Tailored laparoscopic resection for suspected gastric gastrointestinal stromal tumors

Surgical tips and tricks for laparoscopic intragastric surgery for submucosal tumors relative to the esophagogastric junction

Recent reports have described the practicality of laparoscopic intragastric surgery (l-IGS) as an alternative for resecting submucosal tumors (SMTs) near the esophagogastric junction (EGJ), where excision using an exogastric approach would be difficult. However, even using IGS to perform a full-thickness resection of SMTs that are in or extremely close to the EGJ is very difficult to do safely and avoid disrupting or causing stenosis of the EGJ, without advanced experience. This study retrospectively examined the usefulness of l-IGS for gastric SMTs located in or extremely close to the EGJ. Fourteen patients with gastric SMTs < 2 cm of the EGJ and underwent l-IGS were eligible for this study. We examined the tumor location, operative time, intraoperative hemorrhage, degree of deformation, gastroesophageal reflux disease, perioperative complications, and recurrence. Furthermore, we compared patients with tumors in the EGJ with those with tumors near the EGJ and patients in whom three-port l-IGS was performed with those who underwent single-incision laparoscopic surgery. The average tumor size, operative time, intraoperative hemorrhage, and postoperative hospitalization of the 14 patients were 30.9 ± 21.3 mm, 125.2 ± 31.1 min, 30.7 ± 103.3 mL, and 9.2 ± 3.1 d, respectively. No differences in these parameters according to the type of l-IGS or tumor location were observed. All patients underwent l-IGS without complications and were free from EGJ deformation or esophagitis. We believe that l-IGS is useful for gastric SMTs located < 2 cm of the EGJ as it can be safely performed for difficult tumor locations and does not cause deformation of the EGJ.

Single-port intragastric wedge resection using the tunnel method: a novel surgical approach for treating endophytic gastric subepithelial tumors

BACKGROUND

Intragastric wedge resection is an effective method for treating endophytic gastric subepithelial tumors (SETs). However, retracting the stomach wall to the umbilicus is difficult in certain patients. In response, we developed a novel surgical technique for single-port intragastric wedge resection, which we termed the "tunnel method."

METHODS

A transumbilical incision is made, and a wound retractor is applied. After diagnostic laparoscopy, a gastrostomy is made on the greater curvature, lower body. Another small wound retractor is inserted into the gastrostomy, and extracted through the transumbilical incision, creating a tunnel from the gastrostomy site to the umbilicus. Articulating laparoscopic instruments are inserted via the tunnel, and intragastric wedge resection is performed. We collected and analyzed the clinicopathologic and operative data of patients who underwent intragastric wedge resection via the tunnel method.

RESULTS

Twenty-seven patients who underwent single-port intragastric wedge resection via the tunnel method in a single tertiary referral hospital were included in this study. The mean age of the patients was 54.6 ± 11.4 years, body mass index was 26.5 ± 3.4 kg/m2. Twenty-four (88.9%) patients had tumors located in the upper third of the stomach. The average operative time was 65.0 ± 24.2 min. None of the patients experienced Clavien-Dindo grade IIIa or higher postoperative complications. The average postoperative hospital stay length was 2.5 ± 0.8 days. Thirteen gastrointestinal stromal tumors, nine leiomyomas, and one neuroendocrine carcinoma, schwannoma, lipoma, spindle cell proliferative lesion, and fibrotic lesion were pathologically diagnosed. The average tumor size was 2.6 ± 1.3 cm. All cases had negative resection margins.

CONCLUSIONS

Single-port intragastric wedge resection by the tunnel method is a feasible and safe approach for treating endophytic gastric SETs.

Classification of GIST and other benign gastric tumors based on minimally invasive surgical strategy

PURPOSE

Gastrointestinal mesenchymal tumors (GMTs) include malignant, intermediate malignancy, and benign lesions. The aim is to propose a new surgical classification to guide the intraoperative minimally invasive surgical strategy in case of non-malignant GMTs less than 5 cm.

METHODS

Primary endpoint is the creation of a classification regarding minimally invasive surgical technique for these tumors based on their gastric location. Secondary endpoint is to analyze the R0 rate and the postoperative morbidity and mortality rates. Tumors were classified in two groups based on their morphology (group A: exophytic, group B: transmural/intragastric). Each group is then divided based on the tumor location and consequently surgical technique used in subgroup: AI (whole stomach area) and AII (iuxta-cardial and pre-pyloric areas) both for the anterior and posterior gastric wall; BIa (greater curvature on the anterior and posterior wall), BIb (lesser curvature on the anterior wall); BII (iuxta-cardial and pre-pyloric area in the anterior and posterior wall, including the lesser curvature on the posterior wall).

RESULTS

Forty-two patients were classified and allocated in each subgroup: 17 in AI, 2 in AII, 5 in BIa, 3 in BIb, and 15 in BII. Two postoperative Clavien-Dindo I complications (4.8%, subgroup BIa and BIb) occurred. One patient (2.4%, subgroup AI) underwent reintervention due to R0 resection.

CONCLUSIONS

This classification proved to be able to classify gastric lesions based on their morphology, location, and surgical treatment, obtaining encouraging perioperative results. Further studies with wider sample of patients are required to draw definitive conclusions.

A case of a gastric gastrointestinal stromal tumor in the esophagogastric junction successfully treated by laparoscopic intragastric resection

INTRODUCTION AND IMPORTANCE

Laparoscopic wedge resection has been widely performed for gastric gastrointestinal stromal tumors (GISTs). However, because GISTs in the esophagogastric junction (EGJ) are prone to deformity and postoperative functional disorders, laparoscopic resection is technically very difficult and rarely reported. Herein, we report a case of a GIST in the EGJ successfully treated by laparoscopic intragastric surgery (IGS).

CASE PRESENTATION

A 58-year-old man with a GIST, which was intragastric growth type, 2.5 cm in diameter, located in the EGJ, and confirmed by upper gastrointestinal endoscope and endoscopic ultrasound-guided fine needle aspiration biopsy. We successfully performed IGS and the patient was discharged without complications.

CLINICAL DISCUSSION

Using laparoscopic wedge resection by exogastric approach, it is problematic to resect a gastric SMT located at the EGJ because of the difficulty in viewing the surgical field and additional concerns of deformation of the EGJ. We suppose IGS as a suitable method for such tumors.

CONCLUSION

Laparoscopic IGS for gastric GIST was useful in terms of safety and convenience even though the tumor was in the ECJ.

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

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.

Necessity of Individualized Approach for Gastric Subepithelial Tumor Considering Pathologic Discrepancy and Surgical Difficulty Depending on the Gastric Location

Background: Depending on the location of gastric subepithelial tumors (SETs), surgical access is difficult with a risk of postoperative complications. This study aimed to evaluate the clinicopathological characteristics of small-sized gastric SETs and their surgical outcomes depending on location and provide considering factors for their treatment plans. Methods: This single-center, retrospective study reviewed patients who underwent surgical resection for gastric SETs (size < 5 cm). SETs were divided into benign SETs and gastrointestinal stromal tumors (GISTs) for comparison. The clinicopathological characteristics of SETs in the cardia were compared to those in the other regions. Results: Overall, 191 patients with gastric SETs (135 GISTs, 70.7%; and 56 benign SETs, 29.3%) were included. In multivariate analysis, age > 65 years (odds ratio (OR), 3.183; 95% confidence interval (CI), 1.310−7.735; p = 0.011), and non-cardiac SETs (OR, 2.472; 95% CI, 1.110−5.507; p = 0.030) were associated with a significant risk of malignancy. Compared to SETs in other locations, cardiac SETs showed more complications (3 versus 0; p = 0.000), and open conversion rates (2 versus 0; p = 0.003). However, the proportion of GISTs of SETs in the cardia is not negligible (52.9%). Conclusions: Considering the malignancy risk of SETs, active surgical resection should be considered in old age and/or location in the non-cardiac area. However, in young patients, SETs located in the gastric cardia have a considerably benign nature and are associated with poor short-term surgical outcomes. An individualized surgical approach for asymptomatic small SETs according to the gastric location is warranted.

Feasibility of Non-Exposure Simple Suturing Endoscopic Full-Thickness Resection in Comparison with Laparoscopic Endoscopic Cooperative Surgery for Gastric Subepithelial Tumors: Results of Two Independent Prospective Trials

Simple Summary

Nonexposure simple suturing endoscopic full-thickness resection (NESS-EFTR) is a recently developed method to prevent the exposure of tumor cells, and we performed a small prospective trial of NESS-EFTR for gastric subepithelial tumors (SETs). In this study, we compared the results of NESS-EFTR trial with those of another small prospective trial of laparoscopic and endoscopic cooperative surgery which was performed in different time period. The results of this study show the feasibility of NESS-EFTR for gastric SETs and provide evidence for the clinical application of the NESS-EFTR procedure.

Abstract

Recently, nonexposure simple suturing endoscopic full-thickness resection (NESS-EFTR) method was developed to avoid tumor exposure to the peritoneal cavity. The aim of this study is to compare the short-term outcomes of the NESS-EFTR method with those of laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumors (SETs). A prospective single-center trial of LECS for gastric SETs was performed from March 2012 to October 2013 with a separate prospective trial of NESS-EFTR performed from August 2015 to June 2017, enrolling 15 patients each. Among the 30 enrolled patients, 14 who underwent LECS and 11 who underwent NESS-EFTR were finally included in the analysis. The rate of complete resection and successful closure was 100% in both groups. The operating time was longer for NESS-EFTR group than for LECS (110 vs. 189 min; p < 0.0001). There were no postoperative complications except one case of transient fever in the NESS-EFTR group. One patient in the LECS group had peritoneal seeding of gastrointestinal stromal tumor at 17 months postoperatively, and there was no other recurrence. Although NESS-EFTR had long operating and procedure times, it was feasible for patients with gastric SETs requiring a nonexposure technique.

A Review of Endoscopic Full-thickness Resection, Submucosal Tunneling Endoscopic Resection, and Endoscopic Submucosal Dissection for Resection of Subepithelial Lesions

Gastrointestinal subepithelial tumors (SETs) are often found while performing routine endoscopy. Recently, there has been the development of new endoscopic techniques such as endoscopic submucosal dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection, all minimally invasive approaches which have made it possible to resect SETs that were previously resected with surgery. This review discusses the endoscopic treatment of patients with SETs, outcomes for endoscopic treatment, procedure-related complications, and advantages and disadvantages of these endoscopic techniques.

Results of laparoscopic intragastric surgery

BACKGROUND

Technological and operative advancements have allowed laparoscopic intragastric surgery (LIGS) to be applied in the treatment of superficial gastric or submucosal lesions. The aim of this study was to evaluate short- and long-term outcomes following LIGS.

METHODS

From 2000 to 2013, 25 LIGSs were performed for superficial gastric lesions. Clinical records were reviewed retrospectively for peri-operative course and long-term outcomes with particular attention to the oncological follow-up for patients with malignant lesions.

RESULTS

Nineteen (76%) lesions were located close to the EGJ, three (12%) in the lesser curvature, two (8%) in the posterior wall and one (4%) in the prepyloric-antral region. A multiport technique was used in 15 (60%) patients and a single-access approach in 10 (40%) patients. The median operative time was 140 (50-210) minutes. No conversion to open or conventional laparoscopic surgery was needed. Mortality was nil, and severe morbidity occurred in one (4%) patient. The median length of stay was 6 (3-10) days. Indications of LIGS were adenocarcinoma in 11 (44%) patients, gastrointestinal stromal tumors (GISTs) in 6 (24%) patients and benign lesions in eight (32%) patients. En bloc resection was obtained in 24 (96%) patients with R0 margins in 23 (92%) patients. After a median follow-up of 76 (26-171) months, recurrence was detected in 4 (36%) patients with advanced malignant adenocarcinoma.

CONCLUSION

LIGS provides an interesting alternative to major gastric and EGJ resection when endoscopic resection is not suitable for highly selected patients with superficial gastric lesions.

Laparoscopic versus Open Resection for Gastric Gastrointestinal Stromal Tumors: A Meta-analysis

We conducted our meta-analysis to compare outcomes between laparoscopic resection and open resection for gastric gastrointestinal stromal tumors (GISTs) from all published comparative studies in the literature. Databases, including PubMed, Embase, Cochrane Library, Ovid, Web of Science, and CNKI, were searched to identify studies comparing outcomes after laparoscopic resection and open resection for gastric GISTs. The meta-analysis was performed by RevMan 5.1. Eleven comparative studies comprising 495 patients were identified. Patients undergoing laparoscopic resection of gastric GISTs were found to have similar operative time (weighted mean difference [WMD], 2.29; 95% confidence interval [CI], -16.01 to 11.43; P = 0.74) and complications rate (odds ratio [OR], 0.76; 95% CI, 0.36 to 1.58; P = 0.46). Less intraoperative blood loss (WMD, -55.91; 95% CI, -90.26 to -21.56; P = 0.001), earlier passing first flatus (WMD, -0.89, 95% CI, -1.60 to -0.18; P = 0.01), earlier having the first liquid diet (WMD, -1.54; 95% CI, -2.44 to -0.64; P = 0.0008), and shorter hospital stay (WMD, -4.25; 95% CI, -5.63 to -2.88; P < 0.00001) were observed in the laparoscopic resection group. The recurrence rate was higher in the group of open resection compared with the group of laparoscopic resection (OR, 0.26; 95% CI, 0.09 to 0.75; P = 0.01). Laparoscopic resection is safe and efficient in the treatment of patients with gastric GISTs as compared with open resection procedure. Laparoscopic resection may be a preferred treatment for gastric GISTs.

Comparison of Safety and Outcomes between Endoscopic and Surgical Resections of Small (≤ 5 cm) Primary Gastric Gastrointestinal Stromal Tumors

BACKGROUND AND AIMS

Endoscopic resection is increasingly performed for gastric gastrointestinal stromal tumors (GIST). However, the safety and outcomes remain elusive. We aimed in this retrospective study to compare operative complications and prognosis between endoscopically and surgically resected small (≤ 5 cm) GIST tumor groups.

METHODS

In this single-center retrospective study, we compared demographics, clinical outcomes, and the R0 resection rate between the endoscopy (n =268) and surgery (n =141) groups. Only GIST tumors in size of ≤ 5.0 cm were recruited for this comparison study.

RESULTS

Overall, the mean age of patients was 59.0 years (range: 31.0-83.0). The male-female ratio was 0.68. The most common site of GIST was, in the descending order, the gastric fundus (55%), corpus (27.6%), cardia (10.8%), and antrum (6.6%). Compared with the surgery group, GIST tumors in the endoscopy group were significantly smaller (1.69±0.9 cm, vs. 3.20±1.2 cm in the surgery group; P <0.001) in size; postoperative hospital stay was significantly shorter (4.66±1.5 days, vs. 8.11±5.0; P <0.001); post-resection time to first liquid diet was significantly shorter (1.94±1.1 days, vs. 4.63±2.6; P < 0.001); the incidence of operative and post-operative complications was significantly fewer (p < 0.05), and hospital costs were significantly lower (20115.4±5113.5¥, vs. 43378.4±16795.7¥; P < 0.001). The R0 resection rate was significantly lower in the endoscopy (93.3%) than in the surgery (99.3%) groups (P< 0.01). In the endoscopy group, 176 (65.7%) and 69 (25.7%) patients were found to be at very low and low risk of aggressiveness, respectively, in comparison to 27(19.2%) and 86 (61.0%) patients in the surgery group, respectively (P <0.001). Among 409 cases, 50 (12.2%) were found to be at intermediate or high risk of aggressiveness, 20 of which were treated with adjuvant imatinib therapy and but only 8/20 taking imatinib for 1 to 3 months because of side effects and high costs. No local or distant tumor recurrence was observed over an average of 33.5-month follow-ups. Two patients died of other disease in the surgery group.

CONCLUSIONS

Endoscopic resection of selected small gastric GISTs (≤ 5cm) was feasible, safe, and associated with better intraoperative results and an equal postoperative course, compared to surgical resection.

Laparoscopic-endoscopic Rendezvous Procedures for Upper Gastrointestinal Tumors Guided by Laser-supported Reverse Diaphanoscopy: A Modified Technique

INTRODUCTION

Precisely locating benign upper gastrointestinal tumors during laparoscopic-endoscopic surgery remains difficult and inaccurate. We describe reverse laser-supported diaphanoscopy (RLSD) for locating gastrointestinal tumors during laparoscopic surgery and present prospective evaluation results of the first cases.

MATERIALS AND METHODS

We studied 13 patients [women:men=7:6; mean age, 67 (range, 41 to 83) y] who underwent gastroscopic-laparoscopic rendezvous procedures during 2015 to 2018. Surgery duration, marking duration, and specimen resection size were recorded. The largest and smallest specimen resection margins were measured.

RESULTS

After locating tumors using RLSD, patients underwent successful resections. Histopathologic examination confirmed 5 cases of gastrointestinal stromal tumor; 3, neuroendocrine tumors; 2, heterotopic pancreatic tissue; 1, leiomyoma; 1, adenoma; 1, hyperplastic polyp. We employed 4 to 6 marks, depending on tumor location and size. The average marking duration was 14 minute (1 to 21 min); the average surgery duration, 73 minute (37 to 143 min). The smallest resection median margin was 2.0 mm (1.0 to 5.0 mm); the largest, 7.0 mm (2.0 to 12.0 mm).

CONCLUSIONS

RLSD precisely locates gastric benign tumors during laparoscopic-endoscopic rendezvous procedures.

Clinicopathologic Characteristics and Optimal Surgical Treatment of Duodenal Gastrointestinal Stromal Tumor

BACKGROUND

The clinicopathologic characteristics of duodenal gastrointestinal stromal tumor (GIST) were unclear and the optimal surgical procedure for duodenal GIST remains poorly defined. We aimed to analyze clinicopathological characteristics, survival outcomes based on the surgical procedure, and recommend optimal surgical treatment for duodenal GIST.

METHODS

From July 2000 to April 2017, 118 patients with localized duodenal GIST underwent curative surgical resection at a single institution. We retrospectively reviewed the clinicopathological characteristics and survival outcomes.

RESULTS

The 5-year overall survival (OS) and disease-free survival (DFS) rates were 94.9 and 79.2%, respectively. On multivariate analysis, the mitotic count was a statistically significant prognostic factor for DFS. Limited resection (LR) was performed in 20 patients with GIST in the first or fourth portion of the duodenum. Both LR and pancreaticoduodenectomy (PD) were performed in 98 patients with GIST in second or third portion of the duodenum. The patients in the LR group had less late complications than in the PD group and no postoperative newly developed diabetes mellitus. The minimally invasive LR (MI-LR) group had a shorter duration of surgery and shorter length of postoperative hospital stay.

CONCLUSION

LR is a feasible and effective surgical treatment for patients with small-sized and antimesenteric-sided duodenal GIST in terms of late complications and postoperative diabetic complications. MI-LR has better perioperative outcomes than open LR. Therefore, we should consider MI-LR as an optimal surgical treatment for selected patients with duodenal GIST.

Effects of CO2 pneumoperitoneum on proliferation, apoptosis, and migration of gastrointestinal stromal tumor cells

BACKGROUND

The purpose of the study was to investigate the proliferation and migration capability of human gastrointestinal stromal tumor line GIST-T1 after exposure to different pressures and times of CO₂ pneumoperitoneum.

METHODS

We established simulated CO₂ pneumoperitoneum environment in vitro and divided the human GIST cell GIST-T1 into open control group, 8 mmHg CO₂ pneumoperitoneum treatment group and 15 mmHg CO₂ pneumoperitoneum treatment group. Each group was divided into two subgroups respectively cultured for 1 h and 3 h. pH value of cell culture, cell growth curve, and cell cycle distribution of each group was measured. By application of scratch healing tests and Transwell chamber experiments, mobility ratio and number of cells through 8 µm membranes were measured to assess the migration ability of cells in each group after intervention.

RESULTS

Cell culture pH value of each subgroup in CO₂ group decreased significantly after exposed in CO₂ pneumoperitoneum (P < 0.01). The proliferation of GIST-T1 cells in 15 mmHg CO₂ group was significantly inhibited early (1-2 days) (P < 0.05) and the proliferation of GIST-T1 cells in 8 mmHg CO₂ 1 h subgroup and 15 mmHg CO₂ 1 h subgroup was increased significantly late (4-6 days) (P < 0.05) after the interventions of CO₂ pneumoperitoneum. The percentage of cells in G0-G1 phase increased, the percentage of S phase cells decreased (P < 0.01) in 1-h subgroup and 3-h subgroup of 15 mmHg CO₂ group 24 h after exposure to CO₂. The percentage of cells in S phase increased in 1-h subgroup of 8 mmHg CO₂ group and decreased in 3-h subgroup of 15 mmHg CO₂ group 72 h after exposure to CO₂. In the Transwell chamber experiment, the cell number through 8-µm membrane increased significantly (P < 0.01) in 3-h subgroup of CO₂ group compared to that in 3-h subgroup of control group.

CONCLUSIONS

The routine pressure and duration of CO₂ pneumoperitoneum used in clinic did not promote the proliferation of gastrointestinal stromal tumors, but had a potential risk of increasing postoperative recurrence and distant metastasis.

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.

Optimal minimally invasive surgical procedure for gastric submucosal tumors

BACKGROUND

Laparoscopic wedge resection (LWR) is widely performed for managing gastric submucosal tumors (SMTs). Despite the development of novel procedures such as laparoscopy-endoscopy cooperative surgery (LECS) and nonexposed endoscopic wall-inversion surgery (NEWS), the most appropriate surgical intervention for gastric SMTs remains unclear.

METHODS

We retrospectively reviewed patient characteristics, surgical outcomes, postoperative courses, results of histopathological examinations, and surgical costs of 71 consecutive patients who underwent LWR, LECS, or NEWS for gastric SMTs from January 2010 to June 2016 in our institute.

RESULTS

LWR, LECS, and NEWS were performed in 31, 14, and 26 cases, respectively. Patient backgrounds were comparable between groups. LWR was not performed for esophagogastric (E-G) junction tumors to avoid postoperative stricture, and LECS was not performed for ulcerated tumors to prevent tumor dissemination. NEWS was considered for tumors smaller than 3 cm for transoral extraction. Resected specimen area of the LWR group was significantly larger than that of the other groups. Further, the LWR group had a significantly higher complication rate. Compared to the LECS group, postoperative serum C-reactive protein level was significantly lower and postoperative hospitalization was significantly shorter in the NEWS group. Also, operation costs were significantly lower in the NEWS group.

CONCLUSIONS

The surgical procedure for gastric SMTs must be carefully chosen according to tumor size, location, and presence or absence of ulceration. For selected patients, NEWS is suggested to be an appropriate option for the treatment of gastric SMTs.

Endogastric resection of gastrointestinal stromal tumor

Gastric gastrointestinal stromal tumors (GIST) have a distinct surgical therapy compared to gastric adenocarcinoma. Large oncologic margins and lymphadenectomy are not necessary rendering local resections suitable to treat the disease and spare the stomach. That may be accomplished through a minimally invasive approach. We present a case of a 67-year-old woman with an endophytic 3.5 cm gastric GIST located in the posterior wall of the gastric body that underwent an endogastric resection. Operation was uneventful. The patient was discharged in the following day. Pathologic examination showed free margins and a low grade GIST. Endogastric resection is a feasible option in endophytic GISTs located in the posterior wall of the stomach.

Laparoscopic resection of gastrointestinal stromal tumors: Does laparoscopic surgery provide an adequate oncologic resection?

Gastrointestinal stromal tumors (GISTs) are rare tumors of the GI tract. Surgical resection remains the mainstay of non-metastatic disease. However, the ability to provide an adequate oncologic resection using laparoscopic surgery is still an area of debate. This is a thorough review of the current literature, looking particularly at the use of laparoscopic surgery for larger GISTs and the long-term oncologic outcomes compared to the results of open surgery. Laparoscopic resections provide an adequate oncologic result for GISTs of all sizes, including those greater than 5 cm in size.

Effectiveness and safety of endoscopic resection for gastric GISTs: a systematic review

AIMS

To evaluate the effectiveness and safety of endoscopic resection for gastric gastrointestinal stromal tumors (GISTs).

MATERIAL AND METHODS

The effectiveness and safety of endoscopic resection were mainly assessed by complete resection rate, postoperative adverse event rate, and recurrence rate. Moreover, a comparison of endoscopic with laparoscopic resection for gastric GISTs was made through weighted mean difference by STATA 12.0 with regard to operation time, blood loss, and length of stay after including patients who underwent endoscopic or laparoscopic resection for gastric GISTs in the comparative studies.

RESULTS

Eleven studies investigating endoscopic resection for GISTs were included. For stromal tumors <2 cm in average diameters the pooled rates of complete resection, postoperative adverse events and recurrence were 0.97, 0.08, and 0.03, respectively. Only five retrospective studies directly compared endoscopic with laparoscopic resection for gastric GISTs with average diameters from 1.1 cm to 3.8 cm, and endoscopic resection had a shorter operation time than laparoscopic resection, but there were no significant differences in intraoperative blood loss, length of stay, postoperative complications, and postoperative recurrence rates between the two approaches.

CONCLUSIONS

Endoscopic resection is predominantly tried for gastric GISTs of relatively small size. It seems effective and safe for gastric GISTs <2 cm in average diameter, with relatively short operation times.

Clinicopathological and Prognostic Analysis of Primary Gastrointestinal Stromal Tumor Presenting with Gastrointestinal Bleeding: a 10-Year Retrospective Study

OBJECTIVES

The objectives of this paper were to investigate the clinicopathological characteristics and prognostic factors of GI-bleeding GIST patients and explore whether GI bleeding is a risk factor for GIST relapse.

METHODS

Primary GIST patients with initial symptoms of GI bleeding or no GI bleeding were retrospectively studied.

RESULTS

Up to 178 GI-bleeding GIST patients including 108 (60.7%) males and 70 (39.3%) females were evaluated for the clinicopathological characteristics. The stomach, small bowel, and colorectum were the tumor sites in 82 (46.1%), 85 (47.8%), and 11 (6.2%) patients. Of the 178 patients, 163 GI-bleeding patients had follow-up while another 363 patients from the total population presented without GI bleeding were followed up. Up to 526 patients who received postoperative follow-up were included in the survival analysis. Compared with the 363 non-GI-bleeding patients, GI-bleeding patients developed smaller tumors (P = 0.015) and had a longer relapse-free survival (RFS; P = 0.014). For the 163 GI-bleeding patients, a Cox regression analysis showed that the mitotic count and the platelet-lymphocyte ratio before surgery were independent prognostic predictors for poor outcome regarding RFS. For all 526 patients, a Cox regression analysis indicated that tumor location, mitotic index, platelet-lymphocyte ratio, and GI bleeding were independent prognosis predictors.

CONCLUSION

Compared to non-GI-bleeding GIST patients, patients with GI bleeding were more likely to be male and to have more small intestine GISTs, smaller tumors, and a longer RFS. For GI-bleeding patients, mitotic count and platelet-lymphocyte ratio were independent prognostic indicators. GI bleeding served as a surrogate for smaller GIST and was a protective factor for GIST recurrence.

Application of laparoscopy, endoscopy and laparoscopic and endoscopic cooperative surgery in gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) constitute the most common mesenchymal neoplasms of the gastrointestinal tract, among which 60%-70% are located in the stomach. All GISTs have malignant potential, varying from small lesions to aggressive sarcomas. Surgical resection with negative margins remains the best treatment for GISTs. Lymphadenectomy is not necessary because GISTs rarely metastasize to lymph nodes. Because of these biological behavior characteristics, the advantages of minimally invasive surgeries such as laparoscopic surgery and endoscopic surgery can be fully reflected in the surgical management of GISTs. The advent of laparoscopic and endoscopic cooperative surgery has broadened the scope and enhanced the safety of minimally invasive surgical treatment of GISTs. In this paper we will discuss the application of laparoscopy, endoscopy and laparoscopic and endoscopic cooperative surgery in the treatment of GISTs.

Comparison of minilaparoscopy and single-incision intragastric surgery for gastric submucosal tumor resection in a porcine model

BACKGROUND

The aim of this study was to develop an easy-to-induce and reproducible model of gastric submucosal tumor in swine to compare minilaparoscopy (ML) with single-incision (SI) intragastric surgery.

METHODS

Twelve healthy female pigs (weight 30.94 ± 2.49 kg) underwent a transparietal injection of sterile alginate at the level of Z-line (n = 6) and at the pre-pyloric area (n = 6) creating a model of gastric submucosal pseudotumor. The operative procedures included intragastric resection with ML and SI approaches of cardiac and pre-pyloric lesions, with gastroscopic assistance. After resection, the gastric mucosal layer was closed using intracorporeal sutures. The operative time, complication rate and clinical evolution after 1 month were compared in the four groups that the pigs were arranged.

RESULTS

The pseudotumors ranged in size from 3 to 6 cm in diameter. The access of the gastric cavity and resection of the experimental SMP and suturing of the mucosa were performed successfully in 12 animals using both approaches. Mean time to perform the exeresis of gastric cardia tumors was significantly higher in single-incision approach. No significant differences were observed in the surgical time during pyloric surgery. Minilaparoscopic approach reduced significantly the mucosa closure time in esophagogastric and pyloric pseudotumors. One month after, no alterations were shown in the abdominal cavity using exploratory laparotomy.

CONCLUSIONS

The technical feasibility of performing safe and efficient intragastric approach of submucosal pseudotumors in swine model was verified in this study. Intragastric ML has advantages over SI, namely regarding the reduction in total surgical times and the fewer technical difficulties.

Endoscopic and Laparoscopic Full-Thickness Resection of Endophytic Gastric Submucosal Tumors Very Close to the Esophagogastric Junction

Purpose

Gastric submucosal tumors (SMTs) located very close to the esophagogastric junction (EGJ) are a challenge for gastric surgeons. Therefore, this study reports on the experience of using endoscopic and laparoscopic full-thickness resection (ELFR) with laparoscopic two-layer suturing in such tumors.

Materials and Methods

Six patients with gastric SMTs very close to the EGJ underwent ELFR with laparoscopic two-layer suturing at Kyungpook National University Medical Center. With the patient under general anesthesia, the lesser curvature and posterior aspect adjacent to the EGJ were meticulously dissected and visualized using a laparoscopic approach. A partially circumferential full-thickness incision at the distal margin of the tumor was then made using an endoscopic approach under laparoscopic guidance. The SMT was resected using laparoscopic ultrasonic shears, and the gastric wall was closed using two-layer suturing. Thereafter, the patency and any leakage were checked through endoscopy.

Results

All the ELFR procedures with laparoscopic two-layer suturing were performed successfully without an open conversion. The mean operation time was 139.2±30.9 minutes and the blood loss was too minimal to be measured. The tumors from four patients were leiomyomas, while the tumors from the other two patients were gastrointestinal stromal tumors with clear resection margins. All the patients started oral intake on the third postoperative day. There was no morbidity or mortality. The mean hospital stay was 7.7±0.8 days.

Conclusions

ELFR with laparoscopic two-layer suturing is a safe treatment option for patients with an SMT close to the EGJ, as major resection of the stomach is avoided.

Strategy of Laparoscopic Partial Resection for Gastric Gastrointestinal Stromal Tumors According to the Growth Pattern

Laparoscopic partial gastrectomy is the standard surgical treatment for gastric gastrointestinal stromal tumor (GIST). However, to reduce gastric deformation, the tumor margins should be secured so as to minimize the size of the resection as much as possible. This is the report on the 3 laparoscopic resection techniques for gastric GIST depending upon the growth pattern and location of the tumor, and their results. We performed laparoscopic partial gastrectomy for 41 gastric GISTs between 2004 and 2012. Simple resection was used on exophytic or small GISTs. Seromuscular resection was used on exoendophytic (intramural) and relatively small endophytic tumors. Transgastric resection was used in cases of large endophytic tumors. We performed simple resection on 24 lesions (58.5%), seromuscular resection on 14 lesions (34.1%), and transgastric resection on 3 lesions (7.3%). There were no intraoperative complications. Postoperative complications included 1 case (2.5%) of bleeding from the staple line.

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

AIM: To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors.

METHODS: A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach.

RESULTS: The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described.

CONCLUSION: Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.

Various features of laparoscopic tailored resection for gastric submucosal tumors: a single institution's results for 168 patients

BACKGROUND

Laparoscopic resection is a standard procedure for gastric submucosal tumors. Herein, we analyzed the features of various laparoscopic approaches.

METHODS

Between January 2007 and November 2013, 168 consecutive patients who underwent laparoscopic resection for gastric submucosal tumors were enrolled. Patients' demographics and clinicopathologic and perioperative data were reviewed retrospectively.

RESULTS

Among the 168 patients, exogastric wedge resection was performed in 99 cases (58.9%), single-port intragastric resection was performed in 30 cases (17.9%), eversion technique was used in 17 cases (10.1%), transgastric resection was performed in 8 cases (4.8%), and single-port wedge resection was performed in 6 cases (3.6%). The remaining cases underwent single-port exogastric wedge resection, laparoscopic and endoscopic cooperative surgery, or major resection. Mean age was 56.8 ± 13.3 years, and body mass index was 24.0 ± 3.2 kg/m(2). Mean operation time was 96.1 ± 58.9 min; laparoscopic proximal gastrectomy had the longest operation time (3 cases, 291.7 ± 129.0 min). In contrast, the laparoscopic eversion technique had the shortest operation time (82.6 ± 32.8 min). Pathologic data revealed a mean tumor size of 2.9 ± 1.2 cm (with a range of 0.8-8.0 cm). Tumors were most common on the body (98 cases, 58.3%), followed by the fundus (44 cases, 26.2%). Exophytic growth occurred in 39 cases (23.2%), endophytic growth occurred in 89 cases (53.0%), and dumbbell-type growth occurred in 40 cases (23.8%). Gastrointestinal stromal tumors occurred in 130 cases (77.4%), and schwannomas occurred in 23 (13.7%). Thirteen patients had postoperative complications (delayed gastric emptying in 5, stricture in 3, bleeding in 3, others in 2). The mean follow-up period was 28.8 ± 20.8 months, and there were three recurrences (1.8%) at 6, 19 and 31 months after the initial surgery.

CONCLUSIONS

For gastric submucosal tumors with appropriate locations and growth types, laparoscopic tailored resection which facilitates safer and more precise resection can be good alternative treatment option.

Reduced port laparoscopic gastrectomy: a review, techniques, and perspective

Reduced port laparoscopic surgery has been used increasingly. It is a concept that has grown out of the various efforts aimed at minimally invasive surgery, with SILS being the ultimate reduced port technique. Reduced port laparoscopic surgery has been used to perform sleeve gastrectomy in bariatric surgery and excision of benign gastric submucosal tumor, applications that generally do not require lymph node dissection or complicated reconstruction. It can be done safely, result in a permanent cure, and offer good cosmetic outcomes. Reduced port laparoscopic surgery for gastric cancer has a short history, and its usefulness has not yet been fully established. This review describes the present situation and challenges faced as well as standardized procedures and the future prospects of reduced port laparoscopic gastrectomy for gastric cancer, which my team performs almost daily. These aspects of reduced port laparoscopic surgery are presented in light of the literature.

Surgical management of gastrointestinal stromal tumors of the stomach

Laparoscopic gastric resection for selected cases of gastrointestinal stromal tumors of the stomach appears to be safe, feasible, and effective.

Background:

Laparoscopy has emerged as the “gold standard” procedure for many diseases that require surgical treatment. Our goal was to assess the outcomes of laparoscopic vs open partial gastrectomies for the management of gastrointestinal stromal tumors of the stomach (gGIST) using a national database.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2006–2009), we identified patients who underwent laparoscopic and open partial gastrectomy gGIST. Overall morbidity and mortality were assessed. The relationships between anesthesia time, operative duration, surgical site infection (SSI), and hospital stay were also examined. Two-sample t tests were used.

Results:

Of 486 patients, 146 (30%) underwent laparoscopic resection (LR) and 340 (70%) underwent open resection (OR). Patients who underwent LP were older (mean: 65 vs 62 years; P = .062). Patients treated with LR experienced shorter anesthesia time (mean: 183 vs 212 minutes; P < .05) and shorter operative time (mean: 119 vs 149 minutes; P < .05) compared with those who underwent OR. All patients treated with LR had fewer SSIs compared with those who underwent OR (0.68% vs 6.7%; P < .001). Patients treated with LR were less likely to experience an overall morbidity (mean: 3.9% vs 11.7%; P < .001) or mortality (mean: 0.23% vs 0.72%; P < .001) and shorter total hospital stay (mean: 3.17 vs 7.50 days; P < .001) compared with those who underwent OR.

Conclusions:

In ACS NSQIP hospitals, laparoscopic resection of gGIST appears to be preferable to open surgery. However, prospective studies with large sample sizes comparing both surgical approaches with size-matched tumors are strongly suggested.

Single-incision intragastric resection for upper and mid gastric submucosal tumors: a case-series study

Purpose

Laparoscopic gastric wedge resection is a standard treatment for removing gastric submucosal tumors (SMTs). So far, however, there have been few reports of single-incision laparoscopic intragastric wedge resection. Our aim was to describe this procedure and our experience with it.

Methods

From January 2010 to December 2013, a total of 21 consecutive patients with gastric SMTs underwent single-incision intragastric resection at our institution. Their clinicopathologic data were analyzed retrospectively.

Results

The patients consisted of nine men and 12 women with a mean age of 51.9 ± 12.9 years (22-69 years). Their mean body mass index was 22.6 ± 2.0 kg/m². Mean tumor size was 2.4 ± 0.7 cm, with the following anatomic distribution: esophagogastric junction in three patients, fundus in twelve, upper body in three, and lower body in two. Mean operating time was 68.6 ± 12.0 minutes. There were no conversions to open surgery and no major intraoperative complications. Time to resumption of water intake was 1.4 ± 0.5 days. Mean hospital stay was 4.9 ± 1.7 days. There were no recurrences or deaths during the mean 19-month follow-up.

Conclusion

Single-incision intragastric wedge resection is a feasible and safe procedure. It is especially efficient for treating small endophytic gastric SMTs located on the upper and mid portion of the stomach.

Single-port laparoscopic and endoscopic cooperative surgery for a gastric gastrointestinal stromal tumor: report of a case

We herein report a case of single-port laparoscopic and endoscopic cooperative surgery (LECS) for a gastric gastrointestinal stromal tumor (GIST). A 75-year-old female with an endoluminal GIST located near the esophagogastric junction underwent LECS. Both the mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. The endoluminal GIST was exteriorized to the abdominal cavity. The tumor and the edge of the incision line were closed using an endoscopic linear stapler. The LECS was successfully accomplished without the need for any skin incisions or additional ports. The length of the operation was 120 min and blood loss was 5 ml. Oral intake was resumed on the second day and the length of hospital stay was 5 days. No complications were noted and the patient had an excellent cosmetic result. In our experience, single-port LECS is feasible and safe for gastric GIST when performed by a surgeon experienced in laparoscopic and gastric surgery.

Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria

BACKGROUND AND AIMS

This retrospective study evaluated the safety and efficacy of endoscopic full-thickness resection (eFTR) with defect closure using clips and an endoloop for the treatment of gastric subepithelial tumors (SETs) arising from the muscularis propria (MP).

METHODS

From January 2009 to December 2012, 51 patients with gastric SETs arising from the MP underwent eFTR with defect closure using clips and an endoloop. The key steps were (1) several milliliters of mixture solution was injected into the submucosa after dots were marked around the tumor; (2) a cross incision was made in the mucosa to reveal the tumor; (3) subsequently, circumferential excavation was performed as deep as the muscularis propria, and full-thickness resection of the tumor was performed with an insulated-tip knife, including its underlying MP and serosa; (4) the gastric wall defect was closed with clips and an endoloop was then placed to fix and tighten all of the clips together.

RESULTS

Successful complete resection by eFTR was achieved in 50 cases (98.0%). One case failed and was converted into a laparoscopic resection due to the tumor falling into the peritoneal cavity during the procedure. The mean procedure time was 52 min. No patients had severe complications, such as massive bleeding, delayed bleeding, peritonitis, or gastrointestinal tract leakage. The mean tumor length was 2.4 cm. Pathological diagnoses of the tumors were leiomyomas (21/51) and gastrointestinal stromal tumors (30/51). The median follow-up period after the procedure was 22.4 months (range 1-48 months), and no residual tumor or tumor recurrence was detected during the follow-up period.

CONCLUSIONS

eFTR with defect closure with clips and an endoloop appears to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP, especially for those with extraluminal growth or adhesions to the MP.

Long-term and surgical outcomes of laparoscopic surgery for gastric gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. Surgical resection with a free margin is the gold standard treatment for these lesions.

OBJECTIVE

The aim of this study was to evaluate the feasibility of performing laparoscopic resection for gastric GIST from the viewpoint of operative and long-term oncological outcomes.

METHODS

Between 2005 and 2011, a total of 78 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a retrospective single-center study. Patient and tumor characteristics, surgical procedures, risk classification, postoperative complications, mortality, recurrence, and survival time were collected from a database, and the descriptive statistics were estimated.

RESULTS

Patients (N = 78; 32 males and 46 females) with a median age of 63 years (range 31-82) were evaluated. The tumors were located at the cardia (10.3%), upper stomach (59.0%), middle stomach (23.1), and lower stomach (7.7%). The mean size of the tumors was 34.7 ± 12.1 mm. The laparoscopic procedures included wedge resection (92.3%), such as laparoscopy and endoscopy cooperative surgery (51.3%), and gastrectomy (7.7%). All cases exhibited a pathologically negative margin. The mean operative time was 147.5 ± 63.8 min, and the mean estimated amount of blood loss was 17.8 ± 47.9 ml. The mean length of hospitalization was 9.4 ± 12.8 days. The incidence of perioperative complications higher than grade III was 2.6%, including two cases of anastomotic leakage. Regarding risk classification, low, intermediate and high were observed in 61, 6, and 11 cases, respectively. During a mean follow-up period of 45.3 ± 18.5 months, one patient experienced local recurrence in the omentum. Meanwhile, four patients died due to other diseases; all other patients survived.

CONCLUSIONS

Adequate oncologic resection was achieved in all cases. Laparoscopic surgery is a feasible option for gastric GISTs <5 cm.

Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases

OBJECTIVE. Subepithelial tumors (SETs) in the stomach are usually considered benign. However, some do have potential for malignant transformation, especially when originating in the muscularis propria (MP). Our study aimed to evaluate the clinical efficacy and safety of endoscopic submucosal dissection (ESD) for gastric SETs originating in MP. MATERIAL AND METHODS. A total of 145 gastric MP SETs in 144 patients were treated by ESD between September 2008 and December 2012. Characteristics of patients and SETs, therapeutic outcomes, pathologic characteristics, complications and follow-up outcomes were evaluated. RESULTS. Among the 144 patients, 104 were female (72.22%) and 40 were male (27.78%), and the mean age was 55.75 ± 11.29 years (range 18-78 years). The mean size of the tumors determined by endoscopic ultrasound (EUS) was 15.14 ± 9.70 mm (range 3-50 mm). En bloc complete resection was achieved in 134 of 145 tumors, giving a complete resection rate of 92.41%. The final histopathologic diagnoses included 52 leiomyomas, 89 gastrointestinal stromal tumors, 3 neurogenic tumors and 1 lipoma. Perforations occurred in 21 patients (14.48%) and were endoscopically repaired with clips or nylon bands. Intraoperative bleeding occurred in seven patients (4.83%) and was corrected with argon plasma coagulation (APC) or hot biopsy forceps. No local recurrence or distant metastasis was detected during a mean follow-up of 19.14 ± 10.29 months (range 3-51 months). CONCLUSIONS. ESD appears to be an effective and safe treatment for gastric SETs originating in MP.

Endoscopic submucosal dissection in the treatment of gastric submucosal tumors: results from a retrospective cohort study

BACKGROUND

A submucosal tumor (SMT) of the stomach, which is an occasional finding during routine upper gastrointestinal endoscopy, may pose diagnostic and therapeutic challenges.

METHODS

To assess whether endoscopic submucosal dissection (ESD) is a feasible approach to definitively cure SMTs, the authors performed a retrospective cohort study with two endoscopic italian centers.

RESULTS

The study consisted of 20 patients with SMTs who underwent ESD. The patients underwent ESD and were followed up by endoscopy. We analyzed complete resection rate, frequency of complications, and survival. The overall rate of R0 resection was 90 % (18/20), with two endoscopic failures, one for a submucosal tumor and one for a neoplasm deeply infiltrating the proper muscle layer. The median procedure time was 119.1 min (range 40-240 min). The median size of the resected specimens was 29 mm (range 15-60 mm). Perforation occurred in 3 patients; all were treated conservatively. There were no cases of severe bleeding. Based on histopathological findings, 6 cases of ectopic pancreas, 1 of ectopic spleen, 3 of leiomyoma, and 10 of gastrointestinal stromal tumor (GIST) were diagnosed. Complete resection was obtained in all GIST cases. Among the 10 GIST cases treated by ESD, no death occurred: the 5-year disease-specific survival rate was 100 %.

CONCLUSIONS

The high success rate of 90 % and the low incidence of complications should indicate ESD is the correct diagnostic and definitive treatment in selected patients.

Submucosal tumors: comprehensive guide for the diagnosis and therapy of gastrointestinal submucosal tumors

Small submucosal tumors (SMT) without symptoms are frequently found by endoscopic and radiological examinations. To find proper diagnostic measures and therapeutic indications for histologically undiagnosed SMT, we reviewed published articles in PubMed between 1990 and March 2013 using the key words 'submucosal tumor' and the name of a specific disease. SMT is observed in a wide range of gastrointestinal (GI) diseases and conditions, including compression by extra-GI organs and lesions, congenital tumors, inflammation, and benign as well as malignant neoplastic lesions. In the diagnosis of diseases and decision-making for therapy, endoscopic ultrasonography (EUS) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) may play a key role. Symptomatic SMT and SMT histologically diagnosed as malignant or potentially malignant tumors such as gastrointestinal stromal tumor (GIST) should be treated by surgery. SMT >5 cm, SMT increasing in size and those with'high-risk features' including irregular border, heterogeneous internal echo such as anechoic area, and heterogeneous enhancement by contrast media may also be removed by surgery. Laparoscopic approach is feasible for gastric GIST <5 cm and this is considered less invasive than the open approach. Emerging techniques using flexible endoscopes appear less invasive, but require further evidence and are still under clinical study. Correct diagnosis of SMT is challenging; however, EUS and EUS-FNA are useful in the histological diagnosis and clinical decision-making. In the future, minimally invasive approaches may be a mainstream of surgical treatment for small SMT.

Single-port versus multiport laparoscopic resection for gastric gastrointestinal stromal tumors: a case-matched comparison

PURPOSE

The aim of this study was to compare the outcomes of single-port laparoscopic gastric resection (SPLGR) with multiport laparoscopic gastric resection (MPLGR) for gastric gastrointestinal stromal tumors (GISTs).

METHODS

Between April 2009 and December 2012, 16 consecutive patients with gastric GISTs underwent SPLGR. The patients undergoing the SPLGR were case-matched for age, sex, body mass index and tumor location with those undergoing MPLGR. The demographic and surgical outcomes were analyzed and compared from the review of a prospectively collected database of 16 patients who underwent MPLGR.

RESULTS

All 16 patients underwent complete SPLGR without any intraoperative complications. No significant differences were observed in the mean length of the operation (91.4 vs. 94.1 min), blood loss (6.3 vs. 10.1 ml) and length of postoperative hospital stay (4.7 vs. 5.4 days) between the SPLGR and MPLGR groups. The tumor size was similar (37.8 vs. 32.1 mm) and negative surgical margins were achieved in all patients. At a mean follow-up of 27 months, all 16 SPLGR patients were disease-free.

CONCLUSIONS

Our initial comparison demonstrated that SPLGR, when performed by experienced surgeons, is a safe and feasible procedure for patients with gastric GISTs, resulting in good surgical and oncological outcomes.

A systematic review and meta-analysis comparing laparoscopic versus open gastric resections for gastrointestinal stromal tumors of the stomach

BACKGROUND

This study is a systematic review and meta-analysis that compares the short- and long-term outcomes of laparoscopic gastric resection (LR) versus open gastric resection (OR) for gastric gastrointestinal stromal tumors (GISTs).

METHODS

Comparative studies reporting the outcomes of LR and OR for GIST were reviewed.

RESULTS

A total of 11 nonrandomized studies reviewed 765 patients: 381 LR and 384 OR. A higher proportion of high-risk tumors and gastrectomies were in the OR compared with LR (odds ratio, 3.348; 95 % CI, 1.248-8.983; p = .016) and (odds ratio, .169; 95 % CI, .090-.315; p < .001), respectively. Intraoperative blood loss was significantly lower in the LR group [weighted mean difference (WMD), -86.508 ml; 95 % CI, -141.184 to -31.831 ml; p < .002]. The LR group was associated with a significantly lower risk of minor complications (odds ratio, .517; 95 % CI, .277-.965; p = .038), a decreased postoperative hospital stay (WMD, -3.421 days; 95 % CI, -4.737 to -2.104 days; p < .001), a shorter time to first flatus (WMD, -1.395 days; 95 % CI, -1.655 to -1.135 days; p < .001), and shorter time for resumption of oral intake (WMD, -1.887 days; 95 % CI, -2.785 to -.989 days; p < .001). There was no statistically significant difference between the two groups with regard to operation time (WMD, 5.731 min; 95 % CI, -15.354-26.815 min; p = .594), rate of major complications (odds ratio, .631; 95 % CI, .202-1.969; p = .428), margin positivity (odds ratio, .501; 95 % CI, .157-1.603; p = .244), local recurrence rate (odds ratio, .629; 95 % CI, .208-1.903; p = .412), recurrence-free survival (RFS) (odds ratio, 1.28; 95 % CI, .705-2.325; p = .417), and overall survival (OS) (odds ratio, 1.879; 95 % CI, .591-5.979; p = .285).

CONCLUSIONS

LR results in superior short-term postoperative outcomes without compromising oncological safety and long-term oncological outcomes compared with OR.

Laparoscopic single-stapling gastric transection for exophytic pedunculated gastrointestinal stromal tumor: is a safe procedure?

Gastrointestinal stromal tumors (GISTs) represent the most common mesenchymal tumors of the gastrointestinal tract. The macroscopic growth of these lesions can be intraluminal, extraluminal, or intramural, but only 6 cases in literature report a description of the pedunculated type. A 69-year-old man was admitted to our department after an echocardiographical control revealing, as an incidental consequence, an epigastric mass. Computed tomography and magnetic resonance imaging showed the presence of an oval lesion between the third segment of the liver and the front wall of the gastric antrum, measuring approximately 40 × 30 mm and suspected for pedunculated GIST. We describe the laparoscopic approach performed and the surgical technique that we suggest in similar cases. Although there are still many controversies on the use of laparoscopy in the treatment of gastric GISTs, laparoscopic resection can safely be adopted for an exophytic pedunculated GIST in an institute with experience in minimally invasive surgery.

Gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the gastrointestinal tract. Soon after GIST was recognized as a tumor driven by a KIT or platelet-derived growth factor receptor mutation, it became the first solid tumor target for tyrosine kinase inhibitor therapies. More recently, alternative molecular mechanisms for GIST pathogenesis have been discovered. These are related to deficiencies in the succinate dehydrogenase complex, NF1-gene alterations in connection with neurofibromatosis type 1 tumor syndrome, and mutational activation of the BRAF oncogene in very rare cases.

Endoscopic muscularis excavation for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer

BACKGROUND

Because of complicating anatomic factors, endoscopic submucosal dissection is seldom performed in subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

AIM

This study was designed to evaluate the feasibility of endoscopic muscularis excavation for treating subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

METHODS

Between December 2008 and December 2011, 68 patients with subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer were treated with endoscopic muscularis excavation. Key steps of the procedure included the following: (1) injecting a mixture solution into the submucosal layer after making several dots around the tumor; (2) making a cross incision of the overlying mucosa, and excavating the tumor from the muscularis propria layer; (3) closing the artificial ulcer with clips after tumor removal.

RESULTS

The mean tumor size was 16.2 mm (range 7-35 mm). Endoscopic muscularis excavation was successfully performed in 65 out of 68 cases (success rate 95.6 %). Pathological diagnosis of these tumors included leiomyoma (39 out of 68) and gastrointestinal stromal tumor (29 out of 68). Perforation occurred in seven patients (10.3 %). No massive bleeding or delayed bleeding occurred. The median follow-up period after the procedure was 23 months (range 6-42 months). No residual or recurrent tumor was detected and no stricture occurred in patients during the follow-up period.

CONCLUSIONS

Endoscopic muscularis excavation is a safe, effective and feasible procedure for providing accurate histopathologic evaluation and curative treatment for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Laparoscopic versus open resection of gastric gastrointestinal stromal tumors

The aims of this study were to explore whether laparoscopic surgical resections of gastric gastrointestinal stromal tumors (GISTs) would produce better perioperative and similar oncologic outcomes compared with open surgical resection in Chinese patients. Thirty-six gastric GISTs cases were divided into a minimally invasive laparoscopic group and open resection group, depending on the surgical approach that was used. The general preoperative information, operative time, incision length, intraoperative blood loss, postoperative time to first flatulence, postoperative complications, postoperative hospital stay, total hospitalization costs, and such follow-up data as recurrence, metastasis, and mortality rates were compared between two groups. Among the 36 gastric GISTs, 15 received laparoscopic surgical treatment (laparoscopy group, n=15), and 21 received routine open resection treatment (open resection group, n=21). The laparoscopy group and the open resection group showed statistically significant differences (P<0.05) in incision length (7.8±2.3 vs. 16.9±3.8 cm), postoperative time to first flatulence (3.8±1.3 vs. 5.1±2.1 d), postoperative hospitalization time (7.6±2.5 vs. 11.3±3.7 d), and total cost of hospitalization (RMB 28,239±5,521 vs. RMB 23,761±5,362). There were no statistically significant differences (P>0.05) between the laparoscopy group and the open resection group in operative time (147.8±59.3 vs. 139.2±62.1 min) and intraoperative blood loss (149.8±98.9 vs. 154.2±99.3 mL). Both groups had no postoperative complications, no recurrence and metastasis, and no postoperative mortality. There were no statistically significant differences between the two groups in postoperative complications, postoperative recurrence and metastasis, and postoperative mortality. In conclusion, compared with open resection, the laparoscopic resection of gastric GISTs offers the advantages of less trauma, faster recovery, and shorter hospital stay.

Laparoendoscopic single site adrenalectomy: initial results of cosmetic satisfaction and the potential for postoperative pain reduction

Background

Recent reports have suggested that laparoendoscopic single site (LESS) surgery is technically feasible. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.

Methods

Medical records of consecutive patients undergoing LESS adrenalectomy were analyzed. All procedures were performed through a single multichannel port. Demographic and operative data were assessed. A visual analog scale (VAS) was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis.

Results

Between January 2010 and July 2012, 14 consecutive patients with benign adrenal tumors underwent LESS adrenalectomies. Of the planned LESS adrenalectomies, 12 (86%) were completed with a single-port, whereas two required an additional port placement. Mean operating time was 128.1 ± 31.5 min and mean blood loss 10.5 ± 12.1 ml. Mean pain scores using the VAS on postoperative days 1, 3, and 14 were 2.3, 1.0, and 0.3 points, respectively. The rate of analgesic use was also lower within 12 hours after surgery (14%). The patient was highly satisfied with the single small wound procedure, and mean cosmesis scores of postoperative days 3 and 14 were 9.4 and 9.8 points, respectively. The postoperative course was uneventful with no morbidity within one month of follow-up.

Conclusions

LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique.

Surgical treatment of gastric gastrointestinal stromal tumor

Gastrointestinal stromal tumor is the most common mesenchymal tumor in the gastrointestinal tract and is most frequently developed in the stomach in the form of submucosal tumor. The incidence of gastric gastrointestinal stromal tumor is estimated to be as high as 25% of the population when all small and asymptomatic tumors are included. Because gastric gastrointestinal stromal tumor is not completely distinguished from other submucosal tumors, a surgical excisional biopsy is recommended for tumors >2 cm. The surgical principles of gastrointestinal stromal tumor are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles. Laparoscopic surgery has been indicated for gastrointestinal stromal tumors <5 cm, and the indication for laparoscopic surgery is expanded to larger tumors if the above mentioned surgical principles can be maintained. A simple exogastric resection and various transgastric resection techniques are used for gastrointestinal stromal tumors in favorable locations (the fundus, body, greater curvature side). For a lesion at the gastroesophageal junction in the posterior wall of the stomach, enucleation techniques have been tried preserve the organ's function. Those methods have a theoretical risk of seeding a ruptured tumor, but this risk has not been evaluated by well-designed clinical trials. While some clinical trials are still on-going, neoadjuvant imatinib is suggested when marginally unresectable or multiorgan resection is anticipated to reduce the extent of surgery and the chance of incomplete resection, rupture or bleeding.

Predictors of unsuccessful laparoscopic resection of gastric submucosal neoplasms

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic submucosal dissection of large gastrointestinal stromal tumors in the esophagus and stomach

BACKGROUND AND AIM

Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumors of the digestive tract with potential for malignant transformation, are mainly treated by open surgery or laparoscopic resection. The aim of this retrospective study was to evaluate the clinical efficacy, safety, and feasibility of endoscopic submucosal dissection (ESD) for large-size (2-5 cm) GISTs in the esophagus and stomach.

METHODS

A total of 31 patients with large-size GISTs in the esophagus (6 patients) and stomach (25 patients) underwent ESD between September 2008 and December 2011. Demographics, clinical data, therapeutic outcomes, complications, pathological characteristics, risk classification, and follow-up outcomes were recorded.

RESULTS

ESD was successfully performed in 31 patients at age of 59.06 ± 7.23 years (range: 46-74). The mean time of the procedure was 70.16 ± 16.25 min (range: 40-105). Perforation for 2-10 mm occurred in six patients (19.35%) and was endoscopically repaired with clips or nylon bands, with no conversions to open surgery. Intraoperative bleeding occurred in three patients (9.68%) and was corrected with argon plasma coagulation or hot biopsy forceps. No mortalities occurred. The mean size of the resected tumors was 2.70 ± 0.72 cm (range: 2.0-5.0). Out of the 31 patients, 24 (77.42%) were at very low risk and 7 (22.58%) were at low risk. Positive rate of CD117, DOG-1, and CD34 were 83.87%, 12.90%, and 100%, respectively. A follow up for 14.29 ± 8.99 months (range: 3-39) showed no recurrence or metastasis.

CONCLUSIONS

ESD appears to be an effective, safe, and feasible treatment for large-size GISTs in the esophagus and stomach.