Non-exposed endoscopic wall-inversion surgery for a gastrointestinal stromal tumor of the stomach: A case report

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.

A case report of gastrointestinal stromal tumor of the duodenum

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) rarely occur in the duodenum, and only a few cases have been reported. Its clinical manifestations are not specific, and the imaging examination results are not typical, so a preoperative diagnosis is difficult. Pathologic examinations and genetic testing after surgical resection are the main diagnostic methods. Here, a case of duodenal stromal tumor complicated by gastrointestinal perforation is reported. A 57-year-old man presented with paroxysmal abdominal pain and bloating for 7 days. Contrast-enhanced computed tomography of the abdomen revealed a large mass (10 cm in diameter) in the right upper abdomen, which was considered neoplastic. The mass was anterior and inferior to the head of the pancreas, and medial to the mesenteric vessels. The tumor surrounded the descending and horizontal parts of the duodenum, and it ruptured into the lumen of the descending duodenum. After the patient underwent tumor resection, we found a rupture of the descending duodenal opening. After that, duodenal fistula drainage, gastrostomy, jejunostomy, small intestinal adhesion release and abdominal irrigation drainage were performed. Immunohistochemical staining results were as follows: CD34 (-), desmin (-), S-100 (-), CD117 (9.7) (+), DoG-1 (+), SDHB (+), Ki-67 (+5%). Based on these results, the lesion was finally diagnosed as duodenal GIST. The patient underwent surgical resection without targeted therapy and recovered well.

DISCUSSION

Duodenal stromal tumors often present with gastrointestinal bleeding and other clinical symptoms, requiring urgent surgery. Complete resection of the tumor is an effective surgical method. Extended resection does not prolong survival. However, surgical treatment should be determined according to the size and location of the tumor and its relationship to the pancreas. This highly malignant duodenal stromal tumor was >10 cm, accompanied by gastrointestinal perforation and necrosis. Surgical resection was required while protecting the organ function.

Choice of LECS Procedure for Benign and Malignant Gastric Tumors

Laparoscopic endoscopic cooperative surgery (LECS) refers to the endoscopic dissection of the mucosal or submucosal layers with laparoscopic seromuscular resection. We recommend a treatment algorithm for the LECS procedure for gastric benign tumors according to the protruding type. In the exophytic type, endoscopic-assisted wedge resection can be performed. In the endophytic type, endoscopic-assisted wedge resection of the anterior wall is relatively easy to perform, and endoscopic-assisted transgastric resection, laparoscopic-assisted intragastric surgery, or single-incision intragastric resection in the posterior wall and esophagogastric junction (EG Jx) can be attempted. We propose an algorithm for the LECS procedure for early gastric cancer according to the tumor location. The endoscopic submucosal dissection (ESD) procedure can be adapted for all areas of the stomach, and single-incision ESD can be performed in the mid to high body and the EG Jx. In full-thickness gastric resection, laparoscopy-assisted endoscopic full-thickness resection can be adapted for the entire area of the stomach, but it cannot be applied to the pyloric and EG Jx. In conclusion, surgeons need to select the LECS procedure according to tumor type, tumor location, the surgeon's individual experience, and the situation of the institution while also considering the advantages and disadvantages of each procedure.

CT Image Examination Based on Virtual Reality Analysis in Clinical Diagnosis of Gastrointestinal Stromal Tumors

With the advancement and development of medical equipment, CT images have become a common lung examination tool. This article mainly studies the application of CT imaging examination based on virtual reality analysis in the clinical diagnosis of gastrointestinal stromal tumors. Before extracting suspected lymph nodes from a CT image of the stomach, the CT image sequence is preprocessed first, which can reduce the cumbersomeness of subsequent extraction of suspected lymph nodes and speed up the subsequent processing. According to medical knowledge, CT images of the stomach show that lymph nodes mainly exist in the adipose tissue around the gastric wall, but there are no lymph nodes in the subcutaneous fat outside the chest. The most basic gray value in the image and the neighborhood average difference feature related to gray level are used as the primary features of visual attention detection. When extracting the neighborhood average difference feature, we use a 3 ∗ 3 sliding window method to traverse each point of the pixel matrix in the image, thereby calculating the feature value of each pixel in the image. After the feature extraction is completed, it is necessary to calibrate the data and make a training data set. The SP immunohistochemical staining method was used. The specimens were fixed with 10% formaldehyde, routinely embedded in paraffin, sectioned, and stained with HE. The tumor tissue was determined by immunohistochemistry, and the reagents were products of Maixin Company. All patients were followed up by regular outpatient review, letters, and visits or phone calls. The data showed that immunohistochemical tumor cells showed positive staining for CD117 (14/15, 93.3%) and CD34 (10/15, 66.7%). The results show that the application of virtual reality technology to CT imaging examination can significantly improve the diagnostic accuracy of gastrointestinal stromal tumors.

Nonexposed wall-inversion surgery as a novel local resection method for neoplasms in the gastrointestinal tract

Nonexposed wall-inversion surgery was invented for the treatment of node-negative gastrointestinal tumors that are difficult to be resected using the endoluminal approach alone. The advantages of this surgery include 1. full-thickness resection procedure of gastrointestinal wall with minimum necessary tumor-negative margins and 2. less risk of bacterial contamination and tumor seeding into the abdominal cavity. We conducted a PubMed search to select relevant articles published until the end of October 2019 for pooled case analyses using the keyword “nonexposed wall-inversion surgery,” Based on our search, we enrolled the data of 88 gastric lesions and 1 duodenal lesion retrieved from 7 case report articles and 4 original articles of clinical cases. The gastric lesions consisted of 59 gastrointestinal stromal tumors, 7 ectopic pancreases, 5 leiomyomas, 3 early gastric cancers, and 14 others, with a mean maximal tumor diameter of 25.0 mm. In 5 lesions (5.7%), intraoperative perforation was performed, and 2 lesions (2.3%) were retrieved by the transabdominal route. All 4 major postoperative complications (4.5%) were managed without resurgical interventions. The duodenal case, neuroendocrine tumor, measuring 13 mm in size, was curatively resected without complications. Nonexposed wall-inversion surgery appears to be an acceptable treatment for node-negative gastric and duodenal tumors; however, further accumulation of cases is necessary to confirm the feasibility.

Laparoscopy-assisted endoscopic full-thickness resection of upper gastrointestinal subepithelial tumors: A single-center early experience

Recently, there have been important developments in minimally invasive full-thickness resection of subepithelial tumors (SETs) of the upper gastrointestinal tract. However, there remain challenges with techniques such as laparoscopy-endoscopy cooperative surgery (LECS) and non-exposed endoscopic wall-inversion surgery (NEWS). The aim of the present study was to further investigate the feasibility, efficacy and safety of laparoscopy-assisted endoscopic full-thickness resection (ETFR) of SETs and to evaluate the clinical outcomes. This retrospective study included 16 patients with upper gastrointestinal SETs who underwent laparoscopy-assisted EFTR between July 2016 and December 2017. The patient characteristics, surgical outcomes, postoperative course, results of the histopathological examination and short-term outcomes were reviewed and analyzed. A total of 10 patients in the LECS group and 6 patients in the NEWS group presented with SETs in the stomach (15 cases) or duodenum (1 case). The mean tumor size in the LECS group (5.6 cm) was larger compared with that in the NEWS group (2.1 cm). R0 resection was achieved in all patients, without adverse events or tumor recurrence. The NEWS group exhibited a lower white blood cell count and C-reactive protein level on the first postoperative day, reflecting the less prominent inflammatory response, less bleeding and shorter hospitalization. Therefore, laparoscopy-assisted EFTR by LECS and NEWS is a feasible and safe minimally invasive treatment option for upper gastrointestinal SETs in selected patients.

Clinical outcomes of non-exposed endoscopic wall-inversion surgery for gastric submucosal tumors: long-term follow-up and functional results

BACKGROUND AND AIMS

To avoid the risk of iatrogenic dissemination during procedures, we have developed a combined laparoscopic and endoscopic surgery with a nonexposure technique for resection of gastric tumors. The study aim was to evaluate the feasibility and safety of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric submucosal tumors (SMTs).

METHODS

Between August 2013 and February 2018, NEWS was performed for 42 patients with gastric SMTs ≤ 3 cm in diameter at our institution. We retrospectively investigated the patients' backgrounds, operative and perioperative outcomes, tumor pathological characteristics, and follow-up data.

RESULTS

All tumors were resected with negative margins by NEWS. The median operation time was 198 min, and the median estimated blood loss was 5.0 mL. Adverse events occurred in one patient with pneumonia. All patients were alive without recurrence within the median follow-up period of 29.2 months. The average body weight loss rate was 0.3 ± 4.0%. No food residue was observed at endoscopic follow-up.

CONCLUSIONS

On the basis of slight body weight loss and the absence of food residue observed in the postoperative endoscopy, NEWS appeared to be safe and feasible for gastric SMTs and to preserve function of the remnant stomach.