Endoscopic treatment for gastrointestinal stromal tumor: Advantages and hurdles

An artificial intelligence model utilizing endoscopic ultrasonography for differentiating small and micro gastric stromal tumors from gastric leiomyomas

BACKGROUND

Gastric stromal tumors (GSTs) and gastric leiomyomas (GLs) represent the primary subtypes of gastric submucosal tumors (SMTs) characterized by distinct biological characteristics and treatment modalities. The accurate differentiation between GSTs and GLs poses a significant clinical challenge. Recent advancements in artificial intelligence (AI) leveraging endoscopic ultrasonography (EUS) have demonstrated promising results in the categorization of larger-diameter SMTs (> 2.0 cm). However, the diagnostic capacity of AI models for micro-diameter SMTs (< 1.0 cm) remains uncertain due to limited imaging features. This study seeks to develop a specialized diagnostic model utilizing EUS images to differentiate small and micro GSTs from GLs effectively.

METHODS

In this study, a dataset comprising 358 EUS images of GSTs or GLs was utilized for training the EUS-AI model. Subsequently, 216 EUS images were allocated for validation purposes, with 159 images in validation set 1 (micro SMTs: tumor diameter < 1.0 cm) and 216 images in validation set 2 (small SMTs: tumor diameter < 2.0 cm). The diagnostic performance of the EUS-AI model for individual tumors was assessed by consolidating the diagnostic outcomes of the corresponding images. Comparative analyses were conducted between the diagnostic outcomes of endoscopists, clinical signatures, and those of the EUS-AI models.

RESULTS

The EUS-AI models were developed using DenseNet201, ResNet50, and VGG19 architectures. Among the three models, the ResNet50 model demonstrated superior performance on EUS images, achieving area under the curve (AUC) values of 0.938, 0.832, and 0.841 in the training set, validation set 1, and validation set 2, respectively. By combining predictions from multiple images for each tumor, the diagnostic efficacy of ResNet50 was further enhanced, resulting in AUCs of 0.994, 0.911, and 0.915 in the aforementioned sets. In comparison, both clinical signatures and endoscopists exhibited notably lower AUC values than those obtained with the EUS-AI model.

CONCLUSIONS

The EUS-AI model utilizing ResNet50 architecture effectively discriminates between micro GSTs and GLs from both image-centric and tumor-centric perspectives. Demonstrating superior diagnostic efficiency compared to clinical models and assessments by endoscopists, the EUS-AI model serves as a valuable tool for clinicians in precisely distinguishing small and micro GSTs from GLs before surgery.

A Rare Case of Massive Gastrointestinal Hemorrhage Caused by an Ileal Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract. Although gastrointestinal bleeding is a common complication of GISTs, life-threatening hemorrhage is rare, particularly with intestinal GISTs. We report a rare case of an ileal GIST in a 71-year-old female patient who presented with massive lower gastrointestinal bleeding. Initial CT angiography (CTA) demonstrated a brisk gastrointestinal bleed in the ileal region. Despite embolization of the associated distal ileal artery branches, the patient experienced persistent hemoglobin drops and hematochezia. Repeat CTA revealed a hyper-enhancing exophytic lesion in the proximal ileum. This 4.7cm ileal tumor had to be excised, and histopathology confirmed a low-grade GIST. This case highlights the diagnostic complexity of ileal GISTs and the importance of imaging modalities such as CTA in managing active gastrointestinal bleeding.

Endoscopic submucosal excavation for gastric muscularis propria tumours less than 10 mm in diameter: What are the risk factors responsible for perforation?

OBJECTIVE

To explore the risk factors for perforation during endoscopic submucosal excavation (ESE) for gastric muscularis propria tumours less than 10 mm in diameter. This study provides clinical guidance for preventing the occurrence of intraoperative adverse events.

METHODS

Samples of gastric muscularis propria tumours less than 10 mm in diameter were removed via ESE at Shenzhen Second People's Hospital and were collected from June 2023 to August 2024. The general clinical characteristics of the patients, location, size, growth pattern, and pathology of the tumours, operation time, resection time, perforation incidence and bleeding incidence were analysed, and logistic regression was used to calculate the risk factors for perforation and bleeding.

RESULTS

A total of 102 patients were included in this study. The tumours were successfully removed from all patients. The mean age was 52.28 ± 11.84 years. There were 34 (33.33%) males. The mean size was 6.96 ± 1.82 mm. 89 (87.25%) tumours exhibited an intraluminal growth pattern. In total, 79 (77.45%) tumours were in the gastric body, and 23 (22.55%) tumours were in the gastric fundus. The mean operation time was 35.26 ± 23.15 min, and the mean resection time was 27.88 ± 21.77 min. A total of 55 (53.92%) tumours were leiomyoma, and 43 (42.16%) tumours were GIST. There were 4 (3.92%) tumours classified as other lesions. 41 (40.20%) patients experienced intraoperative bleeding, all of which had minor bleeding and successful haemostasis under endoscopy.There were 27 (26.47%) concurrent perforation, of which,24(88.89%) were diagnosed as GIST, and 3(11.11%) were diagnosed as leiomyoma. All perforations were successfully managed with an endoscopic suture. According to the multivariate regression analysis, a pathologic diagnosis was a risk factor for perforation. When the pathological diagnosis is GIST, the risk of perforation increases (PE = 18.632, 95% CI 4.571 ~ 75.941; p < 0.001). Gender,age,tumor size, growth pattern, location, and resection time were not found to be risk factors for perforation.all of observed factors were not the risk factors for bleeding.

CONCLUSION

ESE is an effective removal method for gastric muscularis propria tumours less than 10 mm in diameter.Intraoperative bleeding and perforation are common.However, these complications are controllable.GIST is an independent risk factor for the perforation.When the tumour is diagnosed as a GIST, the incidence of perforation is significantly increased.

Comparison of endoscopic and laparoscopic resection of gastric gastrointestinal stromal tumors: A propensity score-matched study

BACKGROUND

Endoscopic resection (ER) and laparoscopic resection (LR) have been widely used for the treatment of non-metastatic gastric gastrointestinal stromal tumors (gGISTs) (2-5 cm), but there are no selection criteria for their application.

AIM

To provide a reference for the development of standardized treatment strategies for gGISTs.

METHODS

Clinical baseline characteristics, histopathological results, and short-term and long-term outcomes of patients who treated with ER or LR for gGISTs of 2-5 cm in Taizhou Hospital of Zhejiang Province from January 2014 to August 2022 were retrospectively reviewed. Propensity score matching (PSM) was employed to achieve balance in baseline characteristics of the two groups.

RESULTS

Among 206 patients, 135 were in the ER group and 71 in the LR group. The ER group had significantly smaller tumors [3.5 cm (3.0-4.0 cm) vs 4.2 cm (3.3-5.0 cm), P < 0.001] and different tumor locations (P = 0.048). After PSM, 59 pairs of patients were balanced. After matching, the baseline characteristics of the ER and LR groups did not differ significantly from each other. Compared with LR, ER had faster recovery of diet (P = 0.046) and fewer postoperative symptoms (P = 0.040). LR achieved a higher complete resection rate (P < 0.001) and shorter operation time (P < 0.001). No significant differences were observed in postoperative hospital stay (P = 0.478), hospital costs (P = 0.469), complication rates (P > 0.999), pathological features (mitosis, P = 0.262; National Institutes of Health risk classification, P = 0.145), recurrence rates (P = 0.476), or mortality rates (P = 0.611).

CONCLUSION

Both ER and LR are safe and effective treatments for gGISTs. ER has less postoperative pain and faster recovery, while LR has a higher rate of complete resection.

Endoscopic removal of gastrointestinal lesions by using third space endoscopy techniques

The concept of submucosal space, or rather the "third space", located between the intact mucosal flap and the muscularis propria layer of the gastrointestinal tract, represents a tunnel that the endoscopist could use to perform interventions in the muscularis propria layer or breech it to enter the mediastinum or the peritoneal cavity without full thickness perforation. The tunnel technique can be used both for the removal of mucosal tumours, called endoscopic submucosal tunnel dissection (ESTD), for the removal of subepithelial tumours (SELs), called submucosal tunnelling endoscopic resection (STER), and for the removal of extra-luminal lesions (for example in the mediastinum or in the rectum), called submucosal tunnelling endoscopic resection for extraluminal tumours (STER-ET). Aim of this updated narrative review, is to summarize the evidences that analyses indications, and outcomes of tunnelling techniques for the treatment of above mentioned lesions.

Understanding Gastric GIST: From Pathophysiology to Personalized Treatment

Background: Gastric gastrointestinal stromal tumors (GISTs) represent a subset of gastrointestinal tumors predominantly found in the stomach. Despite their rarity, these tumors carry significant implications for patient health and management. GISTs are potentially malignant tumors with unpredictable progression. They originate from the interstitial cells of Cajal, which are positioned between the intramural neurons and the smooth muscle cells of the digestive tract. These tumors are characterized primarily by mutations in the c-Kit gene, as well as other mutations such as those in the platelet-derived growth factor receptor alpha (PDGFRA) gene. Methods: Our comprehensive search across five databases initially yielded 2976 articles. After eliminating 197 duplicates, we screened the titles and abstracts of 2779 articles, excluding 2692 for not meeting the inclusion criteria. During the full-text screening, 16 more articles were excluded. Ultimately, 71 papers met the inclusion criteria and were included in our analysis. Results: Due to differences in study designs, inclusion criteria for patients, and reported outcomes, a meta-analysis was not conducted. The accurate diagnosis of GIST is established through histopathological examination and immunohistochemistry. Histopathologically, GISTs are classified into three main types: spindle cell, epithelioid, and mixed. The therapeutic management of GIST involves surgery, endoscopic treatment, and chemotherapy. Conclusions: The prognosis for GIST patients depends on various factors, including risk category, disease stage, applied treatments, and recurrence post-treatment. A significant recent advancement comes from artificial intelligence, which can be increasingly involved in both the diagnosis and treatment of this tumor.

Gastric gastrointestinal stromal tumors: therapeutic strategies and long-term prognosis

OBJECTIVES

This study aimed to evaluate the clinical and prognostic characteristics of primary gastric gastrointestinal stromal tumors (GIST).

METHODS

Patients who underwent resection for primary gastric GIST between January 2002 and December 2017 were included. Recurrence-free survival (RFS) was calculated by Kaplan-Meier analysis, and Cox proportional hazards model was used to identify independent prognostic factors.

RESULTS

Altogether, 653 patients were enrolled. The median patient age was 59 years (range 15-86 years). Open, laparoscopic, and endoscopic resections were performed in 394 (60.3%), 105 (16.1%), and 154 (23.6%) patients, respectively. According to the modified NIH consensus classification, 132 (20.2%), 245 (37.5%), 166 (25.4%), and 88 (13.5%) patients were categorized into very low-, low-, intermediate-, and high-risk, respectively. A total of 136 (20.8%) patients received adjuvant imatinib treatment. The median follow-up time was 78 months (range 4-219 months), and the estimated 5-year RFS rate was 93.0%. In all patients, tumor size and rupture, mitotic counts, and adjuvant imatinib treatment were independent prognostic factors. The prognosis of gastric GIST treated with endoscopic resection was not significantly different from that of laparoscopic or open resection after adjusting for covariates using propensity score matching (log-rank p = .558). Adjuvant imatinib treatment (HR = 0.151, 95%CI 0.055-0.417, p < .001) was a favorable prognostic factor for high-risk patients, but was not associated with prognosis in intermediate-risk patients.

CONCLUSION

Patients with small gastric GISTs who successfully underwent endoscopic resection may have a favorable prognosis. Adjuvant imatinib treatment improve the prognosis of high-risk gastric GISTs, however, its use in intermediate-risk patients remains controversial.

Clinical Efficacy and Safety of Endoscopic Treatment of Gastrointestinal Stromal Tumors in the Stomach

Background/Aims

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the stomach. We evaluated the clinical outcomes of endoscopic treatment for gastric GISTs.

Methods

This is a single center, retrospective study that enrolled 135 cases of gastric subepithelial tumors (SETs) resected by endoscopic procedures and confirmed as GISTs by histopathology from March 2005 to July 2019. The immediate and long-term clinical outcomes were analyzed retrospectively.

Results

The mean patient age was 57.9 years, and the mean tumor size was 2.1 cm. Of the tumors, 43.0% were located in the body, followed by the fundus (26.7%) and cardia (17.0%). Most tumors (85.2%) were resected by endoscopic submucosal dissection, followed by endoscopic mucosal resection (6.7%), submucosal tunneling endoscopic resection (5.9%), and endoscopic full-thickness resection (2.2%). Macroperforation occurred in 4.4% and microperforation in 6.7% of the cases. The R0 resection rate was 15.6%. However, the rate of complete resection by the endoscopic view was 90.4%, of which 54.8% of cases were in the very-low-risk group, followed by the low-risk group (28.1%), intermediate-risk group (11.9%), and high-risk group (5.2%). During 36.5 months of follow-up, recurrence was found in four (3.4%) of the 118 patients who were monitored for more than 6 months (low-risk group, 1/37 [2.7%]; intermediate-risk group, 2/11 [18.2%]; high-risk group, 1/6 [16.7%]).

Conclusions

Endoscopic treatment of a GIST appears to be a feasible procedure in selected cases. However, additional surgery should be considered if the pathologic results correspond to intermediate- or high-risk groups.

Endoscopic Submucosal Dissection for Subepithelial Tumor Treatment in the Upper Digestive Tract: A Western, Multicenter Study

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) has been proposed for removal of gastrointestinal subepithelial tumors (GI-SETs), but data are still scanty. This study aimed to report a case series from a western country.

PATIENTS AND METHODS

Data of patients with upper GI-SETs suitable for ESD removal observed in 4 centers were retrospectively reviewed. Before endoscopic procedure, the lesion was characterized by endosonographic evaluation, histology, and CT scan. The en bloc resection and the R0 resection rates were calculated, as well as incidence of complications, and the 1-year follow-up was reported.

RESULTS

Data of 84 patients with esophageal (N = 13), gastric (N = 61), and duodenal (N = 10) GI-SETs were collected. The mean diameter of lesions was 26 mm (range: 12-110 mm). There were 17 gastrointestinal stromal tumors, 12 neuroendocrine tumors, 35 leiomyomas, 18 lipomas, and 2 hamartomas. En bloc and R0 resection were achieved in 83 (98.8%) and in 80 (95.2%) patients, respectively. Overall, a complication occurred in 11 (13.1%) patients, including bleeding (N = 7) and perforation (N = 4). Endoscopic approach was successful in all bleedings, but 1 patient who required radiological embolization, and in 2 perforations, while surgery was performed in the other patients. Overall, a surgical approach was eventually needed in 5 (5.9%), including 3 in whom R0 resection failed and 2 with perforation.

CONCLUSIONS

Our study found that ESD may be an effective and safe alternative to surgical intervention for both benign and localized malignant GI-SETs.

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.

Endoscopic adventitial dissection of a rectal GI stromal cell tumor

Video 1Demonstration of endoscopic adventitial dissection.

Challenge of gastro-intestinal stromal tumor management in low-income countries: example of Benin

BACKGROUND

GISTs are rare tumors but the most frequent mesenchymal tumors of the digestive tract. Diagnosis and treatment are challenging in low-income countries due to relatively poor access to immunohistochemistry and targeted therapy. In Africa, there are few studies about it. Imatinib, an oral targeted therapy, has been available in Benin since 2010 and free since 2016. This study describes the diagnosis and therapeutic management of GIST in Cotonou, Benin.

METHODS

This is a descriptive cross-sectional study, with retrospective data collection over a 10-year period from 2010 to 2020, focused on patients with histological confirmed gastro-intestinal stromal tumor (GIST). Cases were identified using the registry database and the archival files of the Hubert Koutoukou Maga National University Hospital of Cotonou (CNHU-HKM).

RESULTS

Fifteen GISTs were identified during the study period. The median age was 52 and the sex ratio was 2:1 (10 males and 5 females). The most frequent symptom was abdominal pain (n = 12). Delay in care seeking after onset of symptoms ranged from 24 h to 15 years. The most common site for GISTs was the stomach (n = 8). The median tumor size was 11 cm and the majority (n=10) was metastatic or locally advanced at the time of diagnosis. The tumors were often spindle-shaped at histology (n = 13) and the majority expressed KIT (n = 14). Most of the tumors (n = 12) were at high risk of recurrence according to the Joensuu scoring system. The availability of imatinib has improved the outcome of GIST with response in all cases it was used in neoadjuvant setting (n = 7).

CONCLUSION

GISTs are rare tumors and preferentially affect the stomach in Cotonou). Most of the tumors were large, unresectable at the time of diagnosis and at high risk of recurrence. Access to imatinib has revolutionized the management of those tumors in our country.

Mucosal incision-assisted biopsy versus endoscopic ultrasound-assisted tissue acquisition for subepithelial lesions: a systematic review and meta-analysis

BACKGROUND/AIMS

Mucosal incision-assisted biopsy (MIAB) for tissue acquisition (TA) from subepithelial lesions (SELs) is emerging as an alternative to endoscopic ultrasound (EUS)-guided TA. Only a limited number of studies compared the diagnostic utility of MIAB and EUS for upper gastrointestinal (GI) SELs; therefore, we conducted this systematic review and meta-analysis.

METHODS

A comprehensive literature search from January 2020 to January 2022 was performed to compare the diagnostic accuracy and safety of MIAB and EUS-guided TA for upper GI SELs.

RESULTS

Seven studies were included in this meta-analysis. The pooled technical success rate (risk ratio [RR], 0.96; 95% confidence interval [CI], 0.89-1.04) and procedural time (mean difference=-4.53 seconds; 95% CI, -22.38 to 13.31] were comparable between both the groups. The overall chance of obtaining a positive diagnostic yield was lower with EUS than with MIAB for all lesions (RR, 0.83; 95% CI, 0.71-0.98) but comparable when using a fine-needle biopsy needle (RR, 0.93; 95% CI, 0.83-1.04). The positive diagnostic yield of MIAB was higher for lesions <20 mm (RR, 0.75; 95% CI, 0.63-0.89). Six studies reported no adverse events.

CONCLUSION

MIAB can be considered an effective alternative to EUS-guided TA for upper GI SELs without an increased risk of adverse events.

Correlation between endoscopic resection outcomes and endosonographic findings in gastric tumors with muscularis propria origin

Endoscopic resection is an effective treatment for subepithelial tumors arising from the muscularis propria layer of the stomach. However, the invasion pattern revealed by the pathological examination of tumor specimens is often not consistent with the findings of preprocedural endoscopic ultrasounds (EUS). We compared the real growing patterns of tumors, as evaluated on histopathological examination, with their EUS images, and analyzed the outcomes of endoscopic resections in relation to the EUS findings. From January 2006 to June 2015, 32 patients underwent endoscopic resection for gastric tumors originating from the muscularis propria at our hospital. We divided the patients into 3 groups according to the location of the tumor as diagnosed using pre procedural EUS: submucosa (group I, n = 5), muscularis propria (group II, n = 14), and tumors extending into the outer cavity (group III, n = 13). Histopathological examination revealed 15 patients with gastrointestinal stromal tumors (GISTs), 14 with leiomyomas, and 3 with schwannomas. Accuracy of EUS in evaluating tumor invasion was 56%. Some tumors in groups I and II was removed by endoscopic submucosal dissection only. Muscular dissection was needed in 10 patients (71%) in group II and 9 patients (69%) in group III. Four patients (31%) in group III were found to have subserosal tumors. The complete resection rate was 88% (23 patients) among patients who underwent endoscopic submucosal dissection and endoscopic muscular dissection, and 67% (4 patients) among patients who underwent endoscopic subserosal dissection (ESSD). The tumor was completely removed in 12 patients (86%) in group II and 10 patients (77%) in group III. EUS accurately predicts the layer of the subepithelial tumor in the stomach; however, the pattern of invasion of surrounding structures is difficult to evaluate using EUS.

Effect of endoscopic resection of gastrointestinal stromal tumors in the stomach under double-channel gastroscopy: A retrospective observational study

We aimed to investigate the safety and efficacy of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors (GISTs) under single-channel gastroscopy and double-channel gastroscopy. We identified 154 patients with GISTs of the stomach who underwent endoscopic resection and were retrospectively analyzed at our hospital between May 2016 and March 2020, including 49 patients by single-channel gastroscopy and 105 patients by double-channel gastroscopy. We observed the clinical efficacy, complications, and safety of endoscopic resection of gastric GISTs, and the data were evaluated retrospectively. All patients underwent endoscopic resection successfully, without conversion to open surgery. In the single-channel gastroscopy group, 7 patients had lesions in the gastric cardia, 17 in the gastric fundus, 20 in the gastric corpus, and 5 in the gastric antrum. In the double-channel gastroscopy group, 13 patients had lesions in the gastric cardia, 34 in the gastric fundus, 46 in the gastric body, 10 in the gastric antrum, 1 in the pylorus, and 1 in the gastric angular incisure. The double-channel gastroscopy group had a shorter operation time than the single-channel gastroscopy group (59.9 ± 34.9 minutes vs 74.8 ± 26.7 minutes; P = .009 and P < .01, respectively), while they also had a lower perforation rate than the single-channel gastroscopy group (34.3% vs 51.0%; P = .048 and P < .05, respectively). No residual or recurrent lesions were discovered in any patients by gastroscopy reexamination. Both single-channel gastroscopy and double-channel gastroscopy can provide safe, effective, feasible endoscopic resection. However, double-channel gastroscopy has some distinct advantages in endoscopic resection.

Efficiency of an endoscopic resection strategy for management of submucosal tumors < 20 mm in the upper gastrointestinal tract

Background and study aims  The histologic diagnosis of submucosal tumors (SMTs) < 20 mm is challenging. Monitoring is the main option offered, but compliance is debatable. Endoscopic resection (ER) of malignant SMTs or those with an uncertain diagnosis is an alternative that has already been reported about and proposed in our center. The aims of this study were to confirm the safety of this resection strategy and to perform long-term follow-up of malignant SMTs after resection. Patients and methods  All patients who underwent ER for SMTs < 2 cm in a single center between 2007 and 2019 were included retrospectively. Patients were classified into two groups according to the need for postresection follow-up: benign SMTs (B-SMTs) and follow-up SMTs (FU-SMTs). Results  One hundred and one patients were included. The mean tumor size was 16.7 mm. In total, 92 of 101 SMTs had an uncertain diagnosis. Macroscopic resection was completed for 95 SMTs (93.1 %), with en bloc resection in 94 (92.1%). The morbidity rate was 3 %, with no mortality. A total of 84 of 101 SMTs (84 %) were B-SMTs and did not need monitoring, and 17 SMTs (19.7 %) were FU-SMTs (8 gastrointestinal stromal tumors, 6 neuroendocrine tumors, and 3 others). No relapse was reported in the FU-SMT group, with a median follow-up duration of 33 months [4-127] (61 months [17-127] for the gastrointestinal stroma tumor group). Conclusions  The study results suggest ER is a potentially reliable and effective strategy for upper gastrointestinal tract SMTs < 20 mm. Although the strategy needs further validation in advanced care units, it could eliminate the need for long-term monitoring, therefore targeting such follow-up efforts to patients with FU-SMTs.

Unusual Gastrointestinal Hemorrhaging Mimicking a Rupture of Solitary Gastric Varices Due to a Gastric Gastrointestinal Stromal Tumor with Exogenous Growth

Gastric gastrointestinal stromal tumors can lead to upper gastrointestinal hemorrhaging, which is usually caused by dimpling or ulceration on the tumor surface. While rare, pedunculated gastric gastrointestinal stromal tumors outside the stomach can present as a huge mass with delayed complaints. We herein report an unusual hemorrhaging mimicking a rupture of solitary gastric varices due to a pedunculated gastric gastrointestinal stromal tumor. In this case, contrast-enhanced computed tomography (CECT) was essential for tumor detection. An endoscopic investigation revealed dilated, aberrant veins and arteries in the submucosa of this tumor, recognized as solitary gastric varices.

[Hybrid laparo-endoscopic gastric resection for non-epithelial pyloric tumor]

In January 2020, a patient with a gastrointestinal stromal tumor of the antrum located in close proximity to the pylorus underwent a hybrid laparo-endoscopic organ-sparing gastric resection. There were no intraoperative and postoperative complications. Control endoscopic and X-ray examination of the stomach confirmed normal motor and evacuation function of the stomach. To date, follow-up period is more than 1.5 years. The patient has no complaints. This case demonstrates clear advantages of hybrid access in certain clinical situations, such as localization in anatomically difficult areas and near functional sphincters. Surgical approach ensured pylorus-sparing resection with favorable postoperative result.

Endoscopic Resection for Gastric Subepithelial Tumor with Backup Laparoscopic Surgery: Description of a Single-Center Experience

The aim of this study was to analyze patients who underwent endoscopic resection (ER) for gastric subepithelial tumors (SETs) with a high probability of surgical intervention. Between January 2013 and January 2021, 83 patients underwent ER at the operation theater and 27 patients (32.5%) required backup surgery mainly due to incidental perforation or uncontrolled bleeding despite endoscopic repairing. The tumor was predominantly located in the upper-third stomach (81%) with a size ≤ 2 cm (69.9%) and deep to the muscularis propria (MP) layer (92.8%) but there were no significant differences between two groups except tumor exophytic growth as a risk factor in the surgery group (37% vs. 0%, p < 0.0001). Patients in the ER-only group had shorter durations of procedure times (60 min vs. 185 min, p < 0.0001) and lengths of stay (5 days vs. 7 days, p < 0.0001) but with a higher percentage of overall morbidity graded III (0% vs. 7.1%, p = 0.1571). After ER, five patients (6%) had delayed perforation and two (2.4%) required emergent laparoscopic surgery. Neither recurrence nor gastric stenosis was reported during long-term surveillance. Here, we provide a minimally invasive strategy of endoscopic resection with backup laparoscopic surgery for gastric SETs.

Endoscopic Resection of Gastrointestinal Stromal Tumor: Is It Safe?

Recently, results from clinical studies of endoscopic resection of gastrointestinal stromal tumor (GIST) in the stomach are being reported. This procedure has several advantages, such as the provision of a definite diagnosis and therapeutic plan, avoidance of frequent follow-up examination, and reduction of patients’ anxiety. However, several concerns also exist such as a limited number of studies, low R0 resection rate, and relatively shorter follow-up period compared with surgical resection. Nevertheless, it is encouraging that most of the post-procedural complications have been treated with conservative management and that some of the patients did not show recurrence of the tumor during long-term follow-up. The selection of suitable cases and the experience of the endoscopists are the most important factors for successful endoscopic resection of gastric GIST. Development of novel procedures as well as collaboration with laparoscopic surgeons are currently in progress.

On the Track of New Endoscopic Alternatives for the Treatment of Selected Gastric GISTs-A Pilot Study

Background and Objectives: GISTs (Gastrointestinal stromal tumors) are the most common mesenchymal gastrointestinal tract tumours and are mainly located in the stomach. Their malignant potential depends on size, location, and type. Endoscopic techniques are a less invasive modality for patients not eligible for surgery. ESD (endoscopic submucosal dissection) is mainly used for the removal of smaller GISTs, with intraluminal growth and a more superficial location. Thus, R0 resection capability in some cases may be not sufficient, limited by tumour size, location in the gastric wall, and its connection level with the muscularis propria. In such cases, an endoscopic full-thickness resection can become a new alternative. In this retrospective pilot study, we evaluated ESD and hybrid resection techniques in terms of safety, efficacy, and disease recurrence for selected types of gastric GISTs. Materials and Methods: A retrospective comparison was conducted in a group of patients who underwent ESD or a hybrid technique combining endoscopic resection with endoscopic suturing using the OverStitch system (HT) for type II or III gastric GISTs. A total of 21 patients aged 70 ± 8 years underwent endoscopic resection. Seventeen lesions were treated with ESD and four with the HT. Results: R0 resection was achieved in all patients treated using HT (type III lesions) and in 53% of those treated with ESD (p = 0.08). None of the type III lesions treated with ESD were excised with R0. Lesions treated with R0 ESD resections were significantly smaller (1.76 ± 0.35 cm) than those with R1 ESD resections (2.39 ± 0.40 cm) (p < 0.01). The mean lesion size treated with the HT was 2.88 ± 0.85 cm. Conclusions: HT may be a new resection modality for large gastric GISTs with high muscularis propria connection grades. Further studies are required to evaluate its safety and efficacy and to form precise inclusion criteria for endoscopic resection techniques.

Comparison of Endoscopic Submucosal Dissection Application on Mucosal Tumor and Subepithelial Tumor in stomach

Background: Endoscopic submucosal dissection is minimal invasive endoscopic procedure to deal with gastric tumor. Initially, it was developed to resect mucosal neoplasm since 2000 and extended its application to submucosal tumor in the following years. Although the basic ESD skills are similar in gastric mucosal tumor and subepithelial tumor, the success rate, complication may be different between the two types of gastric tumor resection. This retrospective study is conducted to analyze the ESD procedure in gastric mucosal tumor and subepithelial tumor. Methods: From 2007 to 2016, we reviewed all patients who underwent endoscopic submucosal dissection for gastric mucosal tumor and subepithelial tumor in Kaohsiung Medical University Hospital. Results: Totally, 35 patients with gastric subepithelial tumor and 41 patients with gastric mucosal tumor received endoscopic submucosal dissection are enrolled. Among 35 patients with subepithelial tumor, 32 (91.4%) patients achieved curative treatment. 1 patient received emergent operation and 2 patients received salvage operation to complete tumor resection. 8 patients (22.9%) occurred perforation and no delay bleeding was found. Among 41 patients with mucosal neoplasm, 30 (71.4%) patients achieved curative treatment. 2 patients received emergent operation and 9 patients received salvage operation to complete tumor resection. 9 patients (21.9%) occurred complication, 6 patients occurred delay bleeding and 3 patients had perforation. Conclusions: Comparing ESD between gastric mucosal tumor and subepithelial tumor, ESD had similar efficiency in curative treatment. However, ESD in subepethelial tumor encountered higher perforation and lesser delay bleeding.

Comparison of endoscopic versus laparoscopic resection for gastric gastrointestinal stromal tumors: A preliminary meta-analysis

BACKGROUND AND AIM

For localized disease, complete surgical resection is regarded as the "gold standard" therapeutic modality. With the rapid development of endoscopic techniques, endoscopic resection (ESR) has been confirmed as an efficient and safe alternative for the treatment of gastrointestinal stromal tumors (GISTs) in the stomach. Nevertheless, the management of gastric GISTs remains poorly defined. The purpose of this study is to evaluate the security and effectiveness of ESR with laparoscopic resection (LAR) for gastric GISTs.

METHODS

A literature search of online databases was conducted to identify relevant comparative studies of ESR and LAR procedures for gastric GISTs published before April 10, 2020. The cumulative data analysis was also performed utilizing the software STATA.

RESULTS

In total, 10 studies involving 1165 patients met the inclusion criteria for analysis (651 for ESR and 514 for LAR). From the results of meta-analysis, patients who underwent ESR experienced decreased operative time (P = 0.000), less intraoperative blood loss (P = 0.002), earlier time to diet (P = 0.000), shorter hospital stay (P = 0.000), and lower total charges (P = 0.000) compared with LAR. Moreover, there were no significant differences between these two approaches concerning tumor rupture, conversion rate to other procedure, complete resection rate, postoperative complication rate, recurrence rate, and disease-free survival.

CONCLUSIONS

Endoscopic resection, as an effective alternative treatment strategy with satisfactory outcomes, is acceptable for selective patients with gastric GISTs compared with LAR. Further well-designed randomized controlled trials with large samples are warranted to corroborate our observations.

Recent advances in the management of gastrointestinal stromal tumor

Gastrointestinal stromal tumor (GIST) is a rare but an important clinical entity seen in our clinical practice. It is the most common mesenchymal tumor of the gastrointestinal tract and most common malignancy of the small intestine. Although the exact prevalence of GIST is not known, the incidence of GIST has been increasing. GISTs arise from interstitial cells of Cajal. Most of the GISTs occur due to mutation in c-kit gene or platelet derived growth factor receptor alpha gene. 15% of GISTs do not have these mutations and they are called wild-type GISTs. Almost all GISTs express KIT receptor tyrosine kinase. Histologically, GISTs look like spindle cell tumors most of the time but they can be epitheloid or mixed type. The median size of GISTs varies from 2.7 cm to 8.9 cm. Clinically, patients with small GISTs remain asymptomatic but as the GIST size increases, patients present with various symptoms depending on the location of the GIST. Most of GISTs are located in the stomach or small bowel. Diagnosis is suspected on imaging and endoscopic studies, and confirmed by tissue acquisition with immunohistochemical staining. The aggressiveness of GISTs depends on the size, mitotic index and location. Surgical resection is the treatment of choice. But various endoscopic modalities of resection are increasingly being tried. Tyrosine kinase inhibitors are extremely useful in the management of large GISTs, unresectable GISTs and metastatic GISTs. Treatment options for metastatic GISTs also include radiotherapy, chemotherapy, hepatic artery embolization, chemoembolization and radiofrequency ablation.

Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract

BACKGROUND/AIMS

Endoscopic treatment (ET) has been applied for decades to treat subepithelial tumors, including gastrointestinal stromal tumors (GISTs). However, the efficacy of ET remains debatable. In this study, we evaluated the efficacy and safety of ET for GISTs in the upper gastrointestinal tract.

METHODS

This retrospective single-center study included 97 patients who underwent ET. All patients were enrolled from July 2014 to July 2018. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time, total cost, and follow-up were investigated and analyzed.

RESULTS

Our study achieved 100% en bloc resection and 77.4% (72/93) R0 resection. The most common location was the fundus with a mean tumor size of 2.1±1.43 cm. The mean age, procedure time, hospital stay, and cost were 59.7±11.29 years, 64.7±35.23 minutes, 6.8 days, and 5,337 dollars, respectively. According to National Institutes of Health classification, 63 (64.9%), 26 (26.8%), 5 (5.2%), and 3 (3.1%) patients belonged to the very low, low, intermediate, and high risk classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 21.3±13.0 months showed no recurrence or metastasis.

CONCLUSION

ET is effective and safe for curative removal of GISTs in the upper gastrointestinal tract, and it can be a treatment of choice for patients with no metastasis.

Endoscopic Submucosal Dissection of Gastrointestinal Stromal Tumours: A Retrospective Cohort Study

Background

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms. Endoscopic submucosal dissection (ESD) has been used to remove submucosal tumours for many years. However, whether ESD can be recommended for the treatment of GISTs is still controversial. Therefore, we evaluated the efficacy and safety of ESD for treating GISTs.

Patients and Methods

We retrospectively analysed 75 GIST patients who underwent ESD in our hospital from January 2016 to December 2018, and the demographic data, clinical presentation of tumours, operative parameters, postoperative complications and length of hospital stay were analysed.

Results

Seventy-five patients successfully underwent en bloc resection, and 74 (98.7%) patients underwent complete resection of the lesions, with an average tumour size of 1.7 cm (range 0.3–6.0 cm). The median operation time was 84.8 min (range 20–180 min). Forty-two (56.0%) patients underwent endoscopic purse-string suture with no conversions to an open operation. The median postoperative length of hospitalization was 6.6 days (range 3–14 days). Out of a total of 75 GIST patients, 48 (64.0%) were considered very low risk, 19 (25.3%) were low risk, 5 (6.7%) were mild risk, and 3 (4.0%) were high risk. The median follow-up was 24.0 months (range 6–45 months). During hospitalization and follow-up, no complications, recurrence or metastasis occurred.

Conclusion

Based on our study from a medical centre, ESD is a safe and effective method for treating GISTs. However, further studies are needed.

Optimal Endoscopic Resection Technique for Selected Gastric GISTs. The Endoscopic Suturing System Combined with ESD-a New Alternative?

Background and Study Aim: In terms of therapeutic management, gastrointestinal stromal tumors (GISTs) seem to be the most difficult group of subepithelial gastrointestinal lesions (SELs). Despite various treatment option, choice of optimal management remains a dilemma in daily practice. Our aim was to evaluate a new hybrid resection technique of gastric GISTs type III as a modality of endoscopic full-thickness resection. Methods: Three males and one female (mean age of 68) were qualified for the procedure. Endoscopic full-thickness resections consisted of the endoscopic resection combined with suturing by Apollo OverStitch System. The main inclusion criterium was a complete diagnosis of GISTs (computed tomography (CT), endoscopic ultrasound (EUS), fine-needle biopsy (FNB)) with the evaluation of the tumor features, especially, the location in the gastric wall. All of the tumors were type III with a diameter between 20–40 mm. The lesions were located in the corpus (1), antrum (1) and between gastric body and fundus (2). All procedures were performed in 2019. Results: The technical and therapeutic success rate was 100% and the mean resection time 107.5 min. Neither intra- nor postprocedural complications were observed. In all four cases, R0 resection was achieved. Histopathologic assessment confirmed GIST with <5mitose/50HPF in all of the tumors, with very low risk. Conclusion: Based on our outcomes, endoscopic resection combined with the sewing by Apollo OverStitch of gastric GISTs type III, with the diameter between 20–40 mm, seems to be an effective therapeutic option with a good safety profile, however further studies with a larger treatment group are needed.

Characteristic of extra luminal gastric stromal tumor arising from the lesser curvature of the stomach: A case report

RATIONALE

Gastrointestinal stromal tumor (GIST) is one of the most common malignant mesenchymal tumors of the gastrointestinal tract. They generally arise from the fourth layer (muscularis propria) and rarely from the second or third layer. Although the manifestations of gastric stromal tumors are diverse, to our knowledge, there are only several cases of an extra-gastric stromal tumor in the literature appearing with a pedunculation. Pedunculated large GISTs are not frequent and compress the neighboring organs. When they were huge, it is difficult to differentiate the origin of the masses. Thus, in the clinical setting, physicians should pay more attention to the pattern of manifestation of the gastric stromal tumor.

PATIENT CONCERNS

A 62-year-old man had no gastrointestinal symptoms or significant medical and family histories. During the health examination with US, a cystic-solid tumor was found below liver. The results of the physical examination were unremarkable, and routine laboratory data on admission did not show any abnormal findings.

DIAGNOSIS

Computed tomography of the abdomen showed a mixed echoic mass measuring 10 × 8 × 8 cm and located below the liver, adjacent to the gastric antrum. After endoscopic ultrasound-guided fine-needle aspiration, cytopathology showed that the specimen was filled with red blood cells, and it had no malignant cells. Histopathology revealed that the mass was a GIST, and immunohistochemical analysis showed the following: CD117(+), CD34(+), desmin(-), Dog-1(+), Ki-67% <1%, and smooth muscle actin(-).

INTERVENTIONS

Surgical resection was performed on the patient.

OUTCOMES

The lesion was diagnosed as a gastric stromal tumor with a pedicle and an old hemorrhage. The patient's recovery was uneventful. After surgery, computed tomography at the 6-month and 1-year postoperative follow-up visits did not reveal relapse or any metastasis.

LESSONS

In the clinical setting, physicians should pay more attention to the pattern of manifestation of the extra-gastric stromal tumor in patients with a pedicle or hemorrhage. Additionally, endoscopic ultrasound-guided fine-needle aspiration can be used to make an accurate preoperative diagnosis of such diseases, and its findings can serve as an important basis for surgical excision of the lesions.

Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients' tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection

Background and aims

Endoscopic full-thickness resection (EFTR) has been increasingly applied in the treatment of gastric submucosal tumors (G-SMTs) with explorative intention. This study aimed to compare the efficacy, tolerability, and clinical outcomes of EFTR and surgical intervention for the management of muscularis propria (MP)-derived G-SMTs.

Methods

Between September 2011 and May 2019, the clinical records of patients with MP-derived G-SMTs undergoing EFTR at our endoscopic unit were collected. A cohort of people with primary MP-derived G-SMTs treated by surgery was matched in a 1:1 ratio to EFTR group with regard to patients’ baseline characteristics, clinicopathologic features of the tumor and the procedure date. The perioperative outcomes and follow-up data were analyzed.

Results

In total, 62 and 62 patients were enrolled into the surgery and EFTR group, respectively, with median follow-up of 786 days. The size of G-SMTs (with ulceration) ranged from 10 to 90 mm. For patients with tumor smaller than 30 mm, surgery and EFTR group presented comparable procedural success rate (both were 100%), en bloc resection rate (100% vs. 94.7%), tumor capsule rupture rate (0% vs. 5.3%), and pathological R0 resection rate (both were 100%). EFTR had a statistically significant advantage over surgery for estimated blood loss (3.12 ± 5.20 vs. 46.97 ± 60.73 ml, p ≤ 0.001), discrepancy between the pre- and postprocedural hemoglobin level (5.18 ± 5.43 vs. 9.84 ± 8.25 g/L, p = 0.005), bowel function restoration [1 (0–5) vs. 3 (1–5) days, p ≤ 0.001], and hospital cost (28,617.09 ± 6720.78 vs. 33,963.10 ± 13,454.52 Yuan, p = 0.033). The patients with tumor larger than 30 mm showed roughly the same outcomes after comparison analysis of the two groups. However, the clinical data revealed lower en bloc resection rate (75.0% vs. 100%, p = 0.022) and higher tumor capsule rupture rate (25.0% vs. 0%, p = 0.022) for EFTR when compared to surgery. The procedure time, duration of postprocedural fasting and antibiotics usage, and hospital stay of the two groups were equivalent. The occurrence rate of adverse events within postoperative day 7 were 74.2% and 72.6% after EFTR and surgery, respectively (p = 1.000). No complications occurred during the follow-up.

Conclusion

For treatment of MP-derived G-SMTs (with or without ulceration), our study showed the feasibility and safety of EFTR, which also provided better results in terms of procedural blood loss, the postoperative bowel function restoration and cost-effectiveness when compared to surgery, whereas the surgery was superior in en bloc resection rate for G-SMTs larger than 30 mm. The postprocedural clinical outcomes seemed to be equivalent in these two resection methods.

Laparoscopic and Endoscopic Cooperative Dissection for Small Gastric Gastrointestinal Stromal Tumor without Causing Injury to the Mucosa

Objective

To investigate the feasibility of laparoscopic and endoscopic cooperative dissection (LECD) for small gastric gastrointestinal stromal tumors (GISTs) without causing injury to the mucosa, compared with ESD surgery which is widely used now.

Methods

A total of 25 patients with small gastric GISTs who underwent LECD and 20 patients with small gastric GISTs who underwent ESD between October 2014 and June 2016 were included in this study. All patients underwent curative resection for pathologically diagnosed small gastric GISTs. Patients' clinical data were retrospectively analyzed.

Results

In LECD group, the operation was successfully performed in all patients. However, in the ESD group, three patients were transferred to laparoscopic surgery due to intraoperative massive bleeding or intraoperative perforation. No additional targeted chemotherapy drugs for interstitial tumors were prescribed in two groups. There was no difference in the complete tumor capsule rate (100% vs. 90%, p = 0.11), operation time (80.76 ± 13.86 ml vs. 84.05 ± 15.33 ml, p = 0.45), major intraoperative bleeding (0 vs. 5%, p = 0.26), postoperative bleeding (0 vs. 10%, p = 0.11), and postoperative infection (0 vs. 10%, p = 0.11) between the two groups. Compared to ESD (endoscopic submucosal dissection), LECS patients had shorter postoperative indwelling gastric tube (1.04 ± 0.98 d vs. 2.85 ± 0.24 d, p < 0.01), earlier postoperative eating (1.96 ± 0.98 d vs. 3.50 ± 1.15 d, p < 0.01), shorter average postoperative hospital stay (3.44 ± 1.00 d vs. 7.85 ± 1.18 d, p < 0.01), smaller perforation rate (0 vs. 25%, p < 0.05), and fewer surgical supplies. No recurrence or metastasis cases were found between the two groups during the follow-up period, and there were no cases of death due to gastric GISTs.

Conclusion

LECD is a novel surgery for small gastric gastrointestinal stromal tumors that leads to satisfactory short-term outcomes and meets the idea of minimally invasive surgery and rapid recovery; compared with ESD, LECD surgery has some advantages in clinical practice. However, further follow-up is needed to confirm.

Comparison of Safety and Outcomes between Endoscopic and Surgical Resections of Small (≤ 5 cm) Primary Gastric Gastrointestinal Stromal Tumors

BACKGROUND AND AIMS

Endoscopic resection is increasingly performed for gastric gastrointestinal stromal tumors (GIST). However, the safety and outcomes remain elusive. We aimed in this retrospective study to compare operative complications and prognosis between endoscopically and surgically resected small (≤ 5 cm) GIST tumor groups.

METHODS

In this single-center retrospective study, we compared demographics, clinical outcomes, and the R0 resection rate between the endoscopy (n =268) and surgery (n =141) groups. Only GIST tumors in size of ≤ 5.0 cm were recruited for this comparison study.

RESULTS

Overall, the mean age of patients was 59.0 years (range: 31.0-83.0). The male-female ratio was 0.68. The most common site of GIST was, in the descending order, the gastric fundus (55%), corpus (27.6%), cardia (10.8%), and antrum (6.6%). Compared with the surgery group, GIST tumors in the endoscopy group were significantly smaller (1.69±0.9 cm, vs. 3.20±1.2 cm in the surgery group; P <0.001) in size; postoperative hospital stay was significantly shorter (4.66±1.5 days, vs. 8.11±5.0; P <0.001); post-resection time to first liquid diet was significantly shorter (1.94±1.1 days, vs. 4.63±2.6; P < 0.001); the incidence of operative and post-operative complications was significantly fewer (p < 0.05), and hospital costs were significantly lower (20115.4±5113.5¥, vs. 43378.4±16795.7¥; P < 0.001). The R0 resection rate was significantly lower in the endoscopy (93.3%) than in the surgery (99.3%) groups (P< 0.01). In the endoscopy group, 176 (65.7%) and 69 (25.7%) patients were found to be at very low and low risk of aggressiveness, respectively, in comparison to 27(19.2%) and 86 (61.0%) patients in the surgery group, respectively (P <0.001). Among 409 cases, 50 (12.2%) were found to be at intermediate or high risk of aggressiveness, 20 of which were treated with adjuvant imatinib therapy and but only 8/20 taking imatinib for 1 to 3 months because of side effects and high costs. No local or distant tumor recurrence was observed over an average of 33.5-month follow-ups. Two patients died of other disease in the surgery group.

CONCLUSIONS

Endoscopic resection of selected small gastric GISTs (≤ 5cm) was feasible, safe, and associated with better intraoperative results and an equal postoperative course, compared to surgical resection.

Tailored management of primary gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common human sarcoma and can form along the entire gastrointestinal tract. Over the last 20 years, considerable advances have been made in our understanding of the biology of GISTs. The advent of tyrosine kinase inhibitors has provided effective medical therapy for the first time. In fact, given that GIST typically is driven by either a KIT or PDGFRA gene mutation, it has become a paradigm of targeted molecular therapy. In addition, diagnostic and surgical techniques have been refined. Here, the critical aspects of primary GISTs and how they are now managed with an integrated approach are summarized. Treatment plans are developed based on specific pathologic and molecular features of the tumor. The authors outline the general principles of therapy and highlight some of the nuances. Particular focus is given to diagnosis, surgical considerations, and the use of preoperative and postoperative tyrosine kinase inhibitors.

Value of contrast-enhanced harmonic endoscopic ultrasonography in differentiating between gastrointestinal stromal tumors: A meta-analysis

OBJECTIVE

Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is a valuable device to diagnose and determine the malignant potential of gastrointestinal stromal tumors (GIST) as early as possible when making clinical therapeutic decisions. This study aimed to estimate the ability of CH-EUS to discriminate between GIST and benign submucosal lesions (SML) and to predict their malignant potential.

METHODS

PubMed, MEDLINE, EMBASE, the Web of Science, and Cochrane Central Register of Controlled Trials databases were screened. Using the data provided in the literatures, 2 × 2 tables were constructed to obtain the pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. A receiver operating characteristic (ROC) curve was generated and the area under the ROC curve (AUROC) was calculated.

RESULTS

Four studies with a total of 187 patients were identified to evaluate the value of CH-EUS in discriminating between GIST and benign SML. The pooled sensitivity, specificity, and AUROC were 89% (95% CI 0.82-0.93), 82% (95% CI 0.66-0.92), and 0.89, respectively. Five studies including 143 patients were analyzed to assess the accuracy of CH-EUS in determining the malignant potential of GIST. The pooled sensitivity, specificity, and AUROC curve of CH-EUS were 96% (95% CI 0.90-0.99), 53% (95% CI 0.40-0.66), and 0.92, respectively.

CONCLUSIONS

CH-EUS is a safe, noninvasive method that can distinguish between GIST and benign subepithelial lesions and to predict their malignant potential to a certain extent. Large-scale, multicenter prospective studies are needed in the future.

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.

Clinical Overview of GIST and Its Latest Management by Endoscopic Resection in Upper GI: A Literature Review

AIMS

To review the clinical presentation, diagnosis, assessment of risk of malignancy, and recent advances in management (mainly focusing on the role of endoscopic resection) of gastrointestinal stromal tumors (GISTs) in upper GI.

METHOD

We searched Embase, Web of science, and PubMed databases from 1993 to 2018 by using the following keywords: "gastrointestinal stromal tumors," "GIST," "treatment," and "diagnosis." Additional papers were searched manually from references of the related articles.

FINDINGS

The improvement of endoscopic techniques in treating upper gastrointestinal subepithelial tumors especially gastrointestinal tumors has reduced the need for invasive surgery in patients unfit for surgery. Many studies have concluded that modified endoscopic treatments are effective and safe. These treatments permit minimal tissue resection, better dissection control, and high rates of en bloc resection with an acceptable rate of complications.

Tumor rupture of gastric gastrointestinal stromal tumors during endoscopic resection: a risk factor for peritoneal metastasis?

BACKGROUND AND STUDY AIMS

 Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract. Up to the present time, complete surgical excision has been the standard treatment for primary GISTs greater than 2 cm. It is well known that tumor rupture during surgery is an independent risk factor for peritoneal metastasis; however, it is not known whether the risk of peritoneal metastasis increases in cases where the tumor is ruptured during endoscopic resection.

PATIENTS AND METHODS

 A total of 195 patients treated for GIST between January 2014 and December 2016 in our hospital were enrolled in this study. They were divided into two groups according to whether the tumor was ruptured during endoscopic resection. The rate of peritoneal metastasis in patients in the two groups who also suffered perforation was investigated from the follow-up results.

RESULTS

 Approximately 55.4 % of all patients were female and the average age of the study group was 59.0 ± 10.3 years. Of the 195 patients, the tumors in 27 were ruptured and the remaining 168 patients underwent en bloc resection. There was no statistically significant difference in gender or age between the two groups. The median tumor size (maximum diameter) in all patients was 1.5 cm (0.3 - 5.0 cm): 2.5 cm (0.8 - 5.0 cm) and 1.4 cm (0.3 - 4.0 cm) in the tumor rupture group and en bloc resection group, respectively ( P  < 0.001). Most of the tumors were located in the gastric fundus. At a median follow-up of 18.7 ± 10.2 months, neither tumor recurrence (liver metastasis, peritoneal metastasis, local recurrence) nor mortality related to GISTs were detected.

CONCLUSIONS

 Tumor rupture during endoscopic resection of gastric GISTs may not be a risk factor for peritoneal metastasis.

Submucosal tunnel endoscopic resection for extraluminal tumors: a novel endoscopic method for en bloc resection of predominant extraluminal growing subepithelial tumors or extra-gastrointestinal tumors (with videos)

BACKGROUND AND AIMS

The management of subepithelial tumors with a predominant extraluminal growth pattern or extra-GI tumors can be challenging and traditionally requires a surgical resection that is not only invasive but may carry a significant risk of morbidity and mortality. We aimed to assess the feasibility, safety, and efficacy of a novel endoscopic technique termed submucosal tunnel endoscopic resection for extraluminal tumors (STER-ET).

METHODS

We prospectively enrolled patients who underwent STER-ET for GI subepithelial tumors with a predominant extraluminal growth pattern or extra-GI tumors located at the level of cardia or the proximal part of the lesser curvature of the stomach seen on cross-sectional imaging between January 2016 and March 2017.

RESULTS

Eight patients underwent STER-ET. The mean (± standard deviation) tumor size was 2.8 ± 0.6 cm and 2.3 ± 0.8 cm in longest and shortest dimension, respectively. The average procedure time was 67 ± 4.4 minutes. The rates of curative en bloc resection and en bloc retrieval was 100% and 87.5%, respectively. On final histology, 6 tumors were GI stromal tumors, 1 was a schwannoma, and 1 was a foregut cyst. Five patients had capnoperitoneum during the procedure and required abdominal decompression. One patient had a small mucosotomy successfully treated with a hemostatic clip. There were no major adverse events or deaths. The median length of hospital stay was 3 days. There was no residual tumor on surveillance imaging after a mean follow-up period of 10.0 ± 2.1 months.

CONCLUSIONS

STER-ET is a novel technique that appears to be safe and effective in achieving a curative resection for GI subepithelial tumors with a predominantly extraluminal growth pattern or extraluminal tumors in a selected group of patients. However, larger studies are required to validate our finding.

Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor

BACKGROUND AND AIM

A retrospective study was conducted to compare two resection methods, namely, endoscopic resection (ER) procedures (endoscopic submucosal dissection [ESD], endoscopic muscularis dissection [EMD], and endoscopic full-thickness resection [EFTR]) and laparoscopic resections (LR) (laparoscopic endoscopic cooperative surgery [LECS] and laparoscopic wedge resection).

METHODS

Seventy-three patients who underwent ER (N = 33: ESD, N = 4; EMD, N = 15; EFTR, N = 14) or LR (N = 39: LECS, N = 16; wedge resection, N = 23) for gastric submucosal tumor (G-SMT) smaller than 50 mm were included in this study. Patient/tumor characteristics and intra/postoperative factors were compared between the ER and LR groups.

RESULTS

The ER group had a significantly higher percentage of intraluminal growing type of tumor (100% vs 41%) and smaller tumor size (23 vs 33 mm) than the LR group. The ER group had a significantly shorter operative time (93 vs 145 min) and less blood loss (13 vs 30 mL) than the LR group. In the ER group, three patients who had tumors located on the anterior wall of the stomach required laparoscopic closure after EFTR because of difficulty in endoscopic closure of the gastric-wall defect. Postoperative complication rates and duration of postoperative hospital stays did not differ between the two groups.

CONCLUSIONS

ER may be technically feasible, safe, less invasive, and oncologically appropriate options for selected patients with the intraluminal growing type of G-SMT smaller than 30 mm. EFTR may be more reasonable alternatives to LR in selected patients with a small G-SMT located on the lesser curvature side.

Endoscopic resection of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract, and about 60% of them are found in the stomach. With the widespread application of endoscopy and endoscopic ultrasonography (EUS), more and more gastric GISTs are being found in an early stage (with a relative small diameter and no metastasis), giving the chance of complete resection. Endoscopic resection such as endoscopic band ligation (EBL), endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER), is a minimally invasive method compared with the conventional surgical approaches (open or laparoscopic), and has been demonstrated to be safe and effective for treating gastric GISTs. This review summarizes the recent advances on endoscopic resection of gastric GISTs, aiming to provide a rational management strategy for gastric GISTs.

[Endoscopic Treatment of Gastric Adenoma]

Gastric adenoma (dysplasia) is a precancerous lesion. Therefore, managements of gastric adenomas are important for preventing the development of gastric cancers and for detecting gastric cancers at earlier stages. The Vienna classification divides gastric adenomas into two categories: high-grade dysplasia and low-grade dysplasia. Generally, endoscopic resection is performed for adenoma with high-grade dysplasia due to the coexistence of carcinoma and the potential of progression to carcinomas. However, the treatments of adenoma with low-grade dysplasia remain controversial. Currently two treatment strategies for the low-grade type have been suggested; First is the 'wait and see' strategy; Second is endoscopic treatment (e.g., endoscopic mucosal resection, endoscopic submucosal dissection, or argon plasma coagulation). In this review, we discuss the current optimal strategies for endoscopic management of gastric adenoma.

Comparison between submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric stromal tumors originating from the muscularis propria layer

BACKGROUND

Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective method for treating gastric gastrointestinal stromal tumors (GISTs); however, little is known about the comparison between STER and EFTR. The aim of the study was to compare the safety and efficacy of STER and EFTR for treating gastric GIST.

METHODS

We retrospectively collected the clinical data about patients with gastric GISTs who received STER or EFTR at our hospital from April 2011 to June 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, length of stay, cost and follow-up data were compared between STER and EFTR.

RESULTS

A total of 52 patients were enrolled, and 20 of them received STER, while the other 32 cases received EFTR. There was no significant difference between the two groups in terms of gender, age, concomitant diseases, tumor size, en bloc resection rate, operation time, complications, pathohistological grade of GIST, hospital stay and cost (P > 0.05). However, patients who received EFTR had a longer suture time and needed more clips to close the gastric-wall defect (STER vs EFTR, 291.5 ± 68.7 vs 380.6 ± 96.9s and 6.0 ± 1.2 vs 7.6 ± 1.6, P < 0.05). No recurrence was noted in the STER and EFTR groups during a mean follow-up of 10.9 and 23.8 months, respectively.

CONCLUSIONS

The treatment efficacy between STER and EFTR for treating gastric GISTs was comparable, and a large-scale, randomized study is necessary for a more confirmed conclusion.

Effectiveness and safety of endoscopic resection for gastric GISTs: a systematic review

AIMS

To evaluate the effectiveness and safety of endoscopic resection for gastric gastrointestinal stromal tumors (GISTs).

MATERIAL AND METHODS

The effectiveness and safety of endoscopic resection were mainly assessed by complete resection rate, postoperative adverse event rate, and recurrence rate. Moreover, a comparison of endoscopic with laparoscopic resection for gastric GISTs was made through weighted mean difference by STATA 12.0 with regard to operation time, blood loss, and length of stay after including patients who underwent endoscopic or laparoscopic resection for gastric GISTs in the comparative studies.

RESULTS

Eleven studies investigating endoscopic resection for GISTs were included. For stromal tumors <2 cm in average diameters the pooled rates of complete resection, postoperative adverse events and recurrence were 0.97, 0.08, and 0.03, respectively. Only five retrospective studies directly compared endoscopic with laparoscopic resection for gastric GISTs with average diameters from 1.1 cm to 3.8 cm, and endoscopic resection had a shorter operation time than laparoscopic resection, but there were no significant differences in intraoperative blood loss, length of stay, postoperative complications, and postoperative recurrence rates between the two approaches.

CONCLUSIONS

Endoscopic resection is predominantly tried for gastric GISTs of relatively small size. It seems effective and safe for gastric GISTs <2 cm in average diameter, with relatively short operation times.

Robotic Versus Laparoscopic Gastric Resection for Primary Gastrointestinal Stromal Tumors >5 cm: A Size-Matched and Location-Matched Comparison

This study compared robotic (RR) and laparoscopic resection (LR) for primary gastrointestinal stromal tumors (GISTs) of the stomach >5 cm. Twelve consecutive patients who underwent RR from 2012 to 2015 were matched for tumor size and location with 24 patients who underwent LR from 2000 to 2012. The median tumor size was 7.1 cm (range, 5.5 to 11.5). GISTs were resected by wedge resection (91.7%) or distal gastrectomy. The median RR operative time was longer than that of LR (162.5 vs. 130 min, respectively; P=0.004). Only 1 LR patient required conversion. The time to flatus and hospital stay were similar between groups. Overall, 3 patients developed minor postoperative complications that were medically treated. Mortality was nil. All resections were R0. No difference was observed in the incidence of recurrence. RR was significantly more expensive (+21.6%) than LR. RR appears to be safe and feasible for GISTs>5 cm, but is associated with longer operative times and greater costs.

Laparoscopic management of gastric gastrointestinal stromal tumors: A retrospective 10-year single-center experience

AIM

To determine the feasibility, safety, and oncological outcome of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) based on favorable or unfavorable location.

METHODS

Our hospital database included 207 patients who underwent laparoscopic removal of gastric GISTs from January 2004 to September 2015. Patient demographics, clinical presentation, surgery, histopathology, postoperative course, and oncological outcomes were reviewed and analyzed.

RESULTS

Gastric GIST in favorable locations was present in 81/207 (39.1%) cases, and in unfavorable locations in 126/207 (60.9%) cases. Overall mean tumor size was 3.28 ± 1.82 cm. No conversions occurred, and complete R0 resection was achieved in 207 (100%) cases. There were three incidences of iatrogenic tumor rupture. The feasibility and safety of laparoscopic surgery were comparable in both groups with no statistical difference between unfavorable and favorable location groups, respectively: for operative time: 83.86 ± 44.41 vs 80.77 ± 36.46 min, P = 0.627; conversion rate: 0% vs 0%; estimated blood loss: 27.74 ± 45.2 vs 29.59 ± 41.18 mL, P = 0.780; tumor rupture during surgery: 0.90% vs 2.82%, P = 0.322; or postoperative complications: 3.74% vs 7.04%, P = 0.325. The follow-up period recurrence rate was 1.89% with no significant differences between the two groups (3.03% vs 0%, P = 0.447). Overall 5-year survival rate was 98.76% and survival rates were similar between the two groups: 98.99% vs 98.39%, P = 0.623 (unfavorable vs favorable, respectively).

CONCLUSION

The laparoscopic approach for gastric GISTs is safe and feasible with well-accepted oncological surgical outcomes. Strategies for laparoscopic resection should be selected according to the location and size of the tumor. Laparoscopic treatment of gastric GISTs in unfavorable locations should not be restricted in gastrointestinal centers.

Laparoscopic wedge resection for suspected large (≥5 cm) gastric gastrointestinal stromal tumors

BACKGROUND

Laparoscopic wedge resection (LWR) for small gastric gastrointestinal stromal tumors (GIST) is now widely accepted, but its application for large GISTs remains controversial. This study aims to evaluate the feasibility and safety of LWR for suspected large (≥5 cm) gastric GISTs.

METHODS

Retrospective review of 82 consecutive patients who underwent attempted LWR for suspected gastric GIST. LWR for large (≥5 cm) (n = 23) tumors was compared with LWR for small (<5 cm) tumors (n = 59). The 23 patients with LWR for large tumors were also compared to 36 consecutive patients who underwent open wedge resection (OWR) for large tumors.

RESULTS

Comparison between patients who underwent LWR for large versus small tumors demonstrated that resection of large tumors was associated with a longer operating time. There was no difference in other perioperative outcomes, and oncological outcomes such as frequency of close margins (≤1 mm) and recurrence-free survival. Comparison between patients who underwent LWR versus OWR for large tumors showed that LWR was associated with decreased median time to fluid or solid diet, shorter postoperative stay but longer operating times. There was no difference in oncological outcomes.

CONCLUSION

LWR for suspected large gastric GIST is feasible and safe. It is associated with similar short-term outcomes with LWR for small tumors and favorable short-term outcomes over OWR for large tumors without compromising on oncological outcomes.