• Diagnosis
• Endoscopic ultrasound
• Gastrointestinal stromal tumors
• Risk classification

• Male
• Humans
• Female
• Gastrointestinal Stromal Tumors/diagnostic imaging
• Gastrointestinal Stromal Tumors/surgery
• Retrospective Studies
• Stomach Neoplasms/pathology
• Endosonography/methods
• Mitotic Index

• colonoscopy
• endoscopic procedures
• endoscopy

• Small gastric gastrointestinal stromal tumors
• endoscopic resection
• endoscopic ultrasound
• gastric submucosal tumors
• risk potential
• treatment recommendations

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, primarily arising from the stomach. With the widespread utilization of and technical advancements in endoscopy, gastric GISTs are being increasingly detected at an early stage, enabling complete endoscopic resection. Endoscopic full-thickness resection (EFTR) is an advanced technique that has been recognized as a treatment tool for neoplasms in the digestive tract in selected patients. Although a number of methods are available, closing large iatrogenic defects after EFTR can be a concern in clinical practice. If this potential problem is appropriately solved, patients with gastric GISTs would be suitable candidates for resection utilizing this technique. To our knowledge, this is the first study to propose omental patching and purse-string endosuture closure following EFTR as a feasible endoscopic option in patients with gastric GISTs.

• Endoscopic suturing
• Endoscopic full-thickness resection
• Gastrointestinal stromal tumors
• Omentum
• Therapeutic endoscopy

• Endoscopic resection
• gastrointestinal stromal tumors
• laparoscopic resection
• meta-analysis
• systematic review

• Endoscopy
• Gastric GISTs
• Long-term outcomes

• Endoscopic submucosal dissection
• Gastric gastrointestinal stromal tumor
• Gastric-wall defect

• Adult
• Aged
• Cohort Studies
• Endoscopic Mucosal Resection/adverse effects
• Endoscopic Mucosal Resection/methods
• Female
• Follow-Up Studies
• Gastric Mucosa/surgery
• Gastrointestinal Stromal Tumors/surgery
• Gastroscopy/methods
• Humans
• Male
• Middle Aged
• Muscle, Smooth/pathology
• Postoperative Complications/epidemiology
• Retrospective Studies
• Risk Factors
• Stomach/pathology
• Stomach/surgery
• Stomach Neoplasms/surgery
• Treatment Outcome

The National Comprehensive Cancer Network recommends conservative follow-up for gastric gastrointestinal stromal tumors (GISTs) less than 2 cm. We have previously reported that the mitotic index of 22.22% of small gastric GISTs exceeded 5 per 50 high-power fields and recommended that all small gastric GISTs should be resected once diagnosed. The aim of the present study is to compare the safety and outcomes of endoscopic and open resection of small gastric GISTs. From May 2010 to March 2014, a total of 90 small gastric GIST patients were enrolled in the present study, including 40 patients who underwent surgical resection and 50 patients who underwent endoscopic resection. The clinicopathological characteristics, resection-related factors, and clinical outcomes were recorded and analyzed. The clinicopathological characteristics were comparable between the two groups except for tumor location and DOG-1 expression. Compared with the surgical resection group, the operation time was shorter (P = .000), blood loss was less (P = .000), pain intensity was lower (P < .05), duration of first flatus and defecation was shorter (P < .05), and medical cost of hospitalization was lower (P = .027) in the endoscopic resection group. The complications and postoperative hospital stay were comparable between the two groups. No in situ recurrence or liver metastasis was observed during follow-up. Endoscopic resection of small gastric GISTs is safe and feasible compared with surgical resection, although perforation could not be totally avoided during and after resection. The clinical outcome of endoscopic resection is also favorable.

AIM: To investigate the clinical characteristics and treatment methods for upper gastrointestinal submucosal tumors located in different sites.

METHODS: One hundred and fifty-nine patients with upper gastrointestinal tract submucosal tumors were included. Endoscopic submucosal dissection (ESD) was performed, and the resected lesions were subjected to pathological examination. Gender and age composition ratio, maximum diameter of lesions, operation time and the rate of complications were compared among tumors located in different sites. All patients underwent gastroscopy two and six months after operation.

RESULTS: There were 28 lesions in the esophagus, 12 in the cardia, 44 in the gastric fundus, 48 in the gastric body (including 2 cases of residual stomach), 22 in the gastric sinus, and 5 in the duodenum. Complete resection was performed in 155 (155/159, 97.5%) cases, and 154 cases were resected as a whole piece (154/159, 96.9%). In the esophagus, 16 cases were resected by submucosal tunneling endoscopic resection; in the gastric fundus, 16 cases were resected by endoscopic filtering resection. There was no significant difference in operation time between submucosal tunneling endoscopic resection and ordinary ESD for tumors in the esophagus. There was also no significant difference in operation time between endoscopic filtering resection and ordinary ESD for tumors in the gastric fundus. The pathologic diagnoses mainly included leiomyoma, stromal tumors and ectopic pancreas. The major complications were perforation, intraoperative bleeding and postoperative delayed bleeding. A total of 19 cases developed perforation and underwent endoscopic filtering resection to close the wound successfully. Intraoperative bleeding was managed successfully with electric coagulation forceps and titanium clip in all patients. The two cases with postoperative delayed bleeding were managed successfully by emergency endoscopic titanium clipping. All patients underwent gastroscopy after two and six months, which revealed that the wound healed well, and no recurrence occurred.

CONCLUSION: Upper gastrointestinal submucosal tumors located in different sites show different clinical and pathological features, and different ESD operation methods should be selected.

• Endoscopic submucosal dissection
• Upper digestive tract
• Submucosal tumor

Minimally invasive surgery has become common in the surgical resection of gastrointestinal submucosal tumors (SMTs). The purpose of this article is to review recent trends in minimally invasive surgery for gastric SMTs. Although laparoscopic resection has been main stream of minimally invasive surgery for gastrointestinal SMTs, recent advances in endoscopic procedures now provide various treatment modalities for gastric SMTs. Moreover, investigators have developed several hybrid techniques that include the advantages of both laparoscopic and endoscopic procedure. In addition, several types of reduced port surgeries, modification of conventional laparoscopic procedures, have been recently applied to the surgical resection of SMTs. Meanwhile, robotic surgery for SMTs requires further evidence and improvement.

• Minimally invasive
• Surgery
• Submucosal tumor
• Gastrointestinal tract

• Gastrectomy/adverse effects
• Gastrectomy/methods
• Gastric Mucosa/pathology
• Gastric Mucosa/surgery
• Gastroscopy/adverse effects
• Humans
• Laparoscopy/adverse effects
• Robotics
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Surgery, Computer-Assisted
• Treatment Outcome

AIM: To explore whether clinical presentations of gastric small gastrointestinal tumors (GISTs) mimics gastrointestinal dyspepsia symptoms.

METHODS: The endosonographic data of 167 patients who underwent endoscopic submucosal dissection at the Tianjin Medical University General Hospital, China between 2009 and 2011 were analyzed. GISTs and leiomyomas had a similar intragastric distribution and similar locations within the gastric wall. Therefore, patients with GISTs were chosen as the study group and those with leiomyomas were chosen as the control group. Dyspepsia symptom questionnaires were used to investigate and compare the gastrointestinal symptoms of patients with GISTs and those with gastric leiomyomas before and after endoscopic submucosal dissection (ESD). The questionnaires evaluated symptoms such as epigastric pain, heartburn, regurgitation, epigastric discomfort, nausea and vomiting, abdominal bloating, and eructation. Symptoms were assessed using a four-point scoring scale.

RESULTS: GISTs were the most common gastric submucosal lesion (67 cases, 40.12%), followed by leiomyomas (38 cases, 22.75%). Both groups were similar in terms of gender distribution (P = 0.49), intragastric location (P = 0.525), and originating layer within the gastric wall (P = 0.449), but leiomyomas were more commonly found in the proximal fundus (P < 0.05). Overall, 94.2% of the patients with small GISTs and 93.5% of those with gastric leiomyomas experienced some dyspepsia; however, total symptom scores were significantly lower in the GIST group than in the leiomyoma group (1.34 ± 1.27 vs 2.20 ± 1.70, P < 0.05). Each component of the symptom score demonstrated a statistically significant improvement in the GIST patients after ESD (P < 0.05), including epigastric pain (0.80 ± 0.90 vs 0.13 ± 0.46), heartburn (0.63 ± 1.08 vs 0.13 ± 0.41), regurgitation (0.55 ± 0.87 vs 0.22 ± 0.57), epigastric discomfort (0.70 ± 0.98 vs 0.32 ± 0.47), nausea and vomiting (0.27 ± 0.62 vs 0.05 ± 0.21), abdominal bloating (0.70 ± 0.90 vs 0.27 ± 0.49), and eructation (0.36 ± 0.61 vs 0.21 ± 0.46). For leiomyoma patients, symptoms such as heartburn, nausea, vomiting, and eructation improved after treatment; however, these improvements were not statistically significant (P > 0.05). Thus, the pathophysiology of dyspepsia symptoms may be different between the two groups.

CONCLUSION: Symptoms of gastric small GISTs may mimic those of functional dyspepsia. An alternative diagnosis should be considered in patients with functional dyspepsia and treatment failure.

• Gastric small gastrointestinal stromal tumor
• Gastric leiomyoma
• Clinical presentation
• Endoscopic ultrasonography

• Adult
• Aged
• Case-Control Studies
• Dissection/methods
• Dyspepsia/diagnosis
• Dyspepsia/etiology
• Endosonography
• Female
• Gastrointestinal Stromal Tumors/complications
• Gastrointestinal Stromal Tumors/diagnosis
• Gastrointestinal Stromal Tumors/surgery
• Gastroscopy
• Humans
• Leiomyoma/complications
• Leiomyoma/diagnosis
• Leiomyoma/surgery
• Male
• Middle Aged
• Predictive Value of Tests
• Stomach Neoplasms/complications
• Stomach Neoplasms/diagnosis
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Surveys and Questionnaires
• Tumor Burden

• Endoscopic ultrasound
• fine needle aspiration
• gastrointestinal tract
• submucosal tumor

• Endoscopic mucosal cutting biopsy
• Gastrointestinal stromal tumors
• Submucosal tumors

• Ampulla of vater
• ESD
• GIST

AIM: To evaluate the feasibility and safety of a new style of laparoscopic and endoscopic cooperative surgery (LECS), an improved method of laparoscopic intragastric surgery (LIGS) for the treatment of gastric stromal tumors (GSTs).

METHODS: Six patients were treated with the new-style LECS. Surgery was performed according to the following procedures: (1) Exposing and confirming the location of the tumor with gastroscopy; (2) A laparoscopy light was placed in the cavity using the trocar at the navel, and the other two trocars penetrated both the abdominal and stomach walls; (3) With gastroscopy monitoring, the operation was carried out in the gastric lumen using laparoscopic instruments and the tumor was resected; and (4) The tumor tissue was removed orally using a gastroscopy basket, and puncture holes and perforations were sutured using titanium clips.

RESULTS: Tumor size ranged from 2.0 to 4.5 cm (average 3.50 ± 0.84 cm). The operative time ranged from 60 to 130 min (average 83.33 ± 26.58 min). Blood loss was less than 20 mL and hospital stay ranged from 6 to 8 d (average 6.67 ± 0.82 d). The patients were allowed out of bed 12 h later. A stomach tube was inserted for 72 h after surgery, and a liquid diet was then taken. All cases had single tumors which were completely resected using the new-style LECS. No postoperative complications occurred. Pathology of all resected specimens showed GST: no cases of implantation or metastasis were found.

CONCLUSION: New-style LECS for GSTs is a quick, optimized, fast recovery, safe and effective therapy.

• Laparoscopic and endoscopic cooperative surgery
• Gastric stromal tumor

• Adult
• Blood Loss, Surgical
• Enteral Nutrition
• Feasibility Studies
• Female
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Gastrointestinal Stromal Tumors/pathology
• Gastrointestinal Stromal Tumors/surgery
• Gastroscopy/adverse effects
• Humans
• Laparoscopy/adverse effects
• Length of Stay
• Male
• Middle Aged
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Suture Techniques
• Time Factors
• Treatment Outcome
• Tumor Burden

Gastrointestinal stromal tumor is the most common mesenchymal tumor in the gastrointestinal tract and is most frequently developed in the stomach in the form of submucosal tumor. The incidence of gastric gastrointestinal stromal tumor is estimated to be as high as 25% of the population when all small and asymptomatic tumors are included. Because gastric gastrointestinal stromal tumor is not completely distinguished from other submucosal tumors, a surgical excisional biopsy is recommended for tumors >2 cm. The surgical principles of gastrointestinal stromal tumor are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles. Laparoscopic surgery has been indicated for gastrointestinal stromal tumors <5 cm, and the indication for laparoscopic surgery is expanded to larger tumors if the above mentioned surgical principles can be maintained. A simple exogastric resection and various transgastric resection techniques are used for gastrointestinal stromal tumors in favorable locations (the fundus, body, greater curvature side). For a lesion at the gastroesophageal junction in the posterior wall of the stomach, enucleation techniques have been tried preserve the organ's function. Those methods have a theoretical risk of seeding a ruptured tumor, but this risk has not been evaluated by well-designed clinical trials. While some clinical trials are still on-going, neoadjuvant imatinib is suggested when marginally unresectable or multiorgan resection is anticipated to reduce the extent of surgery and the chance of incomplete resection, rupture or bleeding.

• Gastrointestinal stomal tumors
• Laparoscopy
• Neoadjuvant therapy
• Surgery

AIM: To investigate the feasibility and safety of the treatment of an upper gastrointestinal (GI) submucosal tumor with endoscopic submucosal dissection (ESD).

METHODS: A total of 20 patients with esophageal and gastric submucosal tumors emerged from the muscular layer identified by endoscopic ultrasonography were collected from January 2009 to June 2010. Extramural or dumbbell-like lesions were excluded by an enhanced computerized tomography (CT) scan. All patients had intravenous anesthesia with propofol and then underwent the ESD procedure to resect these submucosal tumors. The incision was closed by clips as much as possible to decrease complications, such as bleeding or perforation, after resection of the tumor. All the specimens were collected and evaluated by hematoxylin, eosin and immunohistochemical staining, with antibodies against CD117, CD34, desmin, α-smooth muscle actin and vimentin to identify the characteristics of the tumors. Fletch’s criteria was used to evaluate the risk of gastrointestinal stromal tumors (GISTs). All patients underwent a follow-up endoscopy at 3, 6 and 12 mo and CT scan at 6 and 12 mo.

RESULTS: The study group consisted of 5 men and 15 women aged 45-73 years, with a mean age of 60.2 years. Three tumors were located in the esophagus, 9 in the gastric corpus, 4 in the gastric fundus, 3 lesions in the gastric antrum and 1 in the gastric angulus. Apart from the one case in the gastric angulus which was abandoned due to being deeply located in the serosa, 94.7% (18/19) achieved complete gross dissection by ESD with operation duration of 60.52 ± 30.32 min. The average maximum diameter of tumor was 14.8 ± 7.6 mm, with a range of 6 to 30 mm, and another lesion was ligated by an endoscopic ligator after most of the lesion was dissected. After pathological and immunohistochemical analysis, 12 tumors were identified as a GI stromal tumor and 6 were leiomyoma. Mitotic count of all 12 GIST lesions was fewer than 5 per 50 HPF and all lesions were at very low (9/12, 75.0%) or low risk (3/12, 25.0%) according to Fletch’s criteria. Procedure complications mainly included perforation and GI bleeding; perforation occurred in 1 patient and conservative treatment succeeded by a suturing clip and no post-operative GI bleeding occurred. All patients were followed up for 6.5 ± 1.8 mo (range, 3-12 mo) by endoscopy and abdominal CT. Local recurrence and metastasis did not occur in any patient.

CONCLUSION: ESD shows promise as a safe and feasible technique to resect esophageal and gastric submucosal tumors and the incidence of complications was very low. Clinical studies with more subjects and longer follow-up are needed to confirm its treatment value.

• Endoscopic submucosal dissection
• Stromal tumors
• Leiomyoma
• Upper gastrointestinal tract

Gastric subepithelial tumors are usually asymptomatic and observed incidentally during endoscopic examination. Although most of these tumors are considered benign, some have a potential for malignant transformation, particularly those originating from the muscularis propria layer. For this type of tumor, surgical resection is the standard treatment of choice. With recent advent of endoscopic resection techniques and devices, endoscopic submucosal dissection (ESD) has been considered as an alternative way of treatment. The aim of this study is to demonstrate the feasibility of a modified ESD technique with enucleation for removal of gastric subepithelial tumors originating from the muscularis propria layer, and to evaluate its efficacy and safety.

From November 2009 to May 2011, a total of 16 patients received a modified ESD with enucleation for their subepithelial tumors. All tumors were smaller than 5 cm and originated from the muscularis propria layer of the stomach, as shown by endoscopic ultrasonography (EUS). The procedure was conducted with an insulated-tip knife 2. Patient’s demographics, tumor size and pathological diagnosis, procedure time, procedure-related complication, and treatment outcome were reviewed.

Fifteen of the sixteen tumors were successful complete resection. The mean tumor size measured by EUS was 26.1 mm (range: 20–42 mm). The mean procedure time was 52 minutes (range: 30–120 minutes). Endoscopic features of the 4 tumors were pedunculated and 12 were sessile. Their immunohistochemical diagnosis was c-kit (+) stromal tumor in 14 patients and leiomyoma in 2 patients. There was no procedure-related perforation or overt bleeding. During a mean follow up duration of 14.8 months (range: 6–22 months), there was no tumor recurrence or metastasis.

Using a modified ESD with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer and larger than 2 cm, complete resection can be successfully performed without serious complication. It is a safe and effective alternative to surgical therapy for these tumors of 2 to 5 cm in size.

AIM: To investigate the clinical characteristics, diagnosis, treatment and prognosis of gastrointestinal stromal tumors (GISTs) of the stomach.

METHODS: The clinical and pathological data for 114 patients with GISTs of the stomach who were treated from January 2005 to September 2010 at Wuhan Union Hospital were analyzed retrospectively.

RESULTS: GISTs of the stomach were mainly located in the cardia or fundus (53.5%) and the stomach body (36.8%). The common presenting symptoms included gastrointestinal hemorrhage and abdominal pain. EUS and CT had a high accuracy of preoperative diagnosis. Pathological and immunohistochemical examinations were necessary for a clear diagnosis. All but one patient received complete surgical resection. Immunohistochemistry demonstrated that tumor cells were positive for CD117 in 112 cases (98.2%) and for CD34 in 105 cases (92.1%). The follow-up period ranged from 3 to 68 months, with a mean value of 26.2 months. Twenty-four cases received imatinib mesylate after surgery. The 5-year survival rate and tumor-free survival rate were 100% and 98.0%, respectively.

CONCLUSION: Gastric GISTs have atypical clinical features. EUS and CT are effective diagnostic methods. Surgery is the main therapy and targeted therapy can significantly improve the survival of patients with gastric GISTs.

• Gastrointestinal stromal tumors
• Stomach
• Surgical procedure
• Imatinib mesylate
• Prognosis

• Colonoscopy
• Dissection/methods
• Gastrointestinal Stromal Tumors/surgery
• Humans
• Male
• Middle Aged
• Rectal Neoplasms/surgery