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

Defining Textbook Outcomes for Minimally Invasive Surgical Resection of Small Gastrointestinal Stromal Tumors (GIST) of the Stomach

BACKGROUND

Textbook outcome (TO) has been utilized to assess the quality of surgical care. This study aimed to define TO rates for minimally invasive gastric gastrointestinal stromal tumor (GIST) resections in a bi-institutional cohort.

METHODS

Patients with gastric GIST (≤ 5 cm) who underwent laparoscopic or robotic resection (January 2014 to January 2024) were retrospectively identified from two GIST centers. We excluded patients with concurrent procedures, tumor involvement of adjacent organs, or metastatic disease. To balance perioperative and oncologic outcomes, we defined TO as: R0 resection, no conversion to open surgery, operative time ≤ 120 min, no perioperative transfusions, no intraoperative complications, no Clavien-Dindo ≥ II complications, hospital length of stay (LOS) ≤ 3 days, no 90-day readmission or death, no tumor rupture, and recurrence-free status at 2 years (5% predicted recurrence risk for tumors with a low mitotic index).

RESULTS

A total of 83 patients were included. TO was achieved in 62.7% of cases (N = 52). Mean tumor size was 3.0 ± 1.0 cm and 86.7% of GIST were modified-NIH low or very low risk (i.e., mitotic index ≤5/mm2). Mean operative time was 102.7 ± 49.3 minutes. Mean LOS was 2.3 ± 1.2 days. Among non-TO cases, the most common disqualifying factors were operative time > 120 minutes (N = 20, 24.1%) and LOS > 3 days (N = 15, 18.1%). There were four 90-day readmissions (4.8%) and one case with staple line bleeding requiring endoscopic clipping. During a mean follow-up of 32.6 ± 24.1 months, 3 patients (3.6%) recurred within 2 years. On multivariable regression analysis, no factors were independently associated with non-TO.

CONCLUSIONS

Minimally invasive gastric GIST resection is well-described. Herein, we propose new TO standards to serve as a measure of short- and long-term outcomes for monitoring institutional performance.

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.

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.

Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

BACKGROUND

Minimally invasive surgery had been tailored to individual cases of gastric subepithelial tumors (SETs) after comparing the clinical outcomes of endoscopic resection (ER), laparoscopic resection (LR), and hybrid methods.

AIM

To study the use of Goldilocks principle to determine the best form of minimally invasive surgery for gastric SETs.

METHODS

In this retrospective study, 194 patients of gastric SETs with high probability of surgical intervention were included. All patients underwent tumor resection in the operating theater between January 2013 and December 2021. The patients were divided into two groups, ER or LR, according to the tumor characteristics and the initial intent of intervention. Few patients in the ER group required further backup laparoscopic surgery after an incomplete ER. The patients who had converted open surgery were excluded. A logistic regression model was used to assess the associations between patient characteristics and the likelihood of a treatment strategy. The area under the curve was used to assess the discriminative ability of tumor size and Youden's index to determine the optimal cut-off tumor size.

RESULTS

One-hundred ninety-four patients (100 in the ER group and 94 in the LR group) underwent tumor resection in the operating theater. In the ER group, 27 patients required backup laparoscopic surgery after an incomplete ER. The patients in the ER group had small tumor sizes and shorter procedure durations while the patients in the LR group had large tumor sizes, exophytic growth, malignancy, and tumors that were more often located in the middle or lower third of the stomach. Both groups had similar durations of hospital stays and a similar rate of major postoperative complications. The patients in the ER group who underwent backup surgery required longer procedures (56.4 min) and prolonged stays (2 d) compared to the patients in the LR group without the increased rate of major postoperative complications. The optimal cut-off point for the tumor size for laparoscopic surgery was 2.15 cm.

CONCLUSION

Multidisciplinary teamwork leads to the adoption of different strategies to yield efficient clinical outcomes according to the tumor characteristics.

Oncological outcomes of large gastrointestinal stromal tumors treated by laparoscopic resection

BACKGROUND

The resection of large gastric gastrointestinal stromal tumors (GISTs) by laparoscopic has been controversial. Extending from our prior study, the long-term oncological outcome of laparoscopic resection of large (5-8 cm) gastric GISTs was reported.

METHODS

From 2002 to 2018, a consecutive 66 patients with gastric GISTs of 5-8 cm were treated at National Taiwan University Hospital. Among them, 30 patients received open surgery, and 36 received laparoscopic surgery. The clinicopathological data, peri-operative and oncological outcomes were compared between groups.

RESULTS

The clinical demographics including sex, age, BMI, tumor locations and ratio of wedge resection were similar between groups. The mean tumor size was 6.0 ± 0.83 cm versus 6.3 ± 1.07 cm (Open vs. Laparoscopic, p = 0.3). The operation time, blood loss, and post-operative complications, were also similar. The mean hospital stay was shorter in the laparoscopic group (8.8 ± 2.5 days) than in the open group (12.0 ± 8.9 days), though not significantly different. The median follow-up time was 108 ± 58 months (97 ± 50 in laparoscopic group; 122 ± 64 in open group). All except three patients remain disease-free. One in the open group and two in the laparoscopic group had recurrence of tumor, and they were stable of disease under Imatinib treatment. Eight patients died in non-GIST causes during follow-up. The 5-year recurrence-free survival were 100% for the open and 94.2% for the laparoscopic group (p = 0.2).

CONCLUSION

Our data showed that laparoscopic surgery for gastric GIST between 5 and 8 cm was safe and oncologically feasible.

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

Introduction

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

Presentation of case

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

Discussion

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

Conclusions

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

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Laparoscopic surgical approach for giant gastric GIST is still challenging

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Emergency surgery for bleeding GIST has not been frequently described

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

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.

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.

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

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