Minimally invasive surgery for gastric gastrointestinal stromal tumors

Oncologic outcomes and survival of modern surgical approaches for gastric gastrointestinal stromal tumor (GIST)

BACKGROUND

Studies have demonstrated comparable outcomes between laparoscopic and open resection of gastrointestinal stromal tumor (GIST). We sought to compare outcomes among robotic, laparoscopic, and open resection of gastric GIST in the era of expanding minimally invasive surgery.

METHODS

A retrospective analysis was performed of adult patients with gastric GIST undergoing definitive surgery using the National Cancer Database from 2010 to 2020, excluding cases converted to open. Patients were stratified into minimally invasive surgery (MIS), (combined robotic (R) and laparoscopic (L)), and open (O). Hospital length of stay (LOS), 30-day mortality, 90-day mortality, and margin status were assessed. Subgroup analysis was performed to evaluate outcomes between R and L cohorts. Entropy balancing was used to adjust for intergroup differences. Kaplan-Meier survival estimates were used to compare unadjusted 5-year survival.

RESULTS

Of the 15,022 patients (R = 10.4%, L = 44.3%, O = 45.3%), 63.2% were stage I and 70.6% underwent partial gastrectomy. MIS approach was associated with shorter hospital LOS (β: - 2.58; 95% CI: - 2.82 to - 2.33) and lower odds of 30-day (OR 0.45; 95% CI: 0.30-0.68) and 90-day mortality (OR 0.54; 95% CI: 0.39-0.74) compared to O. Likelihood of R0 resection similar between groups (OR 1.00; 95% CI: 0.88-1.14). Hospital LOS (β: + 0.25; 95% CI: - 0.14-0.64), odds of 30-day (OR 0.99; 95% CI: 0.40-2.46) and 90-day mortality (OR 0.89; 95% CI: 0.47-1.70), and rate of R0 resection (OR 1.02; 95% CI: 0.82-1.27) were comparable between R and L cohorts. Compared to O, MIS approach was associated with improved 5-year OS (log rank p < 0.001). Overall survival was not significantly different between R and L (log rank p = 0.44).

CONCLUSION

These findings suggest that MIS approach may be considered for resection of gastric GIST in select patients. Among patients receiving an MIS approach, the robotic technique can be considered an oncologically safe alternative to laparoscopic surgery.

A giant gastrointestinal stromal tumor revealed by a life-threatening hematemesis: A case report of a rare entity and a challenging management

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal malignancies in the digestive tract. Despite the stomach being their site of predilection, only a few giant GISTs have been discovered in hypovolemic shock and require urgent surgery.

CASE PRESENTATION

A 62-year-old patient was admitted for hematemesis. Initial examination revealed a compensated hemodynamic shock with a mass in the left hemi abdomen of 20 cm without signs of portal hypertension or peritonitis. After resuscitation, an abdominal CT scan was performed, showing an exophytic mass of the gastric antrum without local or distant lymph node involvement. Later, the patient went into hemodynamic shock, requiring vasoactive drugs. An urgent midline laparotomy was performed, revealing a 20-cm gastric GIST in the anterior wall of the antrum. Wedge resection was performed. The anatomopathological report confirmed the diagnosis of gastric GIST with a moderate risk of recurrence. The patient received adjuvant therapy for 3 years. No recurrence was detected.

CLINICAL DISCUSSION

Bleeding gastric GISTs revealed by a hypovolemic shock is a rare yet critical scenario. Considering GISTs as an etiology of digestive bleeding in life-threatening cases requires a high index of clinical suspicion. Prompt intervention is vital to control hemostasis and ensure patient stability.

CONCLUSION

Open surgery is mandatory for large bleeding GISTs. The surgical approach must be tailored to the tumor's specific location. Diligent execution of the surgical procedure is vital to prevent tumor rupture. Despite their size, these tumors have a favorable prognosis, enhanced by adjuvant therapy for moderate to high recurrence risk.

Laparoscopic subtotal gastrectomy in case of large subcardial GISTs

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

Robotic resection of duodenal gastrointestinal stromal tumour: Preliminary experience from a single centre

BACKGROUND

Experience in minimally invasive surgery in the treatment of duodenal gastrointestinal stromal tumors (DGISTs) is accumulating, but there is no consensus on the choice of surgical method.

AIM

To summarize the technique and feasibility of robotic resection of DGISTs.

METHODS

The perioperative and demographic outcomes of a consecutive series of patients who underwent robotic resection and open resection of DGISTs between May 1, 2010 and May 1, 2020 were retrospectively analyzed. The patients were divided into the open surgery group and the robotic surgery group. Pancreatoduodenectomy (PD) or limited resection was performed based on the location of the tumour and the distance between the tumour and duodenal papilla. Age, sex, tumour location, tumour size, operation time (OT), estimated blood loss (EBL), postoperative hospital stay (PHS), tumour mitosis, postoperative risk classification, postoperative recurrence and recurrence-free survival were compared between the two groups.

RESULTS

Of the 28 patients included, 19 were male and 9 were female aged 51.3 ± 13.1 years. Limited resection was performed in 17 patients, and PD was performed in 11 patients. Eleven patients underwent open surgery, and 17 patients underwent robotic surgery. Two patients in the robotic surgery group underwent conversion to open surgery. All the tumours were R0 resected, and there was no significant difference in age, sex, tumour size, operation mode, PHS, tumour mitosis, incidence of postoperative complications, risk classification, postoperative targeted drug therapy or postoperative recurrence between the two groups (P > 0.05). OT and EBL in the robotic group were significantly different to those in the open surgery group (P < 0.05). All the patients survived during the follow-up period, and 4 patients had recurrence and metastasis. No significant difference in recurrence-free survival was noted between the open surgery group and the robotic surgery group (P > 0.05).

CONCLUSION

Robotic resection is safe and feasible for patients with DGISTs, and its therapeutic effect is equivalent to open surgery.

Robotic Wedge Resection for Unfavorably Located Gastric Gastrointestinal Stromal Tumors: Perioperative and Long-Term Oncological Outcomes

Background and Objectives: Robotic wedge resection for gastrointestinal stromal tumors (GISTs) located in the stomach offers remarkable advantages, especially for lesions in unfavorable places. Although promising, long-term oncological results associated with this surgical procedure are poorly represented in literature. We present our experience of robotic wedge resection with gastrotomy for challenging gastric GISTs, in terms of both surgical outcomes and long-term oncological results. Methods: From April 2014 to February 2020, all consecutive patients affected by unfavorably located gastric GISTs (based on the Privette/Al-Thani classification system) underwent robotic wedge resection. Clinicopathological, surgical, and long-term oncological results were retrospectively analyzed. Results: Seventeen patients underwent full-thickness gastric wedge resection with primary robot-sewn closure of the defect. In 64.7% of cases, the lesion was ≥5 cm in diameter. No conversion nor tumor rupture were recorded and complete R0 resection was achieved in all cases. Median hospital stay was 5 days (range 3-18). At a median follow-up of 46 months (range 7-67), the disease-free survival rate and the overall survival rate were 94.1% and 82.3%, respectively. Conclusions: Robotic wedge resection with gastrotomy and robotic-sewn suture is a safe and feasible procedure for GISTs located in unfavorable anatomic positions, without compromising oncological outcomes.

Open versus laparoscopic versus robotic gastric gastrointestinal stromal tumour resections: A multicentre cohort study

PURPOSE

To present the outcomes of gastric gastrointestinal stromal tumour (GIST) resection from five Italian centres, focussing the analysis on the comparison among open (OG), laparoscopic (LG) and robotic (RG) approaches.

METHODS

All consecutive gastric wedge resections for GIST between 2009 and 2019 were included.

RESULTS

In total 101 (OG = 14, LG = 63 and RG = 24) were included. No differences were seen in the preoperative characteristics among the groups. Robotic procedures were longer (RG 180 min vs. LG 100 vs. OG 110; p < 0.0001). Time-to-first flatus and length of hospital stay were significantly longer in the OG group. Complication rates were similar among the groups. A sub-analysis on minimally invasive (RG = 19 vs. LG = 20) wedge resections and hand/robot-sewn suture showed that operative time was longer in the RGs (p = 0.007). No conversions were recorded in the RG group versus three in the LG group (p = 0.231). Safety-related factors were similar.

CONCLUSIONS

Gastric GIST can be safely treated with a minimally invasive approach which is also associated with improved postoperative outcomes.

Indocyanine green-loaded injectable alginate hydrogel as a marker for precision cancer surgery

Background

Accurate identification of tumor sites and boundaries is of paramount importance during minimally invasive surgery. Although laparoscopic resection is being increasingly and widely performed for early gastric and colorectal cancers, the detection of tumors located inside the stomach and intestine is difficult owing to the lack of tactile sensation. Here, we propose the application of an indocyanine green (ICG)-loaded alginate hydrogel system as a fluorescence surgical marker for precise laparoscopic operations.

Methods

A physical complex of ICG and human serum albumin (HSA) was mixed with sodium alginate to form an injectable hydrogel system. Calcium carbonate and D-gluconic acid (GA) were added to the gel to control its strength and gelation time, respectively. The optimal conditions for the preparation of injectable hydrogels were determined by analyzing the fluorescence spectra and sol-gel transition time of the prepared samples at various concentrations and compositions. Next, the aqueous solutions of ICG, ICG-HSA, and ICG-HSA-loaded alginate were subcutaneously injected into nude mice (three mice per group), and near-infrared (NIR) fluorescence images of the mice (λ_ex. =780 nm, λ_em. =845 nm) were obtained at different points in time for 8 days. Then, fluorescence intensities at the injection sites, target-to-background ratio, and areas of ICG fluorescence were analyzed. Finally, the potential utility of ICG-HSA-loaded alginate hydrogel as a surgical marker was evaluated in a porcine model. The ICG-HSA-loaded alginate solution was injected into three sites in the submucosal space of the porcine stomach via a catheter. A fluorescent laparoscopic system was installed on the abdomen of the pig 3 days post-injection, and the fluorescence signal generated from the fluorescence surgical marker located inside the stomach was evaluated using the fluorescence laparoscope system (λ_ex. =785 nm, λ_em. =805 nm).

Results

The optimal concentration of ICG-HSA complex was determined to be 30 µM, and maximum fluorescence intensity of the complex was obtained at a 1:1 mole ratio of HSA to ICG. The subcutaneous injection of ICG or ICG-HSA solution in mice resulted in the rapid spread of the fluorescence signal around the injection site in 3 h, and a weak fluorescence was detected at the injection site 24 h post-injection. In contrast, the fluorescence detection time was effectively prolonged up to 96 h post-injection in the case of ICG-HSA-loaded alginate gel, while diffusion of the injected ICG from the injection site was effectively prevented. In the laparoscopic operation, injection sites of the hydrogel in porcine stomach could be accurately detected in real time even after 3 days.

Conclusions

This alginate hydrogel system may be potentially useful as an effective surgical marker in terms of accuracy and persistence for laparoscopic operation.

Laparoscopic Endoscopic Cooperative Surgery for Gastrointestinal Stromal Tumors

With the development of laparoscopy and digestive endoscopy, multiple laparoscopic and endoscopic cooperative surgeries (LECSs) for gastrointestinal stromal tumors have recently been developed. Classic LECS has been confirmed as a feasible and safe treatment procedure for gastrointestinal stromal tumors with regard to both short-term surgical and long-term oncological outcomes; however, classic LECS has the potential risk of gastric contents or tumor cells spilling into the abdominal cavity because the gastric wall has to be opened during the procedure. Various modified LECS techniques have aimed at further minimizing invasiveness, such as the full-thickness resection method using the nonexposure technique (combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique), nonexposed endoscopic wall-inversion surgery, and closed LECS. This review describes and summarizes the current LECS for gastrointestinal tumor.

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.

Clinico-pathological characteristics and prognostic factors of gastrointestinal stromal tumors among a Chinese population

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms in the gastrointestinal tract, exhibiting wide variability in their biological behavior. The aim of the present study was to investigate the clinicopathological characteristics and prognostic factors of GISTs in Chinese patients. All GIST cases (n=182) retrieved from the pathology database and the archived files in Shanghai Changzheng Hospital between January 2011 and December 2014 were reviewed. The clinical symptoms, preoperative investigations, treatments, pathological characteristics and follow-up data of these patients were reviewed, and univariate and multivariate survival analyses were performed. A total of 73.1% of the GISTs were located in the stomach, and the most common three symptoms included abdominal pain (30.2%), dyspepsia (23.1%) and gastrointestinal bleeding (21.4%). Univariate analysis revealed that larger tumor size (P<0.001), higher mitotic rate (P<0.001), aggressive behavior (P<0.001), negative smooth muscle actin expression (P=0.009) and palliative resection (P<0.001) contributed toward poor overall survival (OS). In addition, non-gastric disease location (P<0.001), larger tumor size (P<0.001), higher mitotic rate (P=0.004), aggressive behavior (P<0.001) and palliative resection (P<0.001) were associated with poor relapse-free survival (RFS). Multivariate analysis indicated that mitotic rate [hazard ratio (HR=3.761, P=0.015)] and aggressive behavior (HR=3.916, P=0.010) were independent risk factors for OS, while non-gastric location (HR=4.740, P=0.002) and aggressive behavior (HR=4.009, P=0.004) were independent risk factors for RFS. The present study provided information on the clinicopathological characteristics and epidemiology of GISTs in the Chinese population. Non-gastric disease location, higher mitotic rate and tumor metastasis or local invasion prior to treatment were identified as predictors of a poor prognosis.