Combined endoscopic and laparoscopic approach to a gastroesophageal tumor

Laparoendoscopic assisted surgery for a gastrointestinal stromal tumor (GIST): A case report

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are infrequent, and clinical presentation varies between asymptomatic and diffuse symptoms such as abdominal pain and dyspepsia. Surgical approach depends on location and size of the tumor. There are some reports of the specific surgical approach for GIST located at the gastroesophageal junction. This is a case report of a patient with a GIST located specifically at the gastroesophageal junction and the surgical approach selected for the treatment.

PRESENTATION OF THE CASE

A 70-year-old patient who developed an episode of upper gastrointestinal bleeding with hemorrhagic shock accompanied by elevated troponins that required transfusion therapy and whose endoscopic evaluation showed a subcardial ulcerated lesion of 16 × 5 mm, located 2 cm below the z-line. The lesion was biopsied and was negative for malignancy. A combined surgical approach for resection by combined laparoscopy and submucosal resection by upper gastrointestinal endoscopy was performed by the interventional gastroenterology service and surgical oncology service.

DISCUSSION

Specific management of GISTs depends on the location of the tumor, even though, complete surgical resection remains the gold standard treatment. Minimally invasive techniques can be used to assess these tumors leading to shorter hospital stays and lesser risk of complications. Laparoendoscopic cooperative surgery is a promising approach for managing lesions near the gastroesophageal junction.

CONCLUSION

GISTs located near the gastroesophageal junction require a complex approach. The laparaendoscopic approach seems to be a feasible approach for GIST in the gastroesophageal junction.

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.

Safety analysis of laparoscopic endoscopic cooperative surgery versus endoscopic submucosal dissection for selected gastric gastrointestinal stromal tumors: a propensity score-matched study

BACKGROUND

Laparoscopic endoscopic cooperative surgery (LECS) is a safe alternative to endoscopic submucosal dissection (ESD) for select gastric gastrointestinal stromal tumors (GISTs) that are <2 cm in size. To date, there have been no randomized studies comparing the feasibility of these two techniques. Therefore, we compared their feasibility and safety using the propensity score matching method in this study.

METHODS

This was a single-center, retrospective, propensity score-matched study of patients who underwent resection of selected gastric GISTs between 2004 and 2014. All patients underwent curative resection for pathologically diagnosed small gastric GISTs. The primary aim was to determine intraoperative complications and postoperative courses. To overcome selection biases, we performed a 1:1 match using five covariates, including age, gender, body mass index, Charlson comorbidity index, and tumor location, to generate propensity scores.

RESULTS

In total, 32 patients treated with LECS and 102 patients treated with ESD were balanced into 30 pairs. The rate of intraoperative complications was significantly lower in the LECS group than in the ESD group (P = 0.029). LECS patients had less intraoperative bleeding than did ESD patients (15.0 ml [range 9.5-50.0 ml] vs. 43.5 ml [range 22.3-56.0 ml], P = 0.004). The two groups had similar postoperative courses. There was no difference in the reoperation rate between the two groups (P = 0.112). The ESD group had a shorter operating time than did the LECS group (41.5 min vs. 96.5 min, P < 0.001). However, during a follow-up of 57.9 (±28.9) months, the recurrence rate did not differ significantly between the two groups (0.0 vs. 6.7 %, respectively; P = 0.256).

CONCLUSIONS

LECS for selected gastric GIST patients is feasible and is associated with a better intraoperative outcome and an equal postoperative course compared with the results of ESD.

Optimal management of GIST tumors located near the gastroesophageal junction: Case report and review of the literature

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There are several endoscopic, laparoscopic and open surgical procedures available for the management of GIST tumors near the GE junction.

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We present a case-report utilizing both endoscopy and laparoscopy to facilitate resection using the non-touch lesion-lifting technique.

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Pathology demonstrated a 4.7 cm GIST. The patient was discharged on post-operative day 3 with no complications.

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We include a full literature review and describe the various combined modalities available for successful resection.

Introduction

The safety and oncologic outcome of laparoscopic gastric GIST resection is well established especially for lesions <5 cm in diameter. The optimal management of GIST tumors near the GE junction remains unclear.

Methods

We present a case-report of a 4.7 cm GIST tumor near the GE junction managed by endoscopically-assisted laparoscopic wedge resection (EAWR). We present a review of the literature highlighting the various combined laparo-endoscopic techniques available.

Results

We used the non-touch lesion-lifting method to laparoscopically resect the GIST tumor under endoscopic guidance. There were no complications and the patient was discharged on postoperative day 3.

Conclusions

Endoscopically-assisted laparoscopic wedge resections are feasible and safe for GIST tumors near the GE junction.

Surgical management of gastrointestinal stromal tumors: a single center experience

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Although the therapy targeted at inhibiting tyrosine kinases has shown dramatic results in metastatic and inoperable GISTs, the mainstay of treatment in primary localized forms remains surgical resection.

AIM

To provide an overview of our experience of GIST diagnosis and management, with emphasis on comparison of minimally invasive and open surgical resection for primary GISTs.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of all patients who underwent surgical removal of GISTs from 2008 to 2012. Patient demographics, clinical data, surgery, complications, histopathological data and clinical course were analyzed.

RESULTS

Forty-four patients were identified. Average age at diagnosis was 63 years. Minimally invasive (MIS) and open surgery (OS) were each attempted in 22 (50.0%) patients. Laparoscopic removal was performed in 20, laparoendoscopic in 1, and laparoscopy-assisted endoscopic removal in 1. Conversion to an open procedure was performed in 4 (18.2%). We found significant differences in postoperative length of stay (8.5 days vs. 10.1 days, p < 0.001) and tumor size (2.93 cm vs. 5.78 cm, p = 0.018) between MIS and OS groups, respectively.

CONCLUSIONS

Laparoscopic removal is safe and effective for GISTs not exceeding 6 cm. Gastroesophageal junction and cardia GISTs require careful preoperative evaluation and planning to remove safely. We recommend avoiding laparoscopic removal of these tumors due to the high rate of conversion (100.0%) to an open procedure. Laparoendoscopic surgical approach is an appropriate technique for removal of small-sized intraluminal benign GISTs not involving the muscularis propria layer.