Surgical options for submucosal tumors near the esophagogastric junction: does size or location matter?

Background

Submucosal tumors (SMTs) of different etiologies exist from esophagus to rectum. Esophagogastric junction (EGJ) is one of the known difficult locations for tumor resection. Although minimally invasive surgery (MIS) is a well-established approach for gastrointestinal surgery, there is no consensus that MIS for resection of SMTs around EGJ is superior to laparotomy. We tried to clarify the factors that determine the surgeons’ choices between these two approaches.

Methods

From January 2002 to June 2016, 909 patients with SMTs underwent resection in our department. Among them, 119 patients (13%) had SMTs around EGJ were enrolled by retrospective review. The clinicopathological features and tumor-related parameters were reviewed and analyzed.

Results

The cohort was stratified into three groups according to the extent of gastrectomy and surgical approaches. The three groups are as following: major gastrectomy (n = 13), minor gastrectomy by laparotomy (n = 51), and minor gastrectomy with MIS (n = 55). The average tumor size was significantly larger in the major gastrectomy group than in the two minor gastrectomy groups; however, there was no difference between the two minor gastrectomy groups (5.33 cm, 4.07 cm, and 3.69 cm, respectively). The minor gastrectomy with MIS required least hospital stay and operation duration also. We re-stratify the two minor gastrectomy groups (n = 106) according to the orientation of SMTs around the EGJ into 4 zones. Most of SMTs located on the greater curvature side of the EGJ were resected with MIS (82% versus 18%), whereas SMTs in the other zones were resected more often by laparotomy (59% versus 41%). There was no surgical mortality within the cohort, while minor gastrectomy with MIS yielded least number of leakages among the three groups.

Conclusions

For SMTs around the EGJ, larger tumors (diameter of more than 5 cm) are more likely to be resected with major gastrectomy. To resect SMTs around the EGJ in a wedge-like (minor gastrectomy) fashion, tumors located other than the greater curvature side were more often resected by laparotomy. However, MIS yielded acceptable safety and surgical outcomes compared to conventional laparotomy for SMTs around the EGJ of the same size.

Laparoscopic Intragastric Resection: An Alternative Technique for Minimally Invasive Treatment of Gastric Submucosal Tumors

OBJECTIVE

To present the technique for and early results of laparoscopic intragastric resection (LIGR).

BACKGROUND

Treatment of confirmed or suspected submucosal gastric malignancies relies on clear margin resection, for which minimally invasive surgery is widely accepted. However, resection in some localization remains challenging.

METHODS

We present the steps of LIGR for gastric submucosal tumors (GSMTs). We report the results of LIGR in consecutive patients operated at 2 institutions, including intraoperative, pathologic, 30-day major morbidity and mortality characteristics.

RESULTS

After laparoscopic access to the abdominal cavity, cuffed gastric ports are placed to approximate the anterior gastric wall to the abdominal wall. A pneumogastrum is created. The tumor is resected in the submucosal plane and the deficit closed with intragastric suturing. Specimen extraction is performed perorally or through a gastrotomy site. In 8 proximal intraluminal GSMTs with median size of 3.1 cm (range: 1.8-6.0 cm), median operative time was 167.5 minutes (range: 120-300 mins). There was no major morbidity and no mortality. All resections were R0.

CONCLUSIONS

We illustrate the technique of a novel, feasible, and safe minimally invasive approach to GSMTs. LIGR is an alternative to resect challenging GSMTs by limiting surgical invasiveness and preserving gastrointestinal function.

Minimally Invasive Intragastric Approach to Gastroesophageal Junction Disease

BACKGROUND

A minimally invasive intragastric approach to the gastroesophageal junction (GEJ) allows resection of intramural disease while avoiding disruption of the lower esophageal sphincter and vagus nerves. Few surgeons use this approach; thus little is known regarding its indications, feasibility, technical aspects, complication profile, and long-term outcomes. This study reviewed the experience with this technique.

METHODS

A retrospective review was performed of a prospectively maintained, Institutional Review Board-approved database covering the period from January 1, 2005 to August 1, 2017. Indications, operative details, postoperative complications, and outcomes were assessed.

RESULTS

There were 12 patients identified. The mean age of these patients was 51.9 years. The indications for resection included 10 symptomatic leiomyomas, one gastrointestinal stromal tumor, and three cancers of the GEJ. Mean and median length of stay were 4.9 and 2.5 days, respectively. There were two postoperative esophageal leaks managed with laparoscopic repair. Of the 3 patients with cancer, 2 underwent an R0 resection, whereas 1 patient underwent an R1 resection. There were no other complications or recurrences. Mean follow-up was 6.0 years (range, 0.5 to 12.6 years); no patients had stricture or symptomatic gastroesophageal reflux on long term follow-up.

CONCLUSIONS

Resection of selected intramural GEJ disorders through a minimally invasive transgastric approach can be performed safely with acceptable morbidity and good long-term results. The approach allows preservation of the lower esophageal sphincter and vagus nerves, a potential advantage compared with other surgical alternatives to resection in this region.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Diagnosis and therapy of benign tumors of the esophagogastric junction]

Benign tumors of the esophagogastric junction are rare and mostly found incidentally during endoscopic or radiological procedures which are often performed for unrelated reasons. Epithelial lesions must be distinguished from subepithelial findings, where the latter are far more common and mostly represent benign leiomyomas, especially in the esophagus. Some benign tumors, such as small gastrointestinal stromal tumors, have malignant potential and must therefore be distinguished from completely benign lesions. Epithelial tumors can be diagnosed by standard endoscopic biopsies, whereas tissue acquisition of subepithelial lesions is more challenging. For this purpose endosonography is a valuable tool even before tissue acquisition or resection is performed. Endosonography can identify the gastrointestinal wall layer from which the lesion arises and gives additional information by identification of characteristic echographic features. Endoscopic resection techniques are used to remove those tumors that originate from the mucosa or submucosa. Some authors have even described resection of tumors originating from the deep muscle layer, but these techniques have a significant risk of perforation. Several surgical techniques are available for complete resection ranging from laparoscopic enucleation to combined endoscopic laparoscopic (rendezvous) techniques and abdominothoracic approaches. The current diagnostic and therapeutic challenges regarding benign tumors of the esophagogastric junction are outlined in this review article.