Microscopically Positive Resection Margins in Laparoscopic Gastric GIST Resection May Not Confer a Poorer Prognosis

Laparoscopic subtotal gastrectomy in case of large subcardial GISTs

The gastro-intestinal stromal tumours (GISTs) are rare mesenchymal tumours that occur mostly in the stomach. The treatment is usually a limited resection, which is performed by an endoscopy or by a surgical approach. In case of metastasis of the disease proven found during the assessment, the treatment is usually limited to chemotherapy without a radical cure. We report a case of a large (9 cm) subcardial GIST that we treated by laparoscopic subtotal gastrectomy due to the size and the location of the tumour. The laparoscopic resection is shown to be superior in perioperative outcomes compared to open surgery even for large lesions. In unfavourable locations such as in cardia lesions, transgastric, partial or extended gastric resections must be evaluated to avoid functional sequelae and post-operative morbidity.

Endoscopy-Assisted Laparoscopic versus Laparoscopic Surgery for Gastrointestinal Stromal Tumor and the Impact on Patients’ Coagulation, Surgical Condition, and Complications

Objective

To assess the clinical efficiency of endoscopy-assisted laparoscopic versus laparoscopic surgery for gastrointestinal stromal tumors and the impact on patients' coagulation, surgical condition, and complications.

Methods

Between November 2016 and May 2020, 126 eligible patients diagnosed with gastrointestinal stromal tumor (GIST) in our institution were recruited. They were concurrently randomly assigned at a ratio of 1 : 1 to receive either laparoscopic gastrectomy (reference group) or endoscopy-assisted laparoscopic gastrectomy (research group). The two groups were compared in terms of patients' coagulation function, surgical conditions, and complications.

Results

The two groups had similar preoperative coagulation indices and the postoperative levels of activated partial thromboplastin time (APTT) and thromboplastin time (TT) (P > 0.05). Compared with the reference group, the research group showed lower PT levels (10.48 ± 0.68 vs. 11.97 ± 0.46) and higher FIB levels (0.67 ± 0.11 vs. 0.29 ± 0.07) (P < 0.05). Compared with the reference group, the study group had shorter operative time (81.21 ± 10.24 min versus 98.98 ± 15.31 min), shorter surgical incision (3.63 ± 1.12 cm versus 5.01 ± 1.14 cm), and less intraoperative bleeding (18.74 ± 6.98 ml versus 58.69 ± 15.87 ml) (P < 0.05). A markedly shorter length of hospital stay, time to the first postoperative exhaustion, and duration of drainage tube and gastric tube dwelling were observed in the research group versus the reference group (P < 0.05). The study group presented higher nutritional levels of patients at 3 days after surgery and a lower incidence of complication.

Conclusion

Endoscopy-assisted laparoscopic treatment shows significant improvements in the efficiency of minimally invasive surgery and ensures a better prognosis and quality of life of patients with a good safety profile, so it is worthy of clinical application.

Comparison Among Endoscopic, Laparoscopic, and Open Resection for Relatively Small Gastric Gastrointestinal Stromal Tumors (<5 cm): A Bayesian Network Meta-Analysis

Background

Endoscopic resection (ESR) is a novel minimally invasive procedure for superficial tumors. Its safety, efficiency, and outcome for gastric gastrointestinal stromal tumors (gGISTs) less than 5 cm remains unclear compared to laparoscopic resection (LAR) and open resection (ONR). The current network meta-analysis aimed to review and analyze the available evidence of this question.

Methods

PubMed, Embase, Cochrane Library, and Web of Science databases were searched to identify eligible studies published up to July 6, 2020. The perioperative and long-term oncological outcomes among ESR, LAR, and ONR for gGIST (<5 cm) were estimated through the Bayesian network meta-analysis with a random-effect model.

Results

Fifteen studies with 1,631 patients were included. ESR was associated with a shorter operative time [mean difference, MD: -36; 95% confidence interval, CI (-55, -16)], a higher rate of positive margin [odds ratio, OR: 5.1 × 10¹⁰, 95% CI (33, 2.5 × 10³²)], and less costs [MD: -1 × 10⁴, 95% CI (-1.6 × 10⁴, -4.4 × 10³)] but similar time to resume flatus [MD: 0.52, 95% CI (-0.16, 1.1)] and diet [MD: -3.5, 95% CI (-5.6, -1.6)] compared to LAR. A higher rate of total complications [OR: 11, 95% CI (1.2, 140)] was observed in patients who received ESR compared to patients who received LAR. After excluding perforation from the total complication category, the difference of complication between ESR and LAR disappeared [OR: 0.87, 95% CI (0.22, 2.3)]. The recurrence rate [OR: 1.3, 95% CI (0.40, 4.5)] and disease-free survival [hazard ratio: 1.26, 95% CI (0.60, 2.63)] showed no significant difference between ESR and LAR. ESR was associated with better or equivalent perioperative and long-term outcomes compared to ONR, except for positive margin. A subgroup analysis (<2 and 2–5 cm) showed no significantly different results among these three procedures either.

Conclusion

ESR was shown to be a safe and efficient alternative procedure to both LAR and ONR for gGISTs less than 2 cm and within 2–5 cm, respectively, without worsening the oncologic outcomes. However, preoperative assessment of tumor site is of importance for the determination of procedures regarding the increased incidence of a positive margin related to ESR.

Endoscopic Resection of Gastrointestinal Stromal Tumor: Is It Safe?

Recently, results from clinical studies of endoscopic resection of gastrointestinal stromal tumor (GIST) in the stomach are being reported. This procedure has several advantages, such as the provision of a definite diagnosis and therapeutic plan, avoidance of frequent follow-up examination, and reduction of patients’ anxiety. However, several concerns also exist such as a limited number of studies, low R0 resection rate, and relatively shorter follow-up period compared with surgical resection. Nevertheless, it is encouraging that most of the post-procedural complications have been treated with conservative management and that some of the patients did not show recurrence of the tumor during long-term follow-up. The selection of suitable cases and the experience of the endoscopists are the most important factors for successful endoscopic resection of gastric GIST. Development of novel procedures as well as collaboration with laparoscopic surgeons are currently in progress.