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

Clinical Outcomes of Laparoscopic Proximal Gastrectomy With Double-Flap Reconstruction for Tumors in the Upper Third of the Stomach

PURPOSE

Laparoscopic proximal gastrectomy (LPG) has been a standard surgery for early gastric cancer in the upper third of the stomach and large esophagogastric junction gastrointestinal stromal tumor. However, how to reconstruct the stomach after LPG is still debated. This study aimed to evaluate the results of LPG with double-flap reconstruction.

METHODS

A retrospective study was performed with 14 patients undergoing LPG with double-flap reconstruction for early gastric cancer or large tumors in the upper third of the stomach from 2018 to 2021. We evaluated postoperative complications, gastroesophageal reflux and the gastric remnant's function using endoscopy in accordance with the Los Angeles and Residue-Gastritis-Bile classifications, and patients' quality of life by the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire.

RESULTS

Median age was 54 years and 10 patients were male. There were 7 patients with gastrointestinal stromal tumor, 4 with leiomyoma and 3 with early-stage adenocarcinoma. No patient had major complications or required conversion to open surgery. During a median follow-up period of 24.6 months, 1 patient had late anastomotic stricture, 2 had metastasis, and 1 died. Endoscopic evaluation at 6 and 12 months showed good function of the gastric remnant in most patients. Patients' quality of life improved over time: mean GSRS score was 26.9±12.6, 20.3±7.2, and 18.8±4.2 at 6, 12, and 24 months, respectively.

CONCLUSIONS

LPG with double-flap reconstruction is feasible and safe for early gastric cancer or large tumors in the upper third of the stomach. The long-term functional outcomes and patients' quality of life were acceptable.

Nomogram for Predicting Risk of Esophagogastric Junction (EGJ) Resection During Laparoscopic Resection of Gastrointestinal Stromal Tumors in EGJ: A Retrospective Multicenter Study

Background: The established criteria for determining whether to excise the cardia during laparoscopic surgery for gastrointestinal stromal tumors in the esophagogastric junction (EGJ-GISTs) remain controversial. This retrospective multicenter study was conducted to develop a nomogram for predicting the risk of the cardia excision during laparoscopic surgery for EGJ-GISTs. Material and Methods: We reviewed data from 2,127 gastric-GISTs (g-GISTs) patients without distant metastases in four hospital between June 2012 and June 2020. Of those, according to the including criteria, 184 patients [Guangdong Provincial Hospital of Chinese Medicine (n = 81), Nanfang Hospital of Southern Medical University (n = 60), Guangdong General Hospital (n = 34), and The Third Affiliated Hospital of Southern Medical University (n = 9)] with EGJ-GISTs were identified and included in this study. Factors contributing to risk of cardia excision were identified and used to create a nomogram. Nomogram performance was assessed using a bootstrapped concordance index (c-index) and calibration plots. Results: According to the multivariate analysis, the distance from the margin of the tumor to the esophagogastric line (EG-line) (cm) (OR = 0.001, 95% CI: 0.00001~0.056, P = 0.001) and tumor size (cm) (OR = 14.969, 95% CI: 1.876~119.410, P = 0.011) were significantly related to likelihood of cardia structure excision in laparoscopic surgery for EGJ-GISTs. These two factors were used to generate a nomogram for predicting risk of cardia excision using a logistic regression model; a bootstrapped C-index of 0.988 (calibrated C-index = 0.987) indicated strong predictive ability, with broad calibration. Conclusions: This nomogram based on distance from tumor margin to EG-line and tumor size may serve as a tool for predicting risk of cardia damage during laparoscopic removal of EGJ-GISTs to aid in selection of surgical methods and preoperative neoadjuvant therapy.