treatment is surgical resection with clear margins. Although laparoscopic resection of small GISTs is a standard treatment, there is controversy about laparoscopic surgical resection for large and giant GISTs. A 52-year-old woman, a known case of large GIST of the stomach that was under neoadjuvant imatinib therapy, was admitted to the emergency department due to acute massive gastrointestinal bleeding (GIB). The patient underwent laparoscopic total gastrectomy and received adjuvant imatinib after surgery. Laparoscopic resection is a safe and feasible method in large and giant GISTs with oncologic and long-term outcomes comparable to open surgery, and with better short-term outcomes.

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.

Laparoscopic endoscopic cooperative surgery (LECS) for the upper gastrointestinal tract

We developed the laparoscopic and endoscopic cooperative surgery (LECS) technique, which combines endoscopic submucosal dissection (ESD) and laparoscopic gastric resection to resect gastric submucosal tumors (SMTs). Many researchers have reported LECS to be a feasible technique for gastric submucosal tumor resection regardless of tumor location, including the esophagogastric junction (EGJ). Recently, the Japanese National Health Insurance system approved LECS for insurance coverage, and it is now widely applied for gastric submucosal tumor resection. Initially, we applied LECS to gastric SMTs without ulcerative lesions due to concern about the possibility of tumor cells seeding into the peritoneal cavity, in a procedure termed "classical LECS". To expand the indication of LECS for gastric epithelial neoplasms, modified LECS procedures such as inverted LECS, non-exposed endoscopic wall-inversion surgery (NEWS), combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET), and closed laparoscopic and endoscopic cooperative surgery (closed-LECS) have been developed and applied to patients with gastric epithelial neoplasms. As a future perspective of LECS, we plan to combine the modified LECS procedure and sentinel node (SN) navigation surgery (SNNS) for clinical (c)Stage IA gastric cancer resection. This strategy could be a minimally invasive surgical technique for cStage IA early gastric cancer.

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.

Endoscopic submucosal dissection for gastric gastrointestinal stromal tumors: a retrospective cohort study

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has been used to remove submucosal tumors. However, with regard to the potential malignant behavior of gastrointestinal stromal tumors (GISTs), whether ESD can be recommended for treatment is still controversial. Therefore, we evaluated the efficacy and safety of ESD for removal of GISTs in the muscularis propria (MP) layer and to assess the possible risk factors for a gastric-wall defect (GWD).

METHODS

For 168 GISTs located in the MP layer from 168 consecutive patients, the baseline information, complications, and therapeutic outcomes were recorded. Subsequently, risk factors for a GWD were analyzed.

RESULTS

Most GISTs (106/168) were located in the fundus of the stomach. Tumor shapes in 154 patients (91.7%) were regular, and the median size of the tumor was 1.5 (range 0.5-6.0) cm. The en bloc resection rate was 100% and the median procedure time was 46.5 (33-181) min. A GWD was observed in 71 patients (42.3%) and delayed bleeding occurred in 2 patients (1.2%), and they were treated by clips. A total of 117 patients with a GIST were at very low risk, 37 patients were at low risk, and 14 patients were at mild risk. No local recurrences or distant metastases were observed during a median follow-up of 25 (6-67) months. Univariate and multivariate logistic regression analyses identified the tumor type to be an independent risk factor for a GWD during ESD (odds ratio 29.82, 95% confidence interval 10.87-81.80, P < 0.001).

CONCLUSION

ESD is a safe and feasible method for gastric GISTs, especially for tumor types A and B. Endoscopic ultrasound can aid evaluation of the tumor type before ESD, which is an independent risk factor correlated with a GWD upon ESD.