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

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.

Minimally invasive resection of gastric GIST tumor by trans-gastric approach: A case report of a novel technique

INTRODUCTION AND IMPORTANCE

GIST (Gastro Intestinal Stromal Tumor) treatment is surgical however surgical resection, especially for gGIST (gastric GIST), may be challenging due to location of tumor and the possible sequelae post resection.

CASE PRESENTATION

We present a case of 66-year-old female presented for the management of gGIST. We opted for transgastric resection assisted by robot. The resection was with free surgical margins for a 4 cm GIST tumor low in grade.

CLINICAL DISCUSSION

Classical wedge resection of gastric tumors poses post-operative complications especially if the tumor is located near the cardia or pylorus. Various minimally invasive techniques were described aiming to avoid post-operative complications as in stenosis and gastric reflux.

CONCLUSION

Minimally invasive transgastric resection of gGIST tumor seems to be worth of attention for it can prevent stenosis, hemorrhage and can preserve gastric tissue. Further studies need to be involved to endorse this technique.

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.

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.

Endoscopic Treatment for Gastric Subepithelial Tumor

Most gastric subepithelial tumors (SETs) are asymptomatic and are often incidentally discovered during endoscopic procedures conducted for unrelated reasons. Although surveillance is sufficient for the majority of gastric SETs, certain cases necessitate proactive management. Laparoscopic wedge resection, although a viable treatment option, has its limitations, particularly in cases where SETs (especially those with intraluminal growth) are not visualized on the peritoneal side. Recent advances in endoscopic instruments and technology have paved the way for the feasibility of endoscopic resection of SETs. Several promising endoscopic techniques have emerged for gastric SET resection, including submucosal tunneling endoscopic resection, endoscopic full-thickness resection (EFTR), laparoscopic and endoscopic cooperative surgery (LECS), and non-exposure EFTR (non-exposed endoscopic wall-inversion surgery and non-exposure simple suturing EFTR). This study aimed to discuss the indications, methods, and outcomes of endoscopic therapy for gastric SETs. In addition, a simplified diagram of the category of SETs according to the therapeutic indications and an algorithm for the endoscopic management of SET is suggested.

Single-incision transgastric resection for gastric gastrointestinal stromal tumors in anatomically challenging locations

Surgical resection is the mainstay treatment for resectable gastrointestinal stromal tumors (GISTs). However, resection in anatomically challenging locations, such as near the gastroesophageal junction, lesser curve and fundus, remain technically challenging. We herein report the outcomes of the largest series of patients who underwent single-incision transgastric resection of an intraluminal gastric GIST. Our reduced-port resection technique for intraluminal GISTs in these anatomically challenging locations involves a single incision in the left hypochondrium, deepened to access the gastric lumen, with the surgery completed in a transgastric manner. A total of 22 patients received surgery with this technique at the National University Hospital in Singapore from November 2012 to September 2020. The median operative time was 101 (range 50-253) min, with no conversions to open surgery, median lesion size 3.6 (range 1.8-8.2) cm and median postoperative length of stay 5 (range 1-13) days. There was no 30-day mortality and no recurrence during the follow-up period. Our laparoscopic approach for reduced-port transgastric excision of intraluminal GISTs allows for adequate surgical clearance, convenient extraction and secure gastrostomy closure with low morbidity.

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.

Is single incision laparoscopic surgery (SILS) for gastric gastrointestinal stromal tumor (GIST) dependent on the location of the tumor?

BACKGROUND

We compared the surgical outcomes of single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for gastric gastrointestinal stromal tumor (GIST).

METHODS

We performed single-incision gastric wedge resection on prospectively-enrolled 15 consecutive patients with gastric GIST between November 2020 and April 2022 in a single tertiary center. The early perioperative outcomes of these patients were compared to those of patients who underwent CLS. The indications did not differ from those for conventional laparoscopic procedures for gastric GIST.

RESULTS

In total, 30 patients were assigned to the SILS (n = 15) and CLS (n = 15) groups. There were no significant differences in the estimated blood loss and intraoperative blood transfusion between the SILS and CLS groups. There were no intraoperative complications or conversions to multiple-port or open surgery in the SILS group. Proximally located tumors were more commonly treated with CLS than with SILS (P = 0.045). GISTs located in the greater curvature were more commonly treated with SILS than with CLS, although the difference was not statistically significant (P = 0.08). The mean incision length in the SILS group was 4.1 cm shorter than that in the CLS group (3.2 ± 0.7 and 7.3 ± 5.2 cm, respectively, P = 0.01). The postoperative analgesic dose was significantly lower in the SILS than in the CLS group (0.4 ± 1.4 and 2.1 ± 2.3, respectively P = 0.01). Also, the duration of postoperative use of analgesic was shorter in SILS than in CLS (0.4 ± 0.7 and 2.0 ± 1.8, respectively, P = 0.01). There were no significant differences in the early postoperative complications between the groups.

CONCLUSIONS

SILS is as safe, feasible, and effective for the treatment of gastric GIST as CLS with comparable postoperative complications, pain, and cosmesis. Moreover, SILS can be considered without being affected by the type or location of the tumor.

No-touch endoscopic full-thickness resection technique for gastric gastrointestinal stromal tumors

BACKGROUND : There remain concerns regarding the technical feasibility of endoscopic resection for large gastrointestinal stromal tumors (GISTs), mainly relating to the risk of tumor rupture and the adequacy of the resection margins. This study aimed to evaluate the feasibility and therapeutic outcomes of the newly developed no-touch endoscopic full-thickness resection (NT-EFTR) technique for GISTs. METHODS : In this retrospective study, 92 patients with gastric GISTs undergoing NT-EFTR were included. Clinicopathological, endoscopic, and follow-up data were collected and analyzed. RESULTS : The median tumor size was 2.5 cm and en bloc resection was achieved in all patients with negative surgical margins. The median time of the NT-EFTR procedure was 59.5 minutes. Large tumors (> 3.0 cm), extraluminal tumor growth pattern, and large gastric defects were significant contributors to long operative times. Patients were discharged within 4 days postoperatively. During follow-up, all patients were free from local recurrence and distant metastasis. CONCLUSIONS : NT-EFTR was a feasible method for the resection of gastric GISTs and can be expected to achieve complete radical resection. Large tumors with extraluminal growth and large gastric defects impact procedural difficulty.

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.

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

A propensity score-matched analysis of laparoscopic versus open surgical radical resection for gastric gastrointestinal stromal tumor

Background

Surgery is the mainstay of treatment for gastric gastrointestinal stromal tumours (GIST). However, the choice of surgical approach for gastric GIST remains controversial.

Aims and Objectives

To evaluate the short- and long-term efficacies of laparoscopic surgery versus conventional open surgery for gastric GIST.

Materials and Methods

We retrospectively reviewed 148 patients with gastric GIST at our hospital between January 2013 and January 2020. The patients were categorised into the following two groups based on the surgery performed: The laparoscopic surgery group (LG) and the open surgery group (OG). Differences in the tumour size, surgical procedures and modified National Institutes of Health classification were statistically significant. To balance the intergroup confounders, we performed 1:1 propensity score matching (PSM).

Results

A total of 104 patients were selected after PSM (52 in each group). We focused on the short- and long- term outcomes of patients. The baseline information was balanced between the two groups after PSM. The LG benefited from the advantages of a minimally invasive surgery (faster gastrointestinal function recovery, shorter time to drainage tube removal, less blood loss and shorter hospitalisation period), however, it also had high treatment costs. Moreover, both laparoscopic and open surgeries resulted in similar intra-operative and post-operative complications rates, overall survival time and disease-free survival time.

Conclusion

Laparoscopic resection is feasible and oncologically safe for GIST. However, more prospective studies are required to confirm the findings.

Trends and outcomes of minimally invasive surgery for gastrointestinal stromal tumors (GIST)

OBJECTIVE

Minimally invasive surgery (MIS) is increasingly being utilized for the resection of gastrointestinal cancers. National trends for perioperative and oncologic outcomes of MIS for gastrointestinal stromal tumors (GIST) are unknown. We hypothesized that with increased use of MIS, the perioperative outcomes and survival for GIST are preserved.

METHODS

The National Cancer Database (2010-2016) was utilized to assess perioperative and oncologic outcomes for GIST of the stomach and small bowel. Kaplan-Meier method and log rank test were used to compare survival outcomes.

RESULTS

Data from 8923 gastric and 3683 small bowel resections were analyzed. Over the study period, MIS became the prevalent modality for gastrectomies (2010: robotic: 2.4%, laparoscopic: 26.1%, open: 71.5% vs. 2016: robotic: 9.6%, laparoscopic: 48.8%, open: 41.6%; p < 0.001), with a smaller increase in enterectomies (2010: robotic: 1%, laparoscopic: 17.3%, open: 81.6% vs. 2016: robotic: 3.9%, laparoscopic: 27.2%, open: 68.9%; p < 0.001). Age and Charlson comorbidity index were similar among groups. MIS approaches were associated with fewer readmissions and lower 90 day mortality for gastrectomies and similar rates for enterectomies. MIS did not compromise patient survival even in patients who underwent neoadjuvant treatment or harbored tumors ≥ 10 cm.

CONCLUSION

Minimally invasive surgery is increasingly being utilized for resection of gastric and small bowel GIST, with improved postoperative outcomes. In this retrospective review, overall survival after minimally invasive or open surgery was comparable, even in challenging scenarios of neoadjuvant treatment or large tumors (≥ 10 cm).

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.

Comparison of safety and short-term outcomes between endoscopic and laparoscopic resections of gastric gastrointestinal stromal tumors with a diameter of 2-5 cm

BACKGROUND AND AIM

Developments of endoscopic techniques brought the possibility of endoscopic resection for gastrointestinal stromal tumors (GISTs) of larger sizes. We aim to compare safety and short-term outcomes between endoscopic and laparoscopic resections of gastric GISTs with a diameter of 2-5 cm.

METHODS

This is a single-center, retrospective cohort study. The clinical data, perioperative conditions, and the adverse events of patients who underwent endoscopic or laparoscopic resection for gastric GIST of 2-5 cm in Zhongshan Hospital, Fudan University, from January 2016 to December 2020 were retrospectively reviewed.

RESULTS

A total of 346 patients were reviewed; 12 patients who failed to accomplish the planned procedure were excluded; 182 underwent laparoscopic resection; and 152 underwent endoscopic resection. Significant differences exist in the tumor size between the laparoscopic group (3.43 ± 0.86 cm) and the endoscopic group (2.78 ± 0.73 cm) (P < 0.01). Compared with laparoscopic resection, endoscopic resection was associated with faster recovery (P < 0.01), shorter hospital stays (P < 0.01), and lower cost (P < 0.01). The incidence of Clavien-Dindo grade II-V adverse events in the endoscopic group (3/152) was significantly lower than that in the laparoscopic group (12/182) (P = 0.04). After a propensity score matching analysis, the endoscopic group showed similar incidences of complications with the laparoscopic group, while the advantages over laparoscopic resection in postoperative hospital stay, time to first oral intake, and hospitalization expenses remained significant (P < 0.01).

CONCLUSIONS

Endoscopic resection is a safe and cost-effective method for 2-5 cm of gastric GISTs compared with laparoscopic resection.

The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasonography (EUS) has been widely accepted in the diagnosis of all types of tumors, especially pancreatic tumors, lymph nodes, and subepithelial lesions (SELs). One reason is that the examination can provide a detailed observation, with tissue samples being immediately obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Many SELs are detected incidentally during endoscopic examinations without symptoms. Most SELs are mesenchymal tumors originating from the fourth layer, such as gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas. GISTs are potentially malignant. Surgical treatment is recommended for localized GISTs of ≥20 mm. However, the indications for the diagnosis and follow-up of GISTs of <20 mm in size are controversial. There are several reports on the rapid progression or metastasis of small GISTs. Therefore, it is important to determine whether a SEL is a GIST or not. The main diagnostic method is EUS-FNA. Recently, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a new biopsy needle has been reported to obtain larger tissue samples. Additionally, various biopsy methods have been reported to have a high diagnostic rate for small GISTs. In local gastric SELs, regardless of the tumor size, EUS can be performed first; then, EUS-FNA/B or various biopsy methods can be used to obtain tissue samples for decision-making in relation to therapy and the follow-up period.

Open and minimally invasive surgery for gastrointestinal stromal tumours: a systematic review and network meta-analysis protocol

INTRODUCTION

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the digestive system, and complete resection is the only way to provide a radical cure for resectable GISTs. Open surgery and minimally invasive approaches, including laparoscopy, robotic surgery and endoscopy, consist of the mainstream GIST resection. However, there is still a lack of evidence regarding which surgical outcomes and long-term prognosis would be better. Thus, we are planning to conduct a network meta-analysis and systematic review aiming to determine the comparative effectiveness among laparotomy, laparoscopy, endoscopy, robotic surgery, and laparoscopic and endoscopic cooperative surgery in GISTs.

METHOD AND ANALYSIS

PubMed, EMBASE, the Cochrane Library and Web of Science will be searched for published studies to identify the proper literature comparing open resection, laparoscopy, endoscopy, robotic surgery, and laparoscopic and endoscopic cooperative surgery for resecting GISTs from inception to February 2021. Randomised controlled trials (RCTs) and non-randomised studies comparing at least two different interventions for GIST resection will be included. RCTs and non-randomised studies will be synthesised and analysed separately. Bayesian network meta-analysis will be performed to compare the surgical outcomes and long-term prognosis among the resection methods above. The included studies will be divided into several subgroups according to tumour location and size for further analysis. Sensitivity analysis will be performed to identify and explain heterogeneity to make our results robust. Meta-regression will serve as a supplementary method if data are available. The quality of evidence will be evaluated by the Grading of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

No ethical approval is required for this network meta-analysis, as it is based on already published data. The findings of the review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021237892.

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.

Hybrid approach with laparoscopic wall-inversion surgery and single-incision intragastric surgery for intraluminal gastrointestinal stromal tumor: A case report

Laparoscopic wedge resection (LWR) for intraluminal gastrointestinal stromal tumor (GIST) leads to excessive resection of normal gastric wall. We report a case of GIST around the cardia successfully treated with full-thickness partial resection using a hybrid approach of laparoscopic surgery and single-incision intragastric surgery (SIIGS). A 69-year-old woman had a 5 cm intraluminal GIST at the posterior wall around the cardia. Submucosal injection of glycerin and indigo carmine was performed with transoral endoscopy. Circumferential seromuscular incision followed by placement of seromuscular sutures to invert the lesion into the stomach was performed under laparoscopy. By SIIGS, resection of the inverted mucosa and retrieval of the tumor were completed. A hybrid approach consisting of laparoscopic wall-inversion surgery and SIIGS was useful for intraluminal GIST and may expand the indications for laparoscopic wall-inversion surgery by removing size limitations.

Surgical Approaches and Oncological Outcomes in the Management of Duodenal Gastrointestinal Stromal Tumors (GIST)

BACKGROUND

Duodenal gastrointestinal stromal tumors (GIST) are a rare subset of GIST. Their surgical management in this anatomically complex region consists of varied approaches, and the administration of imatinib mesylate (IM) has not been clarified.

METHODS

We retrospectively reviewed patients with duodenal GIST treated during a 10-year-period. We analysed the clinicopathological characteristics and survival factors and evaluated the perioperative and long-term outcomes based on the extent of resection ((ocal-resection (LR) versus pancreaticoduodenectomy (PD)) and the IM-administration. The median follow-up period was 60 months (range, 12-140).

RESULTS

A total of thirteen patients (M:F = 7:6) with median age of 64 years (range, 42-77) underwent resection of duodenal GIST. Median tumor size was 5.2 cm (range, 1.5-13.3). Eight patients (61.5%) underwent LR and five patients (38.5%) PD. R0-resection was achieved in 92.5%. Neoadjuvant IM-therapy was administered in five patients leading to tumor downsizing and in 40% to less-extended resection. The PD group consisted of larger tumors with higher mitotic count, mostly located in D2 (p = 0.031). The PD group had longer operative time (p = 0.026), longer hospital stay (p = 0.016), and higher rate of postoperative complications (p = 0.128). The actuarial 1-, 3-, and 5-year overall survival were 92.5%, 84%, and 73.5%, respectively, whereas the disease-free survival rates at 1, 3, and 5 years were 91.5%, 83%, and 72%, respectively. A tendency towards increased risk of disease recurrence was demonstrated for patients with tumor >5 cm and high-risk potential. There was not statistic survival benefit for one or the other surgical approach.

CONCLUSION

The type of resection depends on duodenal site of origin and tumor size. LR can be the treatment of choice for duodenal GIST whenever technically feasible. Recurrence of duodenal GIST is dependent on tumor biology rather than surgical approach. Administration of IM in neaodjuvant setting should be considered in cases with high-risk GIST scheduled for PD since it might facilitate less-extended resection.

Laparoscopic Partial Gastrectomy for Large Gastric GISTs

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are considered the most common mesenchymal tumors in the gastrointestinal tract and the stomach is the most frequently site affected (50-60%). The safety and feasibility of laparoscopic surgery for gastric GISTs of sizes larger than 5 cm remains unclear. It depends on the surgical skills, tumor location, and the learning curve of the surgeons.

METHODS

Between December 2013 and January 2021, 30 patients diagnosed with gastric GISTs underwent laparoscopic partial gastrectomy. This is a retrospective study done in Surgical Oncology unit, Oncology Center, Mansoura University, Egypt.

RESULTS

The most common tumor location was in the greater curvature in (46.7%). The mean tumor size was 9.5 cm (range 5-17 cm). All of the patients underwent laparoscopic partial gastrectomy. Associated splenectomy was done for only one patient. The mean operative time was 152.67 min and the estimated blood loss (EBL) was 139.33 ml. The mean hospital stay was 3.53 days. The mean follow-up period was 32.4 months.

CONCLUSION

Laparoscopic resection for gastric GISTs has become a feasible method. Patients with large tumors have the same favorable outcomes as small tumors. Large-sized GISTs may receive neoadjuvant therapy to downstage the disease and make it amenable for laparoscopic resection.

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.

Is laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumor at the esophagogastric junction safe?

INTRODUCTION

With technique improvements, indications for laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumor (SET) are gradually expanding for tumors technically difficult to resect. However, surgical outcomes of LECS, including for esophagogastric junction (EGJ) tumors requiring advanced skills, remain unknown.

METHODS

We reviewed patients in whom LECS had initially been attempted for gastric SET at the Cancer Institute Hospital in Tokyo from June 2006 to May 2018. Indications for LECS at the EGJ have gradually expanded during the study period to include tumors with esophageal invasion up to 2 cm, or less than half the EJG circumference, preoperatively. Surgical outcomes and risk factors for conversion to other procedures were investigated.

RESULTS

Twenty (9.3%) of the 214 total patients had EGJ tumors. Four patients (20%) with EGJ tumors developed postoperative complications (Clavien-Dindo grade ≥ II). Among 12 patients in whom LECS could be completed for EGJ tumors, only one non-serious complication occurred. Eight patients required conversion to another operation for EGJ tumors (two laparotomy, six proximal gastrectomy). Among conversion cases with EGJ tumors, anastomotic leakage occurred in both patients undergoing laparotomy after LECS, necessitating additional defect closure. There was only one non-serious complication in six proximal gastrectomy patients. On multivariate analysis, EGJ tumor was an independent risk factor for conversion to another operation.

CONCLUSION

LECS at the EGJ may be a risk factor for conversion operation, and when performing LECS at the EGJ is difficult, conversion to proximal gastrectomy, which can be performed safely, should be considered.

A gastrointestinal stromal tumor of stomach presenting with an intratumoral abscess: A case report

Introduction

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract, GISTs of the stomach presenting as an intratumoral abscess are extremely rare, which necessitates emergency surgery, we report a case of a stomach GIST developing an intratumoral abscess, in whom emergency surgery was performed.

Presentation of case

A 68-year-old man presented with severe abdominal pain and a fever. Laboratory data showed an elevated white blood cell count and C-reactive protein level. Computed to mography scan showed a 15 × 10 cm cystic mass adjacent to greater curvature of the stomach, which contained air. Emergency laparotomy revealed A giant cystic gastric mass was observed. Sleeve gastrectomy were performed. Immunohistochemically, the tumor was diagnosed as a Gastric high risk GIST,and imatinib mesylate was initiated, The patient had an uneventful postoperative course and remains well.

Discussion and conclusion

Such rare cases can be diagnosed and treated properly with careful clinical evaluation, surgical resection and adjuvant chemotherapy with imatinib mesylate is still the mainstay and most effective treatment for GISTs to date.

Small bowel gastrointestinal stromal tumor presenting with gastrointestinal bleeding in patient with type 1 Neurofibromatosis: Management and laparoscopic treatment. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. It may be asymptomatic; nevertheless, gastrointestinal bleeding is the most frequent symptom, due to mucosal erosion. Its poor lymph node metastatic spread makes GIST often suitable of minimally invasive surgical approach. The importance of this study is to increase the awareness among physicians about this condition in particular scenarios as in our case and to stress the role of laparoscopic surgery.

CASE PRESENTATION

A 74-year-old female patient presented to the emergency department with hematemesis, followed by haematochezia and melena. The patient had a medical history of type 1 Neurofibromatosis (NF1). She underwent, after CT scan, esophagogastroduodenoscopy, and endoscopic haemostasis. Finally, we performed a laparoscopic resection of a mass of the first jejunal loop. The postoperative period was predominantly uneventful. Pathological examination confirmed a low-risk GIST.

CLINICAL DISCUSSION

Proximal jejunal GIST may cause an upper and lower gastrointestinal bleeding. A multidisciplinary team approach is mandatory for the correct management of this disease and its complications (bleeding). GISTs are indicated as the most commonly gastrointestinal NF1 associated tumours. In case of localised and resectable GIST surgical treatment is the mainstay and laparoscopic surgery is a valid alternative.

CONCLUSION

In case of abdominal bleeding mass in a NF1 patient, it is important to keep in mind the well-known association between NF1 and GIST to facilitate the diagnosis and to quickly perform the appropriate treatment. Laparoscopic approach is safe and effective if the oncological radicality is respected.

Laparoscopic Versus Open Surgery for Gastric Gastrointestinal Stromal Tumors: a Propensity Score Matching Analysis

BACKGROUND

Surgery is the first choice for the treatment of gastric gastrointestinal stromal tumors (GISTs). With the development of new instruments and techniques, the popularity of laparoscopic resection of GISTs has increased rapidly. Previous studies on the advantages of laparoscopic resection over open surgery are generally limited by methodology or data capacity. This study evaluated the efficacy of laparoscopic resection and open surgery in gastric GISTs using the propensity score matching (PSM) method.

METHODS

Between January 2005 and December 2017, 1027 patients were diagnosed with primary GIST at our institution. Among them, 548 patients were enrolled in this study. Standard demographic and clinicopathological data were collected from our database. Selection bias was eliminated using the PSM methods.

RESULTS

After PSM, 256 cases involved in the comparison (128 laparoscopic (LAP) vs. 128 open surgery (OPEN)) were randomly matched (1:1) by age, sex, body mass index, hypertension, diabetes, heart disease, year of surgery, tumor location, tumor size, mitotic rate, and treatment with adjuvant tyrosine kinase inhibitors. The LAP group was superior to the OPEN group in blood loss (χ² = 6.048, P = 0.049), time to first flatus (49.41 ± 7.56 vs. 71.31 ± 4.87 h, P < 0.001), and hospital stay (10.21 ± 6.05 vs. 12.56 ± 5.43 days, P = 0.001). No significant differences were seen in either the relapse-free survival or overall survival between the LAP and OPEN groups. In tumors located in favorable locations, the LAP group showed less blood loss (P = 0.008) and less multivisceral resection (17.8% vs. 5.5%, P = 0.02).

CONCLUSIONS

Laparoscopic resection for gastric GISTs is associated with improved surgical outcomes and postoperative courses and comparable oncological outcomes, regardless of favorable or unfavorable tumor location.

Gastrointestinal Stromal Tumors of the Small Intestine: Progress in Diagnosis and Treatment Research

In recent years, the diagnosis and treatment of gastrointestinal stromal tumors (GISTs) of the small intestine have been a hot topic due to their rarity and non-specific clinical manifestations. With the development of gene and imaging technology, surgery, and molecular targeted drugs, the diagnosis and treatment of GISTs have achieved great success. For a long time, radical resection was prioritized to treat GISTs of the small intestine. At present, preoperative tumor staging is a novel treatment for unresectable malignant tumors. In addition, karyokinesis exponent is the sole independent predictor of progression-free survival of GISTs. The DNA, miRNA, and protein of exosomes have also been found to be biomarkers with prognostic implications. The research on the treatment of GISTs has become a focus in the era of precision medicine, ushering in the use of standardized, normalized, and individualized treatment.

Primary Gastrointestinal Stromal Tumor Mimicking as Gynecologic Mass: Characteristics, Management, and Prognosis

BACKGROUND

Primary gastrointestinal stromal tumor (GIST)-mimicking gynecologic masses are easily misdiagnosed. This study aimed to investigate the clinicopathological features, management, and prognosis of primary GIST mimicking as gynecologic mass.

METHODS

Clinicopathological and survival data of GIST mimicking as gynecologic mass admitted to our center from January 2005 to December 2017 were retrospectively analyzed.

RESULTS

Thirty-eight patients were included. The most common primary tumor site was the jejunoileum (n = 33, 86.9%), and 33 patients (86.9%) were classified as high recurrence risk. The short-term outcomes of operative incision length (P = 0.004), time to gas passage (P = 0.002), and hospital stay (P = 0.012) with laparoscopy-assisted resection were significantly shorter than those with open resection, showing no significant differences of long-term outcomes. With a median follow-up of 56 mo for 31 patients (81.6%), 18 (58.1%) received adjuvant therapy with imatinib. The 5-year disease-free survival and disease-specific survival of pelvic high-risk GIST was 37.0% and 48.3%, respectively; both were significantly lower than those of the other female high-risk group (both P < 0.05).

CONCLUSIONS

GIST mimicking as gynecologic mass is not uncommon, most originate from the jejunoileum and have a high risk of recurrence. Laparoscopy-assisted resection may be preferable for more favorable short-term outcomes. Compared with the other female high-risk GIST, pelvic high-risk GIST has a significantly worse prognosis; a longer duration of adjuvant therapy with imatinib than recommended may be beneficial.

[Laparoscopic and robot-assisted procedures in patients with gastrointestinal stromal tumors (GIST) of stomach]

OBJECTIVE

To analyze the results of minimally invasive surgical procedures in patients with gastric GIST.

MATERIAL AND METHODS

The study included 30 patients aged 52.2±9.8 years. ASA grade II (44%), III (26%) and I (23%) were predominant. Lesion of stomach body was noted in 17 (56%) patients, antrum - in 8 (27%), fundus - in 2 (7%) and cardia - in 3 (10%) patients. GIST was located on the anterior wall of stomach in 56% of patients. Exophytic growth was observed in 16 (53%) patients, endophytic - in 12 (40%), transmural growth - in 2 (7%) cases. T2 grade of tumor was noted in 67% of cases (TNM 8). All patients underwent laparoscopic or robot-assisted ('daVinci Si') partial resection of the stomach.

RESULTS

Radical resection (R0) without injury of pseudocapsule of tumor was made in all patients. Laparoscopic procedures were performed in 25 (83%) patients, robot-assisted - in 5 (17%). Early postoperative complications (Clavien-Dindo II) were observed in 3 patients. Spindle cell structure of tumors (93%) with low mitotic activity (63%) prevailed. Tumor stage I was observed in 56% of patients. Patients with high mitotic tumor index (44%) were directed to targeted therapy. Recurrence and/or metastasis in long-term period were absent in 26 (87%) patients.

CONCLUSION

Laparoscopic surgery for gastric GIST is safe and characterized by the absence of significant postoperative complications and long-term recurrence-free period. The use of robotic surgical system is effective and justified for anatomically difficult localization of GIST.

Laparoscopic resection is better than endoscopic dissection for gastric gastrointestinal stromal tumor between 2 and 5 cm in size: a case-matched study in a gastrointestinal center

BACKGROUND

The feasibility of endoscopic dissection for gastric gastrointestinal stromal tumor (gGIST) between 2 and 5 cm in size has been demonstrated. However, its impact on short-term and long-term outcomes, compared with laparoscopic resection, is unknown. The purpose of this study was to compare short-term and long-term outcomes between laparoscopic resection and endoscopic dissection for 2-5-cm gGIST.

METHODS

A case-matched study was performed using the propensity score. To overcome selection bias, we performed a 1:1 match using six covariates, including age, sex, BMI, ASA score, tumor size, and tumor location. Short-term and long-term outcomes between laparoscopic resection and endoscopic dissection were compared.

RESULTS

A total of 210 patients with 2-5-cm gGIST were enrolled between 2006 and 2017 in our gastrointestinal center. According to the intention-to-treat approach, 165 patients underwent laparoscopic resection, and 45 patients underwent endoscopic dissection. After the propensity score, 45 pairs were balanced and analyzed. There was no significant difference in the baseline characteristics between the laparoscopic and endoscopic groups after matching. The rate of complications was significantly higher in the endoscopic group compared with the laparoscopic group (P < 0.001). Perforations occurred in 16 patients in the endoscopic group (16/45, 35.6%). The postoperative hospital stay was significantly longer in the endoscopic group compared with the laparoscopic group (P < 0.001). There was no significant difference between the two groups in disease-free survival or overall survival.

CONCLUSION

Laparoscopic resection is better than endoscopic dissection for 2-5-cm gGIST because of the lower complication rate and shorter hospital stay.

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

Laparoscopic resection of gastrointestinal stromal tumor (GIST) has increased popularity with studies showing good outcomes for patients with tumors <5 cm, with a shorter hospital stay, lower blood loss, and morbidity. Our study aims to audit the clinical profile and surgical outcomes of GISTs, with an evaluation of laparoscopic versus open surgery and the prognostic role of positive R1 margins. In our retrospective study, 62 GIST patients who underwent surgery were included and further analysis was made for the 48 gastric GISTs patients. In total, 33 patients underwent laparoscopic gastric GIST resection, whereas the rest underwent open resection. There was no difference in operative duration but the blood loss was lesser and length of stay shorter in the laparoscopic group. The laparoscopic group had a higher incidence of R1 resection but none developed recurrence or metastasis during follow-up. Laparoscopic resection in the management of gastric GISTs resulted in higher R1 resection rates but this did not affect recurrence rates or overall survival.

Multiband mucosectomy versus endoscopic submucosal dissection and endoscopic submucosal excavation for GI submucosal tumors: short and long term follow-up

AIMS

To evaluate the short- and long-term outcomes of 3 different endoscopic dissection techniques for upper gastrointestinal (GI) submucosal tumours (SMTs).

METHODS

Data for 135 patients withGI SMTs who underwent multiband mucosectomy (MBM), endoscopic submucosal dissection (ESD), or endoscopic submucosal excavation (ESE) were retrospectively assessed. The en bloc resection rate, endoscopic complete resection rate, operation time, potential complications and local recurrence rate were compared.

RESULTS

No significant differences were observed in the rate of endoscopic complete resections and pathologic complete resections among the three groups. For SMTs > 15 mm in width, the lowest en bloc resection rate was found for MBM (P = 0.000). MBM was also associated with the shortest procedure time, lowest perforation rate and lowest rate of major bleeding. ESE was the most effective procedure for muscularis propria (MP) lesions but was associated with the longest operation time (P < 0.01). The ESD and ESE groups had similar perforation rates (P > 0.05). No differences were observed in 4-year local recurrence rates among the groups (P = 0.945).

CONCLUSIONS

MBM is a simple and effective method for the treatment of small SMTs and achieves clinical success rates similar to those of ESD and ESE. However, ESD and ESE are preferable for larger and deep lesions and are associated with a longer operation time. Nonetheless, all 3 techniques resulted in a low 4-year local recurrence rate. Large-scale randomized clinical trials are needed to further investigate these results.

Quality of surgery and surgical reporting for patients with primary gastrointestinal stromal tumours participating in the EORTC STBSG 62024 adjuvant imatinib study

BACKGROUND

EORTC (European Organisation of Research and Treatment of Cancer) 62024 is a phase III randomised trial evaluating adjuvant imatinib in patients with gastrointestinal stromal tumours (GISTs) and no evidence of residual disease after surgery in 908 patients from 11 countries participated. As surgical treatment aspects (tumour rupture and incomplete resection) contribute to the risk of recurrence, the data of primary surgery were reviewed.

METHODS

The surgical record, local pathology report and a surgical questionnaire on details of the operation had to be completed when patients entered the study. Surgeons from 5 countries, covering 8 languages, reviewed the full set of data being available from 793 patients (87.3%).

RESULTS

A known GIST was the reason for surgery in only 58% of the cases, and 12% of the patients were treated as an emergency. The R0-resection rate was 87%. The extent of resection was local excision in 17%, segmental resection in 59%, full-organ resection in 11% and multivisceral resection in 11%, with lymphadenectomy performed in 24% of the patients. Shelling out of the tumour was performed in 9.7%, and the proportion of tumours removed in parts was higher in the endoscopy/laparoscopy group. The incidence of tumour rupture (representing M1) was 9%. The consistency between preoperative and intraoperative findings was 82%. The postoperative complication rate was 7.3%.

CONCLUSION

The standardisation of surgery in this study was inferior. Given the review data, 18% of the patients should not have participated in the trial. Quality of surgery and improperly reported intraoperative details might influence the trial results. A detailed surgical questionnaire filled out by the surgeon is mandatory before entering the patient in an adjuvant trial in GIST.

Surgical treatment of gastric GIST with acute bleeding using laparoscopic sleeve gastrectomy: A report of two cases

In this report, we want to emphasize how a laparoscopic bariatric surgical procedure, in experienced hands, has shown to be a valid alternative for the hemorrhage control and the removal of a gastrointestinal tumor in a life-threatening situation.

Gastric ectopic pancreas mimicking a gastrointestinal stromal tumour: A case report

•

The diagnosis and management of gastric submucosal tumours are fraught with difficulty and uncertainty.

•

After a thorough work-up with gastroscopy and endoscopic ultrasonography, a gastrointestinal stromal tumour of the antrum was diagnosed.

•

Laparoscopic excision was performed – histopathologically, an ectopic pancreas was diagnosed.

•

Despite an adequate work-up, surgery was performed for an essentially benign lesion.

Introduction

The diagnosis and management of upper gastrointestinal tract submucosal tumours can be challenging due to the difficulties with adequate pre-operative characterization and tissue sampling.

Presentation of the case

A 61-year-old female patient underwent esophagogastroduodenoscopy because of epigastric pain and episodic vomiting. A submucosal tumour was found along the greater curvature in the antrum. On endoscopic ultrasound, the mass was suspected to be a gastrointestinal stromal tumour. The patient was referred for laparoscopic excision. The final histopathological examination confirmed an ectopic pancreas, not a gastrointestinal stromal tumour as thought preoperatively.

Discussion

Despite an adequate pre-operative diagnostic workup with endoscopic ultrasonography, the lesion was misdiagnosed as a gastrointestinal stromal tumour and surgery was performed to excise an ectopic pancreas, essentially a benign lesion.

Conclusion

The case highlights the absence of firm diagnostic criteria to differentiate submucosal gastric lesions.

Robotic Gastrotomy With Intracorporeal Suture for Patients With Gastric Gastrointestinal Stromal Tumors Located at Cardia and Subcardiac Region

PURPOSE

Few studies of robotic gastric gastrointestinal stromal tumors (GISTs) resection have been conducted. This study was aimed to evaluate the robotic gastrotomy with intracorporeal suture for patients with GISTs located at cardia and subcardiac region.

MATERIALS AND METHODS

From January 2014 to August 2016, 11 patients with GISTs located at cardia and subcardiac region underwent robotic gastrotomy with intracorporeal suture. Data of these patients were collected.

RESULTS

The mean operative time was 82.7 minutes and the mean blood loss was 30.0 mL. No complication was reported. The postoperative length of stay was 3.3 days. On postoperative day 14, inflammation recovered to preoperative level. On postoperative month 6, the nutritional status was similar to that before the surgery. After 25.5 months follow-up, all patients survived with no recurrence or metastasis.

CONCLUSIONS

Robotic gastrotomy with intracorporeal suture for patients with GISTs located at cardia and subcardiac region is safe and feasible.

Is the Surgical Margin in Gastrointestinal Stromal Tumors Different?

Background

Radical surgical excision is the mainstay of therapy of primary, nonmetastatic gastrointestinal stromal tumors (GIST) and margin status after surgery is a significant prognostic factor.

Methods and Results

The aim of this paper is to review principles in primary GIST surgery, i.e. differences between R0, R1, and R2 resection, to describe how surgical margin status and tumor intraperitoneal rupture influence the patients' outcome, and how this may be effected by neoadjuvant and adjuvant treatment in locally advanced tumors. A systematic search of literature published between 2000 and 2018 was performed regarding this topic.

Conclusion

Correct interpretation of margin status after surgery can be affected by many factors during operation and preparation of tissue.

Laparoscopic Surgery for Large Gastric Submucosal Tumors

BACKGROUND

In general, laparoscopic resection for gastric gastrointestinal stromal tumors (GISTs) >5 cm is not recommended. However, there is a lack of evidence to support this recommendation.

PATIENTS AND METHODS

This study included 108 patients who underwent laparoscopic surgery for gastric GISTs. Of the 108 patients, 23 had GISTs>5 cm. The aim of this study is to evaluate the oncological safety of laparoscopic surgery for large gastric GISTs. In addition, we performed a rapid systematic review of laparoscopic surgery for large gastric GISTs.

RESULTS

In our cases, all patients were performed R0 resection without capsular rupture and surgical margins were negative on pathologic examination. In all studies, en bloc resection was achieved without capsular rupture in all patients. The average positive surgical margins rate was 1.6% in total reports.

CONCLUSIONS

The laparoscopic approach for large gastric GISTs>5 cm has been proposed as safe when performed by experienced surgeons.

Development and validation of a nomogram for predicting survival in patients with gastrointestinal stromal tumours

BACKGROUND

This study aimed to develop and validate nomograms for predicting long-term overall survival (OS) and cancer-specific survival (CSS) in gastrointestinal stromal tumours (GISTs).

METHODS

Patients diagnosed with GISTs between 2004 and 2015 were selected for the study from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly separated into the training set and the validation set. Multivariate analysis was used on the training set to obtain independent prognostic factors to build nomograms for predicting 3- and 5-year OS and CSS. The discrimination and calibration plots were used to evaluate the predictive accuracy of the nomograms.

RESULTS

Data for a total of 5622 patients with GISTs were collected from the SEER database. Nomograms were established based on variables that were significantly associated with OS and CSS identified by the Cox regression model. The nomograms for predicting OS and CSS displayed better discrimination power than did the SEER stage and Tumour-Node-Metastasis (TNM) staging systems (7th edition) in the training set and validation set. Calibration plots of the nomograms indicated that OS and CSS closely corresponded to actual observation.

CONCLUSIONS

The nomograms were able to more accurately predict 3- and 5-year OS and CSS of patients with GISTs than were existing models.

Successful Laparoscopic Sleeve Gastrectomy in Emergency for a Gastric Gastrointestinal Stomal Tumor (GIST) with Acute Bleeding: A Case Report

BACKGROUND Gastrointestinal stomal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, and the stomach is the most commonly involved organ. Complete surgical resection with negative margins is the primary and only potentially curative treatment. Surgeon experience with minimally invasive gastric resections in addition to the tumor size and site has to be considered in the choice of laparoscopic or open surgical approach in order to remove the lesion. CASE REPORT A 67-year-old male patient with an history of gastric ulcer presented 2 days after an esophagogastroduodenoscopy with an incidental finding of a 30-mm gastric submucosal lesion that was not histologically defined (biopsies were taken), chest pain in association with hematemesis, and melena. An initial attempt to achieve endoscopic hemostasis with epinephrine injection was followed by the recurrence of the gastric bleeding until the presentation of hemorrhagic shock. An emergent laparoscopic sleeve gastrectomy was then performed for hemorrhage control. There were no intra- or postoperative major complications and the histological findings led to the diagnosis of a gastrointestinal stromal tumor (GIST). CONCLUSIONS Laparoscopic sleeve gastrectomy is a bariatric surgical treatment of morbid obesity. This report describes the application of a bariatric procedure in a life-threatening situation and illustrates how safe and effective it can be when performed by surgeons with excellent laparoscopic skills.

Current clinical management of gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) are the most common malignant subepithelial lesions (SELs) of the gastrointestinal tract. They originate from the interstitial cells of Cajal located within the muscle layer and are characterized by over-expression of the tyrosine kinase receptor KIT. Pathologically, diagnosis of a GIST relies on morphology and immunohistochemistry [KIT and/or discovered on gastrointestinal stromal tumor 1 (DOG1) is generally positive]. The prognosis of this disease is associated with the tumor size and mitotic index. The standard treatment of a GIST without metastasis is surgical resection. A GIST with metastasis is usually only treated by tyrosine kinase inhibitors without radical cure; thus, early diagnosis is the only way to improve its prognosis. However, a GIST is usually detected as a SEL during endoscopy, and many benign and malignant conditions may manifest as SELs. Conventional endoscopic biopsy is difficult for tumors without ulceration. Most SELs have therefore been managed without a histological diagnosis. However, a favorable prognosis of a GIST is associated with early histological diagnosis and R0 resection. Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (EUS-FNA) are critical for an accurate diagnosis of SELs. EUS-FNA is safe and effective in enabling an early histological diagnosis and adequate treatment. This review outlines the current evidence for the diagnosis and management of GISTs, with an emphasis on early management of small SELs.

Surgical and oncological long term outcomes of gastrointestinal stromal tumors (GIST) resection- retrospective cohort study

PURPOSE

Surgery remains the mainstay of gastrointestinal stromal tumors (GISTs) treatment. The aim of our study was to compare postoperative outcomes and long term oncologic results of GISTs resection. An analysis of laparoscopic versus open surgery for GISTs and a subgroup analysis of lesions larger than 5 cm were realized.

MATERIALS AND METHODS

Between January 2005 and December 2014, 143 patients with primary GISTs were treated with radical resection in two tertiary centers. Eight patients with metastatic disease were excluded. The remaining patients were assigned to 2 groups: laparoscopy and open surgery. A separate analysis of tumors larger than 5 cm was realized for the laparoscopy group. Long-term follow-up was used to analyze the oncologic and surgical results. Relevant clinical variables were evaluated using univariate and multivariate analyses.

RESULTS

With similar oncological outcomes(p = 0.09) and morbidity(p = 0.56), laparoscopy compared to open surgery significantly reduced length of hospitalization (p = 0.01). For lesions >5 cm laparoscopic resection is associated with similar short-term outcomes with resection for small tumors without compromising oncological outcomes (p = 0.89). For all patients, the probability of remaining disease free at 3 years, and 5 years was 97, 6% and 95%, respectively.

CONCLUSION

Laparoscopic resection is a technically and oncologically safe and feasible approach for GISTs compared with open resection. Resection of lesions superior of 5 cm by laparoscopy has efficacy and recurrence rates similar to open surgical controls. Large tumor resection should only be attempted by surgeons with a large experience with minimally invasive surgery in order to avoid operative complications and unfavorable long term outcome.

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.