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1
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Stiekema J, Luttikhold J, Heineman D, Neerincx M, Daams F. Minimally invasive technique for gastric GIST at challenging locations: single incision surgical gastroscopy. Updates Surg 2023; 75:953-958. [PMID: 37004654 PMCID: PMC10284978 DOI: 10.1007/s13304-023-01484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/23/2023] [Indexed: 04/04/2023]
Abstract
Organ sparing resection of gastrointestinal stromal tumors (GISTs) located in the proximal stomach or esophagogastric junction can be challenging, resulting in proximal or total gastrectomy to facilitate a radical resection without tumor spill. We developed and evaluated a single incision surgical gastroscopy (SISG) procedure to provide a technically feasible alternative for the removal of gastric GISTs at these challenging locations. We developed an endoluminal resection of gastric GISTs through a small single abdominal incision and longitudinal ventral gastrotomy. Patients with a proximal tumor location, in whom a wedge resection was deemed challenging on pre-operative investigation were included in the current series. Safety, short-term oncological and surgical outcome were evaluated. We performed SISG in six consecutive patients with histopathological proven or suspected gastric GIST. In all patients, the procedure was performed successfully with no tumor rupture. The mean operative time was 61 min and there were no significant complications. Pathological examination showed a microscopically radical resection in all patients. Single incision surgical gastroscopy is a feasible technique with excellent short-term oncological and surgical outcomes. This technique serves as a good alternative for complicated resections for gastric GISTs at challenging locations.
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Affiliation(s)
- Jurrien Stiekema
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Joanna Luttikhold
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - David Heineman
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Maarten Neerincx
- Department of Gastroenterology and Hepatology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
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2
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Storm AC, AbiMansour JP, Bofill-Garcia A, Mahmoud T, Rapaka B, Lescalleet KE, Dayyeh BKA. Use of an intragastric trocar to perform a novel stapling procedure for reflux disease. Endosc Int Open 2022; 10:E1508-E1513. [PMID: 36397862 PMCID: PMC9666069 DOI: 10.1055/a-1933-6573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
Background and study aims A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure. Materials and methods Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days. Results The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm 2 /mmHg, 2.7 ± 0.7 mm 2 /mmHg post-procedurally, and 3.0 ± 0.8mm 2 /mmHg on day 14. Average change in distensibility pre- and post-procedure was -2.3 ± 1.8 mm 2 /mmHg (95 % confidence interval [CI] -0.5 to 5.1, P = 0.08) while change in pre- and day 14 distensibility was -2.0 ± 1.4 mm 2 /mmHg (95 % CI -0.1 to 4.2, P = 0.06). Conclusions An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days.
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Affiliation(s)
- Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Developmental Endoscopy Unit, Mayo Clinic, Rochester, Minnesota, United States
| | - Jad P. AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Aliana Bofill-Garcia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristin E. Lescalleet
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Yahya Z, Liu DS, Foo G, Aly A. Transgastric laparoendoscopic approach to tumours of the stomach. ANZ J Surg 2021; 92:759-763. [PMID: 34704328 DOI: 10.1111/ans.17314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/19/2021] [Accepted: 10/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is currently limited data to reassure the technical efficacy, particularly in attaining clear margins, through a transgastric laparo-endoscopic approach to resecting tumours located near the gastroesophageal junction (GOJ) or the pylorus. METHODS Single institution retrospective analysis of all cases from 1 April 2008 to 31 Dec 2019. RESULTS Overall, 34 patients (38 tumours) underwent transgastric laparo-endoscopic resection. Of these, 27 (71.1%) and 5 (14.7%) cases were located close to the GOJ and pylorus respectively. Three (8.0%) cases were converted to conventional laparoscopic excision. No anatomical gastric resection was required. The mean (SD) operative time was 167.5 (64.2) minutes and reduced with increasing experience. The median (IQR) length-of-stay was 3.0 (3.0-4.5) days. Major post-operative complication (Clavian-Dindo ≥3) occurred in 1 (2.9%) patient, which required surgical control of staple line bleeding. The most common pathology was gastrointestinal stromal tumour (71.1%), followed by leiomyoma (10.5%), schwannoma (5.2%), dysplastic polyp (5.2%), and neuroendocrine tumour (2.6%). The mean (SD) tumour diameter was 3.9 (2.1) cm (largest 10.1 cm, 10 cases >5 cm). Resection margins were clear in all cases. We found no evidence of tumour recurrence or gastric stenosis at a median follow-up of 88 months. CONCLUSION Transgastric laparo-endoscopic resection of junctional and pyloric tumours with low metastatic potential is technically feasible. This approach achieved clear resection margins in all our cases, with acceptable perioperative and longer-term outcomes.
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Affiliation(s)
- Zarif Yahya
- Department of Surgery, Upper GI Surgery Unit, Austin Health, Heidelberg, Victoria, Australia
| | - David S Liu
- Department of Surgery, Upper GI Surgery Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Gary Foo
- Department of Surgery, Upper GI Surgery Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Ahmad Aly
- Department of Surgery, Upper GI Surgery Unit, Austin Health, Heidelberg, Victoria, Australia
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Zhang H, Chen J, Chen C. The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis. J Minim Access Surg 2021; 17:147-152. [PMID: 33723177 PMCID: PMC8083734 DOI: 10.4103/jmas.jmas_294_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Objectives The objective was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery. Methods The randomised controlled trials (RCTs), which are about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours were searched from the PubMed (1998-1990-2018.6), Wanfang Data (1990-2018.6), China National Knowledge Infrastructure (1979-2018.6) and International Statistical Institute (1998-2018.6). The data were extracted from these trials, and the meta-analysis was made through from RevMan 5.3 software. Results Six RCTs involving 451 patients were included in the study (227 patients in the laparoscopy combined with gastroscopy positioning group and 224 patients in laparoscopic surgery group). Compared with laparoscopic surgery group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could shorten the post-operation hospital stay (P < 0.05) and reduce the intraoperative blood loss (P < 0.05). However, there was no significant difference in others between the two groups, such as operation time (P > 0.05), post-operative time of recovery of intestinal peristalsis (P > 0.05) and the total hospital stay (P > 0.05). Conclusion Compared with laparoscopic surgery group, the better total effect occurs in laparoscopy combined with gastroscopy positioning group for the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.
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Affiliation(s)
- Hu Zhang
- Department of General Surgery, Xintai City People's Hospital, Xintai, Shandong Province, China
| | - Jie Chen
- Department of Intensive Care Unit, Xintai City People's Hospital, Xintai, Shandong Province, China
| | - Chen Chen
- Chinese Center for Disease Control and Prevention, Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Beijing, China
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Zhang H, Chen J, Chen C. Comparison of laparoscopy combined with gastroscopy positioning and open resection for gastric stromal tumours: A meta-analysis. J Minim Access Surg 2020; 16:298-307. [PMID: 32978349 PMCID: PMC7597880 DOI: 10.4103/jmas.jmas_269_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Objectives The aim of the study was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery. Methods I searched the randomized controlled trials (RCTs) about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours from the PubMed (1998~2018.06), Wanfang Data (1990~2018.06), China National Knowledge Infrastructure (1979~2018.06) and International Statistical Institute (1998~2018.06). I extracted the data from these trials, and I got the meta-analysis from RevMan 5.3 software. Results Twenty-six RCTs involving 1710 patients were included (870 patients in the laparoscopy combined with gastroscopy positioning group and 840 patients in openresection group). Compared with open resection group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could reduce the intraoperative blood (P < 0.05), shorten the post-operative time of recovery of intestinal peristalsis (P < 0.05), shorten the diet recovery time (P < 0.05), reduce the incidence of the incision infection, intestinal obstruction and pneumonia and also shorten the post-operation hospital stay (P < 0.05). However, there was no significant difference in the operation time (P > 0.05). Conclusion Compared with open resection group, the total effect of laparoscopy combined with gastroscopy positioning group in the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.
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Affiliation(s)
- Hu Zhang
- Department of General Surgery, No.1329, Xinfu Road, Xinfu Road, Xintai City People's Hospital, Xintai, Shandong Province, China
| | - Jie Chen
- Department of Intensive Care Unit, Xintai City People's Hospital, Xintai, Shandong Province, China
| | - Chen Chen
- Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
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Laparoscopic Transgastric Resection of a Gastrointestinal Stromal Tumor and Concomitant Sleeve Gastrectomy: a Case Report. Obes Surg 2020; 30:1596-1599. [PMID: 32060851 DOI: 10.1007/s11695-020-04472-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Incidences of obesity, obesity surgeries, and gastric submucosal tumors (GST) have increased worldwide. This case report aims to demonstrate that concomitant laparoscopic transgastric resection (LTGR) of a gastrointestinal stromal tumor (GIST) near the esophagogastric junction (EGJ) can be performed safely and effectively in a patient with morbid obesity and scheduled sleeve gastrectomy (SG). METHODS The patient was planned to undergo SG surgery after the diagnosis of morbid obesity (BMI, 40.4 kg/m2). The routine preoperative endoscopic examination revealed a 4-cm diameter GIST-compatible lesion in the stomach near the EGJ. The LTGR with concomitant SG was scheduled for the patient. RESULTS The ports were placed for laparoscopic SG. Greater curvature and gastric fundus were fully mobilized. Along the greater curvature gastrotomy was performed, and thus the tumor was localized. The tumor was resected with a linear stapler by considering surgical margins. The frozen section examination showed no malignancy. The gastrotomy was closed, and the SG was performed via the orogastric tube (39F). In the postoperative passage X-ray, there was no stenosis or leaking, and the patient was externed on the third postoperative day. In the immunohistochemical examination, it was reported that the tumor was a GIST, and the surgical margins were negative. CONCLUSION The LTGR may help to protect the stomach or minimize the degree of partial resection in the treatment of especially GSTs near the EGJ.
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Villano AM, Lofthus A, Watson TJ, Haddad NG, Marshall MB. Minimally Invasive Intragastric Approach to Gastroesophageal Junction Disease. Ann Thorac Surg 2018; 107:412-417. [PMID: 30315795 DOI: 10.1016/j.athoracsur.2018.08.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/02/2018] [Accepted: 08/20/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND A minimally invasive intragastric approach to the gastroesophageal junction (GEJ) allows resection of intramural disease while avoiding disruption of the lower esophageal sphincter and vagus nerves. Few surgeons use this approach; thus little is known regarding its indications, feasibility, technical aspects, complication profile, and long-term outcomes. This study reviewed the experience with this technique. METHODS A retrospective review was performed of a prospectively maintained, Institutional Review Board-approved database covering the period from January 1, 2005 to August 1, 2017. Indications, operative details, postoperative complications, and outcomes were assessed. RESULTS There were 12 patients identified. The mean age of these patients was 51.9 years. The indications for resection included 10 symptomatic leiomyomas, one gastrointestinal stromal tumor, and three cancers of the GEJ. Mean and median length of stay were 4.9 and 2.5 days, respectively. There were two postoperative esophageal leaks managed with laparoscopic repair. Of the 3 patients with cancer, 2 underwent an R0 resection, whereas 1 patient underwent an R1 resection. There were no other complications or recurrences. Mean follow-up was 6.0 years (range, 0.5 to 12.6 years); no patients had stricture or symptomatic gastroesophageal reflux on long term follow-up. CONCLUSIONS Resection of selected intramural GEJ disorders through a minimally invasive transgastric approach can be performed safely with acceptable morbidity and good long-term results. The approach allows preservation of the lower esophageal sphincter and vagus nerves, a potential advantage compared with other surgical alternatives to resection in this region.
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Affiliation(s)
- Anthony M Villano
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
| | - Alexander Lofthus
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Thomas J Watson
- Department of Thoracic Surgery, MedStar-Georgetown University Hospital, Washington, DC; Regional Department of Surgery and Thoracic Surgery, MedStar Health, Washington, DC
| | - Nadim G Haddad
- Department of Gastroenterology, MedStar-Georgetown University Hospital Washington, DC
| | - M Blair Marshall
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; Department of Thoracic Surgery, MedStar-Georgetown University Hospital, Washington, DC
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8
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Response to Comment on "Laparoscopic Intragastric Resection: An Alternative Technique for Minimally Invasive Treatment of Gastric Submucosal Tumors". Ann Surg 2018; 270:e28-e29. [PMID: 30256227 DOI: 10.1097/sla.0000000000003063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Qiu G, Wang J, Che X, He S, Wei C, Li X, Pang K, Fan L. Laparoscopic Versus Open Resection of Gastric Gastrointestinal Stromal Tumors Larger Than 5 cm: A Single-Center, Retrospective Study. Surg Innov 2017; 24:582-589. [PMID: 28933252 DOI: 10.1177/1553350617731402] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The technical feasibility and oncological safety of laparoscopic surgery for gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm has not been adequately studied. Therefore, we performed this retrospective study to investigate the clinical outcomes of gastric GIST patients treated with laparoscopic surgery compared with those who underwent open surgery. METHODS We retrospectively evaluated the outcomes of 48 consecutive patients who underwent gastric resection for gastric GISTs larger than 5 cm. The patients were divided into 2 groups based on the surgery performed: the laparoscopic resection group (LAPG) and the open resection group (OG). We assessed all available patient data, including baseline information, tumor characteristics, surgical outcomes, pathological results, postoperative complications, and long-term patient survival. RESULTS The 2 groups had similar baseline data. No differences were found in tumor size, location, mitotic count, and risk grade according to Fletcher's risk classification. The LAPG was superior to the OG in blood loss, time to first flatus, time to oral intake, and length of postoperative hospital stay. Perioperative complications, recurrence rate, and long-term survival, however, did not differ significantly between the groups. The mean operation time in the LAPG was 28 minutes longer than that in the OG. CONCLUSIONS In patients with primary gastric GISTs larger than 5 cm, laparoscopic resection is a technically feasible and oncologically safe surgery when performed by experienced surgeons.
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Affiliation(s)
- Guanglin Qiu
- 1 The First Affiliated Hospital Medical College of Xi'an Jiaotong University, Shaanxi Province, China
| | - Jing Wang
- 2 Baoji Central Hospital, Shaanxi Province, China
| | - Xiangming Che
- 1 The First Affiliated Hospital Medical College of Xi'an Jiaotong University, Shaanxi Province, China
| | - Shicai He
- 1 The First Affiliated Hospital Medical College of Xi'an Jiaotong University, Shaanxi Province, China
| | - Chao Wei
- 3 Xi'an Health School, Shaanxi Province, China
| | - Xuqi Li
- 1 The First Affiliated Hospital Medical College of Xi'an Jiaotong University, Shaanxi Province, China
| | - Ke Pang
- 4 Shaanxi Friendship Hospital, Shaanxi Province, China
| | - Lin Fan
- 1 The First Affiliated Hospital Medical College of Xi'an Jiaotong University, Shaanxi Province, China
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Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications. Surg Laparosc Endosc Percutan Tech 2017; 27:e116-e120. [PMID: 28731956 DOI: 10.1097/sle.0000000000000446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance. METHODS We detail our technique and report a unique application of this versatile approach. RESULTS Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed. CONCLUSIONS Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.
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Ojima T, Nakamura M, Nakamori M, Takifuji K, Hayata K, Katsuda M, Takei Y, Yamaue H. Laparoscopic and endoscopic cooperative surgery is a feasible treatment procedure for intraluminal gastric gastrointestinal stromal tumors compared to endoscopic intragastric surgery. Surg Endosc 2017; 32:351-357. [DOI: 10.1007/s00464-017-5683-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/19/2017] [Indexed: 12/14/2022]
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Kanehira E, Kanehira AK, Tanida T, Takahashi K, Sasaki K. Percutaneous endoscopic intragastric surgery: an organ preserving approach to submucosal tumors at esophagogastric junction. Transl Gastroenterol Hepatol 2017; 2:48. [PMID: 28616604 DOI: 10.21037/tgh.2017.05.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 04/07/2017] [Indexed: 12/12/2022] Open
Abstract
As an organ preserving option in the treatment of submucosal tumor found at the esophagogastric junction (EGJ), percutaneous endoscopic intragastric surgery (PEIGS) plays an important role, while it is not commonly performed and there have been very few reports on this unique operation. The current authors have been performing PEIGS since 1993 and have reported on its short- and long-term outcomes from one of the world largest series. Herein its confusing terminology is discussed and techniques of three different types of PEIGS (original PEIGS, single incision PEIGS, and needlescopic PEIGS) are precisely described. Although reports on clinical outcomes of PEIGS have been rarely published, both short-term and long-term outcomes seem acceptable, as far as we review our own experiences and the past literatures. PEIGS needs to be accessed by the data from larger series or RCT to be further justified and spread for the patients with submucosal tumors at EGJ to salvage their stomach.
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Affiliation(s)
- Eiji Kanehira
- Department of Surgery, Medical Topia Soka, Soka, Japan
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Xiong H, Wang J, Jia Y, Ye C, Lu Y, Chen C, Shen J, Chen Y, Zhao W, Wang L, Zhou J. Laparoscopic surgery versus open resection in patients with gastrointestinal stromal tumors: An updated systematic review and meta-analysis. Am J Surg 2017; 214:538-546. [PMID: 28412996 DOI: 10.1016/j.amjsurg.2017.03.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/11/2017] [Accepted: 03/21/2017] [Indexed: 12/17/2022]
Abstract
PURPOSES The contemporary surgery has reported the safety of laparoscopic surgery (LAP) for patients with gastrointestinal stromal tumors (GISTs). However, its use is still debated due to suspicion of the oncologic equivalence to open surgery (OPEN). We conducted a systematic review and meta-analysis of updated original articles to investigate the short- and long-term clinical outcomes of LAP compared with OPEN for GISTs. METHODS A systematic search was performed in PubMed, Embase, Web of Science, Cochrane Library and CNKI. Comparative studies of laparoscopic and open surgery for GISTs were published before November 2016. The Newcastle-Ottawa scale was utilized to conduct quality assessment. The Review Manager (RevMan) software version 5.0 was used for meta-analysis. RESULTS Twenty-four studies involving 2140 patients were included for the meta-analysis. The meta-analysis results showed that, compared with OPEN, LAP indicated potentially favorable outcomes in terms of operative time (WMD, -30.71; 95% CI, -58.48 to -2.95; P = 0.03); intraoperative blood loss (WMD, -60.90; 95% CI, -91.53 to -30.28; P < 0.0001); time to flatus (WMD, -1.10; 95% CI, -1.41 to -0.79; P < 0.00001); time to oral intake (WMD, -1.25; 95% CI, -1.64 to -0.86; P < 0.00001); length of hospital stay (WMD, -3.42; 95% CI, -4.37 to -2.46; P < 0.00001); overall complications (OR, 0.38; 95% CI, 0.27 to 0.54; P < 0.00001); and recurrence (OR, 0.45; 95% CI, 0.30 to 0.66; P < 0.0001). CONCLUSIONS Laparoscopic surgery is safe and feasible for the treatment of GISTs including less operative time and intraoperative blood loss, earlier postoperative recovery, shorter hospital stay, and lower rate of overall complications and recurrence.
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Affiliation(s)
- Hanchu Xiong
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Ji Wang
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yunlu Jia
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Chenyang Ye
- Cancer Institute (Key Laboratory of Cancer Prevention & Intervention, National Ministry of Education), Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yi Lu
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Cong Chen
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Jianguo Shen
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yongxia Chen
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Wenhe Zhao
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Linbo Wang
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China.
| | - Jichun Zhou
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China; Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Hangzhou, Zhejiang, China.
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Kim HG, Ryu SY, Yun SK, Kim DY. Surgical Outcomes of Laparoscopic Resection for Subepithelial Lesions on the Gastric Fundus Performed in the Supine or Lateral Decubitus Position. J Laparoendosc Adv Surg Tech A 2017; 28:962-966. [PMID: 28191859 DOI: 10.1089/lap.2016.0547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Laparoscopic resection of gastric subepithelial lesions (SELs) located on the posterior wall of the gastric fundus is technically difficult and time-consuming. To facilitate access, we propose performing the laparoscopic procedure with patients in a right lateral decubitus position, rather than the standard supine position. The aim of our study was to compare operative and clinical outcomes for laparoscopic SEL resection performed in either the right lateral decubitus or the traditional supine position. METHODS The analysis was based on the data of 62 patients who underwent laparoscopic resection of SELs of the gastric fundus at Chonnam National University Hospital: 30 patients in the supine position (SUP) group and 32 in the right lateral decubitus position (RLD) group. All surgeries were performed by a single surgeon. Between-group comparisons were evaluated by Student's t, chi-squared, or Fisher's least squared tests, as appropriate for the data set. RESULTS Compared with the SUP group, the RLD had shorter operative time (103 minutes versus 52 minutes, P < .001), less intraoperative blood loss (71 mL versus 31 mL, P < .001), and lower C-reactive protein levels on postoperative days 1 and 2 (P < .005). Time to first flatus and length of hospital stay were comparable between groups. CONCLUSION Laparoscopic gastric wedge resection for SELs on the gastric fundus in the right lateral decubitus position is feasible and safe, and provides operative advantages over the supine position.
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Affiliation(s)
- Ho Goon Kim
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Medical School , Gwangju, Korea
| | - Seong Yeob Ryu
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Medical School , Gwangju, Korea
| | - Sang Kwon Yun
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Medical School , Gwangju, Korea
| | - Dong Yi Kim
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Medical School , Gwangju, Korea
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Ntourakis D, Mavrogenis G. Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status. World J Gastroenterol 2015; 21:12482-12497. [PMID: 26604655 PMCID: PMC4649131 DOI: 10.3748/wjg.v21.i43.12482] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/15/2015] [Accepted: 10/17/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors. METHODS A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach. RESULTS The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described. CONCLUSION Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.
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17
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Mino JS, Guerron AD, Monteiro R, El-Hayek K, Ponsky JL, Patil DT, Walsh RM. Long-term outcomes of combined endoscopic/laparoscopic intragastric enucleation of presumed gastric stromal tumors. Surg Endosc 2015; 30:1747-53. [PMID: 26275537 DOI: 10.1007/s00464-015-4416-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/06/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE Definitive surgical treatment of gastric myogenic neoplasms such as gastrointestinal stromal tumors (GISTs) typically involves full-thickness resection of the lesion with normal gastric wall as the margin. This is not readily possible with proximal gastric lesions near the gastroesophageal junction, nor necessary for small incidental lesions. We have employed a combined endoscopic/laparoscopic intraluminal enucleation technique for selected patients and report long-term surveillance following this novel technique. METHODS Retrospective review of patients who have undergone intraluminal laparoscopic resection from 1994 to 2008. RESULTS Fifteen patients who underwent intraluminal enucleation were followed up for a median of 61 months. There were eight men and seven women with a mean age of 62.1 ± 3.38 years. Eight patients (53 %) underwent endoscopy for gastrointestinal bleeding, six for dyspepsia (40 %), six for anemia (40 %), and four for abdominal pain (27 %). Eight lesions (53 %) were located in the fundus/cardia: six (40 %) in the body and two (13 %) in the antrum. The mean tumor size was 3.5 ± 0.45 (1.5-7.0) cm. GIST lesions with benign histologic features predominated. All operations were successfully completed, including full-thickness resections with no conversion to open procedure, major morbidity, or mortality. Complete endoscopic and endosonographic surveillance was accomplished in 14 patients with no local or distant recurrence and no symptomatic follow-up in any patient. CONCLUSION Enucleation of intact gastrointestinal stromal tumors can be accomplished with low risk of recurrence when done with a combined endoscopic/laparoscopic intraluminal technique. It should be the preferred approach considered for small, proximal, intraluminal tumors.
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Affiliation(s)
- Jeffrey S Mino
- Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Alfredo D Guerron
- Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rosebel Monteiro
- Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kevin El-Hayek
- Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of General Surgery, Cleveland Clinic Foundation, Abu Dhabi, United Arab Emirates
| | - Jeffrey L Ponsky
- Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Deepa T Patil
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Wang YN, Li YM, Lu XF. Value of submucosal tunneling endoscopic resection in treatment of upper gastrointestinal muscularis propria tumors. Shijie Huaren Xiaohua Zazhi 2015; 23:793-799. [DOI: 10.11569/wcjd.v23.i5.793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the feasibility and safety of submucosal tunneling endoscopic resection (STER) in the treatment of upper gastrointestinal muscularis propria tumors, and the value of endoscopic ultrasonography (EUS) in pre-therapy detection of these tumors.
METHODS: All patients with muscularis propria tumors were diagnosed by EUS. Twenty-four patients were treated by STER, and the other 15 patients treated by surgery were used as controls. Clinical effects were compared for the two groups.
RESULTS: In the STER group, three patients were found to have tumors located in the muscularis mucosa and converted to other forms of treatment during operation. For the other cases, the average diameter of resected tumors was similar to that in the control group (P > 0.05). The treatment time for esophagus tumors had no significant difference between the two groups (P > 0.05). However, for stomach tumors, STER was faster than surgery (P < 0.01). Patients in the STER group needed shorter hospitalizing time (P < 0.01) and less cost (P < 0.05) compared with controls. Postoperative pathological examination demonstrated that the rate of correct preoperative diagnosis by EUS was 92.3%.
CONCLUSION: STER is safe and efficient in the treatment of upper gastrointestinal muscularis propria tumors. EUS is important in determining the tumor location and treatment manner.
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Lamm SH, Steinemann DC, Linke GR, Eucker D, Simon T, Zerz A, Stoll R. Total inverse transgastric resection with transoral specimen removal. Surg Endosc 2014; 29:3363-6. [PMID: 25539694 DOI: 10.1007/s00464-014-4037-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 11/05/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic local excision is accepted for gastrointestinal stromal tumors (GIST) and benign lesions of the stomach. Yet, tumors at the gastroesophageal junction, on the posterior wall, or in the distal antrum are difficult to approach. Such tumors often must be exposed via gastrotomy or using a rendezvous maneuver. Our method of total intragastric laparoscopic resection using 'pneumogastrum', rigid laparoscope, and conventional laparoscopic instruments is described in an intuitive video. METHODS Two cases of total inverse transgastric resection involved resection of a submucosal GIST, one at the front wall of the cardia and the other on the posterior wall of the antrum. The third case required excision of a large prepyloric cystic lesion leading to a gastric outlet stenosis. After insertion of three trocars under laparoscopic control, a further trocar was introduced into the stomach and 'pneumogastrum' was established. Two additional 5-mm trocars were intragastrally placed. Intragastric endoscopy with a rigid optic provided an excellent view. The tumor was exposed resected with a linear stapler. The specimen was inserted into an Endo Pouch™ which was sutured to an orally inserted gastric tube. The Endo Pouch™ was gently pulled transorally. After removal of the intragastric trocars, the entrance points were laparoscopically closed. RESULTS From the first and second cases, we retrieved GIST tumors. In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful. CONCLUSIONS Gastric GIST should be resected laparoscopically if negative margins are safely achieved regardless of its size. Tumors at the frontwall and exophytic backwall GIST are addressed by laparoscopic wedge resection. Tumors at the gastrojejunal junction, in the prepyloric region, and fundus as well as submucous GIST of the gastric backwall are best approached by intragastric laparoscopic resection. Transoral specimen retrieval is an interesting option in smaller tumors.
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Affiliation(s)
- Sebastian H Lamm
- Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.
| | - Daniel C Steinemann
- Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.
| | - Georg R Linke
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Dietmar Eucker
- Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland
| | - Thomas Simon
- Department of General and Visceral Surgery, Klinik Sinsheim, Alte Weibstadter Strasse 2, 74889, Sinsheim, Germany
| | - Andreas Zerz
- Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland
| | - Reinhard Stoll
- Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland
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Barajas-Gamboa JS, Acosta G, Savides TJ, Sicklick JK, Fehmi SMA, Coker AM, Green S, Broderick R, Nino DF, Harnsberger CR, Berducci MA, Sandler BJ, Talamini MA, Jacobsen GR, Horgan S. Laparo-endoscopic transgastric resection of gastric submucosal tumors. Surg Endosc 2014; 29:2149-57. [PMID: 25303921 DOI: 10.1007/s00464-014-3910-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/18/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic and endoluminal surgical techniques have evolved and allowed improvements in the methods for treating benign and malignant gastrointestinal diseases. To date, only case reports have been reported on the application of a laparo-endoscopic approach for resecting gastric submucosal tumors (SMT). In this study, we aimed to evaluate the efficacy, safety, and oncologic outcomes of a laparo-endoscopic transgastric approach to resect tumors that would traditionally require either a laparoscopic or open surgical approach. Herein, we present the largest single institution series utilizing this technique for the resection of gastric SMT in North America. METHODS We performed a retrospective review of a prospectively collected patient database. Patients who presented for evaluation of gastric SMT were offered this surgical procedure and informed consents were obtained for participation in the study. RESULTS Fourteen patients were included in this study between August/2010 and January/2013. Eight (8) patients (57.1 %) were female and the median age was 56 years (range 29-78). Of the 14 cases, 8 patients (57.1 %) underwent laparo-endoscopic resection of SMTs with transgastric extraction, 5 patients (35.7 %) had conversions to traditional laparoscopic surgery, and 1 patient (7.2 %) was abandoned intraoperatively. The median operative time for this cohort was 80 min (range 35-167). Ten patients (71.4 %) had GISTs, 3 (21.4 %) had leiomyomas, and 1 (7.1 %) had schwannoma. There were no intraoperative complications. Two patients had postoperative staple line bleeding that required repeat endoscopy. The median hospital stay was 1 day (range 1-6) and there were no postoperative mortalities. At 12-month follow-up visit, only one GIST patient (10 %) had tumor recurrence. CONCLUSION Our experience suggests that this surgical approach is safe and efficient in the resection of gastric SMT with transgastric extraction. This study found no intraoperative complications and optimal oncologic outcomes during the follow-up period. Minimally invasive surgical approaches are emerging as a valid and potentially better approach for resecting malignancies; however, continued investigation is underway to further validate this data.
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Affiliation(s)
- Juan S Barajas-Gamboa
- Center for the Future of Surgery, University of California at San Diego, 9500 Gilman Drive La Jolla, San Diego, CA, 92093, USA,
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Connor C, Pullatt R. Laparoscopic Transgastric Resection of a Gastric Polyp. Am Surg 2014. [DOI: 10.1177/000313481408000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Chelsea Connor
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
| | - Rana Pullatt
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
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Acker S, Dishop M, Kobak G, Vue P, Somme S. Laparoscopic-Assisted Endoscopic Resection of a Gastric Leiomyoma. European J Pediatr Surg Rep 2014; 2:003-6. [PMID: 25642406 PMCID: PMC4310005 DOI: 10.1055/s-0034-1370773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Leiomyomas are infrequent benign intestinal tumors that can arise at any age and location within the gastrointestinal (GI) tract. These tumors can cause symptoms including abdominal pain, obstruction, intussusception, volvulus, GI bleeding, or a mass and should be resected if symptomatic. Open surgical resection is considered the standard for removing these tumors. However, recent improvements in endoscopic and laparoscopic equipment have made it possible to utilize minimally invasive techniques of tumor removal including complete endoscopic resection or endoscopic-assisted laparoscopic resection. We present the case of an adolescent female with a large mass located at the gastroesophageal junction (GEJ) causing GI bleeding. Given the location of the mass near the GEJ and the morbidity associated with surgical resection, we performed laparoscopic-assisted complete endoscopic resection of tumor. In addition, this tumor had an unusual immunohistochemical-staining pattern, with focal expression of markers more often seen in GI stromal tumors, elucidating a gray area between these two tumor classes with potential implications for patient follow-up. Laparoscopic-assisted endoscopic resection of benign tumors is a useful technique that can be employed to facilitate resection of mucosal and subserosal masses near the GEJ with minimal morbidity.
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Affiliation(s)
- Shannon Acker
- Department of General Surgery, University of Colorado, Aurora, Colorado, United States
| | - Megan Dishop
- Department of Pediatric Pathology, University of Colorado, Aurora, Colorado, United States
| | - Gregory Kobak
- Department of Pediatric Gastroenterology, University of Colorado, Aurora, Colorado, United States
| | - Padade Vue
- Department of Pediatric Gastroenterology, University of Colorado, Aurora, Colorado, United States
| | - Stig Somme
- Department of Pediatric Surgery, University of Colorado, Aurora, Colorado, United States
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23
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Sharma S, Milsom JW, Yoo J. Can endoscopy and laparoscopy be combined to remove complex polyps? COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Sam Sharma
- New York – Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
| | - Jeffrey W Milsom
- New York – Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
| | - James Yoo
- Ronald Reagan UCLA Medical Center/David Geffen School of Medicine at UCLA, 10833 LeConte Avenue, 72-253 CHS, Los Angeles, CA 90095, USA
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Dong HY, Wang YL, Li J, Pang QP, Li GD, Jia XY. New-style laparoscopic and endoscopic cooperative surgery for gastric stromal tumors. World J Gastroenterol 2013; 19:2550-2554. [PMID: 23674858 PMCID: PMC3646147 DOI: 10.3748/wjg.v19.i16.2550] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 02/24/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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25
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Kong SH, Yang HK. Surgical treatment of gastric gastrointestinal stromal tumor. J Gastric Cancer 2013; 13:3-18. [PMID: 23610714 PMCID: PMC3627804 DOI: 10.5230/jgc.2013.13.1.3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 03/09/2013] [Accepted: 03/10/2013] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Seong-Ho Kong
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Ganai S, Prachand VN, Posner MC, Alverdy JC, Choi E, Hussain M, Waxman I, Patti MG, Roggin KK. Predictors of unsuccessful laparoscopic resection of gastric submucosal neoplasms. J Gastrointest Surg 2013; 17:244-55; discussion 255-6. [PMID: 23225195 DOI: 10.1007/s11605-012-2095-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 11/13/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome. METHODS From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months. RESULTS Patients were 62 ± 14 years and 56 % male. Mean tumor size was 5.5 ± 4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p < 0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p < 0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1-1.3; p = 0.13). CONCLUSIONS Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.
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Affiliation(s)
- Sabha Ganai
- Department of Surgery, The University of Chicago Medical Center, Chicago, IL, USA
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Desiderio J, Trastulli S, Cirocchi R, Boselli C, Noya G, Parisi A, Cavaliere D. Robotic gastric resection of large gastrointestinal stromal tumors. Int J Surg 2013; 11:191-6. [PMID: 23321346 DOI: 10.1016/j.ijsu.2013.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 12/29/2012] [Accepted: 01/04/2013] [Indexed: 02/09/2023]
Abstract
BACKGROUND The stomach is the most common site for gastrointestinal stromal tumors (GIST) development. Surgical treatment consists of excision of the entire neoplastic mass, with sufficient surgical margins within healthy tissue. This can be achieved with different techniques ranging from wedge resections, typical gastric resections, right up to total gastrectomy. There aren't clear guidelines for the use of minimally invasive approach. MATERIALS AND METHODS From January 2011 to April 2012, 5 patients with presumed preoperative diagnosis of GIST were treated by robotic surgery at the Unit of Surgery and Advanced Oncologic Therapies, Forlì Hospital, Forlì, Italy. We report operative techniques, perioperative outcomes and follow-up. RESULTS Lesions were localized at anterior wall of gastric antrum (N = 2) and near pyloric area (N = 3). Mean tumor size was 5 cm (range 4-7 cm). Surgical procedures were 5 distal gastrectomy. None intervention was converted to open surgery and there weren't major intraoperative complications. Median operative time was 240 min (range 210-300 min) and mean intraoperative blood loss was 96 ml (80-120 ml). All lesions had microscopically negative resection margins. Median follow-up was 13.5 months (range 12-15 months) with a disease-free survival rate of 100%. CONCLUSIONS Surgical robotic approach for large GISTs is feasibility and new evidences are needed to clarify the effective role of different surgical strategies.
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Affiliation(s)
- Jacopo Desiderio
- Department of Digestive Surgery and Liver Unit, St. Maria Hospital, Terni, Italy.
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De Vogelaere K, Hoorens A, Haentjens P, Delvaux G. Laparoscopic versus open resection of gastrointestinal stromal tumors of the stomach. Surg Endosc 2012; 27:1546-54. [PMID: 23233005 DOI: 10.1007/s00464-012-2622-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 09/21/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgical treatment is the only chance of cure for patients with a primary localized GIST. A laparoscopic approach has been considered reasonable for these tumors of gastric origin. The current study compares the outcome of laparoscopic versus open resection of gastric GISTs and compares our series with the few published studies comparing the open versus the laparoscopic approach. METHODS From a prospectively collected database, we found 53 primary gastric GIST resections that were performed in our department. Laparoscopic (LAP) resections were performed in 37 patients and traditional (OPEN) resections in 16 patients. Clinical and pathologic characteristics and surgical outcomes were analyzed according to surgical procedure. RESULTS Patients who underwent LAP or OPEN resection of gastric GISTs did not differ with respect to age at operation, gender, clinical presentation, and tumor size. Operative time was significantly lower for LAP than for OPEN resection, with a mean duration of 45 and 132.5 min, respectively (p < 0.001). LAP resection yielded a significantly shorter length of stay (median 7 vs. 14 days; p = 0.007) and lower 30-day morbidity rate (2.7 % vs. 18.9 %; p = 0.077). The operative mortality was 12.5 % after OPEN resection and there was no operative mortality after LAP (p = 0.087). The recurrence rate was significantly lower after LAP surgery (0 % vs. 37.5 %; p < 0.001). All patients in the LAP group are alive without recurrence, and 25 % (4/16) of the OPEN group are alive with recurrence but in complete remission under imatinib mesylate treatment. Two patients of the open group died due to progression of GIST (p = 0.087). CONCLUSIONS Compared to open resection, laparoscopic resection of gastric stromal tumors is associated with a shorter operation time, a shorter hospital stay, and a lower recurrence rate.
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Ghushe ND, Dulai PS, Trus TL. Laparoendoscopic transgastric resection of a submucosal mass at the gastroesophageal junction. J Gastrointest Surg 2012; 16:2321. [PMID: 23054899 DOI: 10.1007/s11605-012-2038-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 09/12/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Traditional management of gastric submucosal lesions usually involves wedge resection. However, lesions close to the gastroesophageal junction are difficult to manage with wedge resection without compromising the lower esophageal sphincter. This video highlights an interesting combined laparoscopic and endoscopic technique for safe resection of a submucosal lesion adjacent to the gastroesophageal junction. METHODS A 66-year-old male was evaluated by gastroenterology for melena. Upper endoscopy with subsequent endoscopic ultrasound demonstrated a 2-cm submucosal lesion adjacent to the gastroesophageal junction. Biopsies were indeterminate, and the remainder of his workup was negative. A combined laparoendoscopic technique was utilized to safely resect the lesion while protecting the gastroesophageal junction. This was accomplished using three 5-mm trocars placed directly through the abdominal wall into the stomach using endoscopic guidance. All muscle layers were resected en bloc with the specimen, leaving the serosa intact. RESULTS The patient did well and was discharged home on postoperative day 1. Final pathology demonstrated a leiomyoma with negative margins. CONCLUSION Submucosal lesions adjacent to the gastroesophageal junction can be safely and effectively managed using a laparoendoscopic approach. This technique provides improved visualization and facilitates an adequate resection compared to endoscopy or laparoscopy alone.
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Affiliation(s)
- Neil D Ghushe
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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De Vogelaere K, Van Loo I, Peters O, Hoorens A, Haentjens P, Delvaux G. Laparoscopic resection of gastric gastrointestinal stromal tumors (GIST) is safe and effective, irrespective of tumor size. Surg Endosc 2012; 26:2339-45. [PMID: 22350238 DOI: 10.1007/s00464-012-2186-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 01/19/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Feasibility and long-term safety of laparoscopic removal of gastric gastrointestinal stromal tumors (GISTs) of the stomach is well established for lesions smaller than 2 cm. Our specific aim was to explore whether laparoscopic treatment is equally applicable for gastric GISTs larger than 2 cm. METHODS Between 1997 and 2010, 31 consecutive patients presenting with a primary gastric GIST were scheduled for laparoscopic resection, irrespective of tumor size. Prerequisites for laparoscopic approach were the absence of metastases and the presence of a well-defined tumor on CT scanning without involvement of adjacent organs, the esophagogastric junction, or the pylorus of the stomach. Data were retrieved retrospectively from a prospectively collected database, including information on patient demographics, surgical procedure, complications, hospital stay, and recurrence. Diagnosis of GIST was based on microscopic analysis, including immunohistochemistry with a panel of antibodies: CD117, CD34, DOG1, S100, desmin, and smooth muscle actin. RESULTS All 31 laparoscopic resections were carried out successfully. The most common symptoms were melena, anemia, and abdominal pain. In one case we performed a laparoscopic approach for a GIST with acute bleeding. Tumor size was smaller than 2 cm in 5 patients and larger than 2 cm in 26 patients. The median tumor size was 4.4 cm (range = 0.4-11.0 cm). Median blood loss was identical in both groups (20 ml), but duration of operation (60 vs. 103 min) and duration of hospital stay (6 vs. 8 days) were lower when tumor size was less than 2 cm. Only one patient (with tumor size <2 cm) experienced a postoperative hemorrhage. After a median follow-up of 52 months, there were no recurrences or metastases. CONCLUSION The low morbidity rates and the long-term disease-free interval of 100% observed in our cohort indicate that laparoscopic resection is safe and effective in treating gastric GISTs, even for tumors larger than 2 cm.
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Affiliation(s)
- K De Vogelaere
- Department of Abdominal Surgery, Universitair Ziekenhuis Brussel, Jette, Brussel, Belgium.
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Hemoperitoneum caused by a ruptured GIST located in the posterior gastric wall managed by endoscopic diagnosis and laparoscopic treatment: case report and literature review. Surg Laparosc Endosc Percutan Tech 2011; 21:e316-8. [PMID: 22146181 DOI: 10.1097/sle.0b013e318231998b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with <1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall.
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Gayer CP, Edelman DA, Curtis B, Laker S, Webber J. Combined endoscopic and laparoscopic approach to a gastroesophageal tumor. JSLS 2011; 15:228-31. [PMID: 21902981 PMCID: PMC3148877 DOI: 10.4293/108680811x13071180406790] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Smooth muscle tumors of the stomach, especially when benign, are a common clinical entity and can represent a therapeutic challenge. Classically the removal of such a tumor requires open laparotomy. We sought to perform this surgery utilizing minimally invasive technology. METHODS We describe a minimally invasive technique combining laparoscopy with endoscopy to remove a sub-mucosal leiomyoma at the gastroesophageal junction. RESULTS A 3.3-cm smooth muscle tumor of the gastroesophageal junction was removed completely and safely with the described procedure and thus saved the patient from requiring a laparotomy. CONCLUSION Minimally invasive techniques can be used in combination to tackle difficult problems in general surgery leading to shorter hospital stays and improved patient satisfaction.
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Affiliation(s)
- Christopher P Gayer
- 4160 John R, Suite 615, Harper Professional Building, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
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Wang L, Fan CQ, Ren W, Zhang X, Li YH, Zhao XY. Endoscopic dissection of large endogenous myogenic tumors in the esophagus and stomach is safe and feasible: a report of 42 cases. Scand J Gastroenterol 2011; 46:627-33. [PMID: 21366494 DOI: 10.3109/00365521.2011.561364] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Submucosal myogenic tumors, including leiomyoma and stromal tumors, are currently treated primarily by open surgery or laparoscopic excision. The aim of this retrospective study was to evaluate the feasibility of endoscopic dissection (ED) for resecting endogenous esophageal leiomyoma (EL) and gastric stromal tumors (GSTs) with diameters of 5 cm. METHODS We enrolled 42 patients with endogenous EL and GST who had undergone endoscopic surgery (endoscopic group). These cases were compared retrospectively with 22 patients who had undergone thoracotomy or laparotomy (control group). Endoscopic group (n = 42) received ED for EL and GST resection, including circumferential removal of superficial mucosa of targeted tumor. Control group (n = 22) received thoracotomy or laparotomy for resection of esophageal and gastric myogenic tumors. Main outcome measures were operative time, intraoperative bleeding and perforation, postoperative complications, and hospital stays and costs were compared between groups. RESULTS Endogenous EL and GST were successfully removed from all patients. Bleeding and perforation occurred in seven and five EL and GST patients, respectively. Bleeding was corrected with argon plasma coagulation (APC). Perforation was endoscopically repaired with clips. Mean operative time was 49 min for endoscopic EL and 55 min for GST resection. No major bleeding or perforation occurred postoperatively. Endoscopic treatment had shorter length of stay and lower hospital costs than conventional procedures. CONCLUSIONS ED is safe and feasible for resection of endogenous EL and GST in selected cases.
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Affiliation(s)
- Lei Wang
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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Wu JM, Yang CY, Wang MY, Wu MH, Lin MT. Gasless laparoscopy-assisted versus open resection for gastrointestinal stromal tumors of the upper stomach: preliminary results. J Laparoendosc Adv Surg Tech A 2010; 20:725-9. [PMID: 20969456 DOI: 10.1089/lap.2010.0231] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Gastrointestinal stromal tumors (GISTs) are rare neoplasms with malignant potential. Surgery is the definitive management for resectable nonmetastatic lesions. Although minimally invasive resection has been established for GISTs, it is still considered unfeasible when tumors are near the esophagogastric junction. This study aimed to compare the relative efficacy of gasless laparoscopy-assisted (GLA) and open approaches for resection of GISTs. PATIENTS AND METHODS Between January 2006 and December 2008, 28 consecutive patients undergoing surgery for upper GIST were reviewed retrospectively. Among these patients, 15 underwent GLA procedures and 13 underwent open surgeries. RESULTS Patient demographics, comorbidities, and tumor characteristics (mean tumor size and prognosis) were similar for both groups. All patients underwent wedge resection. The mean operating time (129.6 versus 110.8 minutes), mean estimated blood loss (35.5 versus 40.3 mL), mean day of first flatus (2.7 versus 3.2 days), mean tumor size (2.5 versus 2.6 cm), and tumor prognosis or complication rate (13.3% versus 7.7%) between the GLA and open surgery groups were not significantly different. The length of maximal wound (P < 0.001), visual analog scale on postoperative days 1 (P = 0.001), 2 (P = 0.001), and 3 (P = 0.001), the mean time for resuming oral intake (P = 0.028), and the length of hospital stay (P = 0.005) in the GLA group were significantly lesser than the corresponding values in the open surgery group. None of the patients had dysphagia or died. CONCLUSIONS GLA method is a safe and feasible procedure for resecting GISTs of the upper stomach. In addition, it offers better cosmetic results, less pain, and faster recovery.
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Affiliation(s)
- Jin-Ming Wu
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Buchs NC, Bucher P, Pugin F, Hagen ME, Morel P. Robot-assisted oncologic resection for large gastric gastrointestinal stromal tumor: a preliminary case series. J Laparoendosc Adv Surg Tech A 2010; 20:411-5. [PMID: 20459328 DOI: 10.1089/lap.2009.0385] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Laparoscopic resection of gastric gastrointestinal stromal tumor (GIST) has been shown as feasible and safe in terms of oncologic results. However, laparoscopic resection has been demonstrated to be mainly suitable for small, favorably localized GIST. The robotic approach may, by its characteristics, enable the surgeon to perform atypical gastrectomies in an unfavorable location (i.e., close to pylorus or cardia). Its use in oncologic gastric surgery has been poorly defined and has never been reported for GIST. MATERIALS AND METHODS All patients who underwent robotic-assisted gastric resection for GIST at a single institution from 2006 to 2009 were prospectively followed-up. RESULTS There were 5 patients (3 men and 2 women), with a median age of 39 years (range, 32-74), who had a complete resection (R0). Two patients had a cardial GIST and 3 of the antrum. Median tumor sizes were of 5.5 cm (range, 4.2-7). According to Fletcher criteria, 4 tumors (80%) were classified as intermediate or high risk. No postoperative morbidity and mortality were noted. One patient had a conversion to open surgery because of a suspicion of diffuse adenocarcinoma on fresh frozen section and necessitated a total gastrectomy with a radical lymph node dissection. Median operation time was 192 minutes (range, 132-285). With a median follow-up of 18 months (range, 11-27), disease-free survival rate was 100%. CONCLUSIONS The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA) is a valuable instrument for oncologically safe resection with esogastric or duodenogastric junction preservation for an unfavorably located gastric GIST. Moreover, the three-dimensional, high-definition vision, instrument mobility, and ease of performing a difficult suturing enable a safe, large atypical gastrectomy, close to the pylorus or cardia.
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Affiliation(s)
- Nicolas C Buchs
- Department of Surgery, University Hospital Geneva, Geneva, Switzerland.
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Fernández JA, Sánchez-Cánovas ME, Parrilla P. [Controversies in the surgical treatment of primary gastrointestinal stromal tumours (GIST)]. Cir Esp 2010; 88:69-80. [PMID: 20494346 DOI: 10.1016/j.ciresp.2010.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Accepted: 01/19/2010] [Indexed: 02/06/2023]
Abstract
It is estimated that 50% of GIST are located at the time of their diagnosis. A complete surgical resection can be performed in up to 95% of these cases, making this the most important prognostic factor. This surgery must fulfil a series of technical requirements so as to be really effective, as it has to be R0, with no tumour rupture, with preservation of the pseudo-capsule, etc. Although the majority of GIST are gastric, their location in other anatomical areas, such as the oesophagus, duodenum or rectum, require the surgeon to use more complex techniques. Laparoscopy is increasingly used; however, we must avoid its use, due to there being few experienced groups or if there are large tumours. The use of neoadjuvant therapy has revived great interest by allowing to resection tumours that were once non-resectable or in very compromised anatomical locations, with less aggressive surgery. The use of pre-surgical biopsy is not exempt from serious risks, thus it should only be used for establishing a neoadjuvant treatment or if there are diagnostic doubts with other diseases in high risk patients.
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Ke CW, Cai JL, Chen DL, Zheng CZ. Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases. Surg Endosc 2010; 24:1962-8. [PMID: 20135174 DOI: 10.1007/s00464-010-0888-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 01/03/2010] [Indexed: 12/26/2022]
Abstract
BACKGROUND Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. METHODS Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. RESULTS All of the procedures were performed successfully, with mean operation time of 62.6 +/- 8.9 min and mean intraoperative blood loss of 86.2 +/- 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7-2.5 cm, with a mean distance of 1.4 +/- 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 +/- 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. CONCLUSION ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection.
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Affiliation(s)
- Chong-wei Ke
- Minimally Invasive Surgery Center, Changhai Hospital, Shanghai 200433, China.
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Gervaz P, Huber O, Morel P. Surgical management of gastrointestinal stromal tumours. Br J Surg 2009; 96:567-78. [PMID: 19434705 DOI: 10.1002/bjs.6601] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Over the past decade, gastrointestinal stromal tumours (GISTs) have served as a model for the application of tyrosine kinase inhibitors in the treatment of solid neoplasms. Operative and medical management of GISTs is rapidly evolving, but current guidelines appear restricted to basic non-organ-specific recommendations. METHODS A PubMed search was made of the English literature from 1998 to 2008 for references containing the terms 'gastrointestinal stromal tumours' and 'surgery'. This paper reviews the various operative strategies so far reported for GISTs within the digestive tract. RESULTS Many original procedures tailored to the specific characteristics of these rare sarcomas have been reported. GISTs exhibit distinct features, in particular an absence of metastases within locoregional lymph nodes. Operations requiring extended lymph node dissection, typically designed for adenocarcinomas, such as gastrectomy with extended lymph node dissection, Whipple's procedure and total mesorectum excision, are inappropriate for treating GISTs originating from the stomach, duodenum and rectum respectively. CONCLUSION GISTs allow the possibility of performing oncologically adequate but limited (wedge; segmental) resections. Such surgery can be carried out in a variety of ways, such as open, laparoscopic, trans-sacral or endoscopic.
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Affiliation(s)
- P Gervaz
- Department of Surgery, University Hospital Geneva, Geneva, Switzerland.
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Abstract
Gastrointestinal stromal tumors (GISTs) are rare neoplasms. The advent of electron microscopy and immunohistochemistry has led to the realization that these tumors originate from a pleuropotential cell known as the interstitial cell of Cajal (ICC). The morphologic features demonstrated as most predictive of recurrence or metastases are tumor size and mitotic rate. There is oncologic justification for minimally invasive resection techniques with gross margins for GISTs. Minimally invasive resection provides advantages to patients in terms of morbidity and recovery. A variety of endoscopic, laparoscopic, and hybrid techniques are described for surgically excising GISTs in different anatomic locations.
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Laparoscopic intragastric approach for stromal tumours located at the posterior gastric wall. Asian J Surg 2008; 31:6-10. [PMID: 18334462 DOI: 10.1016/s1015-9584(08)60047-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Surgical resection is indicated for gastrointestinal stromal tumour (GIST). Laparoscopic resection with clear margins is effective in gastric GIST. However, GIST located in the posterior gastric wall with close proximity to the oesophagogastric junction poses special challenges. Laparoscopic intragastric resection offers a new approach to the management of these tumours. The surgical technique, our experience and a summary of the literature are presented.
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Hwang SH, Park DJ, Kim YH, Lee KH, Lee HS, Kim HH, Lee HJ, Yang HK, Lee KU. Laparoscopic surgery for submucosal tumors located at the esophagogastric junction and the prepylorus. Surg Endosc 2008; 23:1980-7. [PMID: 18470554 DOI: 10.1007/s00464-008-9955-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 02/18/2008] [Accepted: 04/05/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic partial gastric resection is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, SMTs of either end of the stomach are generally managed by subtotal gastrectomies or total gastrectomies. This study was conducted to evaluate surgical techniques for management of SMTs located at the ends of the stomach. METHODS Among 63 patients who were diagnosed and underwent laparoscopic surgery for gastric SMTs at Seoul National University Bundang Hospital from May 2003 to May 2007, 11 SMTs located at the ends of the stomach were identified. The clinicopathologic results of these 11 SMTs were analyzed. RESULTS Laparoscopic partial wedge resections or tumor excisions were successfully performed on all patients except for those who had prepyloric tumors. Six men and five women had SMTs at the ends of the stomach. The patients ranged in age from 21-63 years (mean 43.4 +/- 13.5 years). Of six esophagogastric junctional tumors that showed low, homogeneous contrast enhancement on computed tomography (CT) scans, five were treated by laparoscopic transgastric enucleation and one by tumor-everting resection. One esophagogastric junctional tumor that leaned toward the fundus and showed a 6-cm-diameter endophytic mass with heterogeneous enhancement on CT scan was resected by laparoscopic wedge resection. The mean operation time was 100 min (range 60-210 min). Three laparoscopy-assisted distal gastrectomies and one laparoscopic wedge resection were performed on SMTs located near the prepyloric antrum. There were no intra- or postoperative complications. Duration of postoperative hospital stay ranged from 4-7 days. CONCLUSION Laparoscopic local resection is an effective treatment for SMTs located at the esophagogastric junction and can be used instead of a total or proximal gastrectomy. However, gastrectomies should be considered for SMTs located near the pylorus because of the small volume of the lower third of the stomach.
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Affiliation(s)
- Sun-Hwi Hwang
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi, Korea
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Laparoscopic gastric resection for gastrointestinal stromal tumors. Surg Endosc 2008; 22:2583-7. [PMID: 18322738 DOI: 10.1007/s00464-008-9807-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 12/02/2007] [Accepted: 01/24/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study aimed to review clinical outcomes for patients selected to undergo laparoscopic resection for gastrointestinal stromal tumor (GIST) of the stomach. METHODS All 112 laparoscopic gastric resections performed from February 1995 to March 2007 were reviewed. Pre- and postoperative variables were analyzed, and data are given as mean +/- standard deviation. RESULTS Laparoscopic gastric resection was attempted for 63 GIST in 61 patients (31 men and 30 women) with a mean age was 59.1 +/- 19 years. The tumors were located at the fundus (n = 19), antrum (n = 18), body (n = 17), gastroesophageal junction/cardia (n = 7), and pylorus (n = 2). Common presentations were upper gastrointestinal bleed (n = 29) and incidental finding on esophagogastroduodenoscopy (n = 17). The laparoscopic procedures performed were partial gastrectomy (n = 52), antrectomy (n = 4), esophagogastrectomy (n = 3), and endoscopically assisted and/or transgastric resection (n = 3). There was one conversion to open procedure for control of bleeding from the spleen. The mean tumor size was 3.8 +/- 1.8 cm. Negative surgical margins were achieved in all but one case. The mean operative time was 151.9 +/- 67.3 min, and the mean estimated blood loss was 97.4 +/- 200.7 ml. A regular diet was resumed at a mean of 2.9 +/- 1.6 days, and the mean length of hospital stay was 3.9 +/- 2.2 days. The perioperative complication rate was 16.4% including deep vein thrombosis postoperative bleed, anastomotic stricture, and incisional hernia. One mortality occurred, due to respiratory failure. The GISTs included 48 rated as low risk, six rated as intermediate risk, and nine rated as high malignant potential. At a mean follow-up period of 15 +/- 21.8 months (range, 0-103 months), three of nine patients with high malignant potential GIST experienced, respectively, metastatic disease to the liver, liver and lung, and peritoneum. At this writing, all the other patients are disease free. CONCLUSIONS Laparoscopic gastric resection for GIST is a feasible option. Adequate oncologic resection was achieved with 98.4% of patients chosen for laparoscopic resection. Resection margin positivity and recurrence rates are low after laparoscopic approaches for appropriately selected patients with GIST, demonstrating favorable characteristics.
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Catena F, Di Battista M, Fusaroli P, Ansaloni L, Di Scioscio V, Santini D, Pantaleo M, Biasco G, Caletti G, Pinna A. Laparoscopic treatment of gastric GIST: report of 21 cases and literature's review. J Gastrointest Surg 2008; 12:561-568. [PMID: 18040747 DOI: 10.1007/s11605-007-0416-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Accepted: 10/31/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the feasibility of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been established, various aspects are debated. This paper describes the problems of minimally invasive resection of gastric GISTs and compares this experience with an extensive literature review. STUDY DESIGN Between August 2001 and December 2006, 21 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a prospective study. A literature review of laparoscopic treatment was performed on Pubmed using keywords GIST and surgery. A comparison with authors' experience with open wedge-segmental resection of GISTs (25 cases from November 1995 to December 2000) was also carried out. Statistical analysis was based on chi-squared test and t Student evaluation. RESULTS Twenty-one patients, mean age 50.1 years (range, 34-68 years), were submitted to laparoscopic wedge- segmental gastric resections. Mean tumor size was 4.5 cm (range, 2.0-8.5 cm). Mean operative time was 151 min (range, 52-310 min), the mean blood loss was 101 mL (range, 10-250 mL), and the mean hospital stay was 4.8 days (range 3-7 days). There were no major operative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 35 months, all patients were disease-free. Morbidity, mortality, length of stay, and oncologic outcomes were comparable to the open surgery retrospective evaluation (p=not significant). CONCLUSIONS As found also in the literature review, the laparoscopic resection is safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by laparoscopic surgery, a minimally invasive approach should be the preferred surgical treatment in patients with small- and medium-sized gastric GISTs.
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Affiliation(s)
- Fausto Catena
- Transplant, General and Emergency Surgery Department, St Orsola-Malpighi University Hospital, Via Massarenti 9, 40138, Bologna, Italy.
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Basu S, Balaji S, Bennett DH, Davies N. Gastrointestinal stromal tumors (GIST) and laparoscopic resection. Surg Endosc 2007; 21:1685-9. [PMID: 17661137 DOI: 10.1007/s00464-007-9445-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM To review management, outcome and the lessons learnt from a laparoscopic approach to GISTs. METHOD All cases of GIST presenting to the upper GI MDT between 2000 and 2006 were reviewed. Presentation, preoperative investigations, management and follow-up were recorded. Surgical resection using a laparoscopic approach, where feasible was the preferred management. RESULTS 25 consecutive patients that included one oesophageal, three oesophago-gastric, 19 gastric and two smallbowel GISTs were treated between 2000 and 2006. There were 11 male and 14 females with a median age of 68 (25-90) years. Clinical presentation was: gastrointestinal bleed 15, pain 6, dysphagia 2, anaemia 3, weight loss 1, and asymptomatic 2. Out of 25, four were inoperable and treated with imatinib. 17 laparoscopic (including 2 conversions) and four open procedures were performed. Two (both GISTs close to the oesophago-gastric junction) required reoperation due to surgical-related morbidity. Of the 25, five were high-, 11 intermediate- and nine low-risk GISTs. No recurrences in follow-up (median 24, range 6-75) months was observed. CONCLUSION GISTs can safely and effectively be treated laparoscopically although larger GISTs in difficult anatomical locations may require open surgery.
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Affiliation(s)
- Sanjoy Basu
- Upper Gastrointestinal Unit, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, United Kingdom.
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Alam I, Kheradmand F, Alam S, Jamil A, Wilson I, Hurley M. Laparoscopic Management of Acutely Presenting Gastrointestinal Stromal Tumors: A Study of 9 Cases and Review of Literature. J Laparoendosc Adv Surg Tech A 2007; 17:626-33. [PMID: 17907976 DOI: 10.1089/lap.2006.0217] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Gastrointestinal stromal tumors (GISTs) are rare. Nevertheless, some may present with a life-threatening hemorrhage or intestinal obstruction. The aim of this study was to review the various modes of the presentation of GIST, especially hemorrhage and obstruction, and to assess the role of laparoscopic surgery in the management of acute cases and the correlation of such cases with malignant potential. METHODS Data were collected from the hospital in the patient records as well as a prospective database. Their presentation, management, histologic features, and follow-up periods were analyzed. RESULTS Nine cases of GIST were collected. Five (56%) presented with hemorrhage, 3 (33%) with intestinal obstruction, and 1 (11%) with a tender epigastric mass. Six patients had a gastroscopy procedure, and 6 had a computed tomography scan of the abdomen and pelvis. Five (67%) patients underwent a partial gastrectomy (3 laparoscopic and 2 open procedures), 1 had a laparoscopic localized resection of a gastric GIST, and 3 (33%) had a resection and anastomosis of the bowel. All patients presented acutely, and 78% had emergency surgery performed. The laparoscopic approach was attempted in 6 patients (67%), and was successful in 4 (67%). All patients who had a laparoscopic treatment performed had less pain, a quicker recovery, and a shorter hospital stay, as compared to those patients who had open surgery. Five cases were malignant tumors. Immunohistochemistry revealed a positive c-kit and CD34 for all tumors. The median follow-up was 24 months with one recurrence. CONCLUSIONS Our experience showed that GISTs can present acutely and may need immediate surgical intervention. A laparoscopic treatment is safe and practical in experienced hands. Tumor size and hemorrhage at presentation can predict a patient's malignant potential.
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Affiliation(s)
- Imran Alam
- Department of Surgery, Morriston Hospital, Swansea, United Kingdom.
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Abstract
The combination of laparoscopy and flexible endoscopy has expanded the minimally invasive approaches to both benign and malignant gastrointestinal disease. This article reviews the current applications of combined approaches to gastric, colonic, and pancreatic pathology.
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Affiliation(s)
- Michael J Rosen
- Department of Surgery, Case Medical Center, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Abstract
Sarcoma of the stomach is a rare histological entity. These differentiated mesenchymal tumors do not differ clinically from other gastric cancers. Endoscopic ultrasonography is the preferred means of exploration because it determines the existence of a submucosal lesion and provides guidance in determining its type. Certainty of diagnosis requires pathologic and immunohistochemical examinations of the surgical specimen. Malignant gastric stromal tumors are the first differential diagnosis of sarcoma of the stomach. They can be better characterized by testing their expression of the c-kit protein. Histological confirmation of malignancy sometimes remains difficult. Locoregional invasion and distant metastases confirm malignancy. Treatment is essentially surgical. Prognosis depends on tumor size, extension, rupture and histological grade.
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Torres-Villalobos G, Leslie D, Kellogg T, Andrade R, Maddaus M, Hunter D, Ikramuddin S. A New Approach for Treatment of Gastro-Gastric Fistula after Gastric Bypass. Obes Surg 2007; 17:242-6. [PMID: 17476879 DOI: 10.1007/s11695-007-9028-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a novel technique for gastro-gastric fistula (GGF) repair. A 44-year-old woman was found to have a fistula between her gastric pouch and bypassed stomach 18 years after Roux-en-Y gastric bypass (RYGBP) for morbid obesity. She underwent an attempted open surgical repair, which was complicated by postoperative abdominal sepsis. An upper gastrointestinal series, abdominal CT scan and upper endoscopy confirmed the diagnosis of failed surgery with recurrent GGF. Under endoscopic and fluoroscopic guidance, two ports were inserted percutaneously into the stomach. The fistula was closed with a percutaneous, transgastric, totally extraperitoneal approach. She remains well 7 months after this intervention. This procedure appears to be a safe and effective minimally invasive approach for closure of GGF after RYGBP. This is the first description of an intragastric, percutaneous closure of a GGF after RYGBP in the medical literature. Further experience with this technique is needed to define the selection criteria, limitations, advantages, and disadvantages.
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Novitsky YW, Kercher KW, Sing RF, Heniford BT. Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors. Ann Surg 2006; 243:738-45; discussion 745-7. [PMID: 16772777 PMCID: PMC1570564 DOI: 10.1097/01.sla.0000219739.11758.27] [Citation(s) in RCA: 291] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Gastric gastrointestinal stromal tumors (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of minimally invasive resection of gastric GIST has been established, the long-term safety and efficacy of these techniques are unclear. We hypothesized that complete resection of gastric GISTs using a combination of laparoscopic or laparoendoscopic techniques results in low perioperative morbidity and an effective long-term control of the disease. METHODS Between August 1996 and June 2005, 50 consecutive patients undergoing laparoscopic or laparoendoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics and outcomes, operative findings, morbidity, and histopathologic characteristics of the tumor. Patient and tumor characteristics were analyzed to identify risk factors for tumor recurrence. RESULTS Fifty patients, mean age 60 years (range, 34-84 years), underwent 47 local and 3 segmental laparoscopic gastric resections. GI bleeding and dyspepsia were the most common symptoms. Mean tumor size was 4.4 cm (range, 1.0-8.5 cm) with the majority of the lesions located in the proximal stomach. Mean operative time was 135 minutes (range, 49-295 minutes), the mean blood loss was 85 mL (range, 10-450 mL), and the mean length of hospitalization was 3.8 days (range 1-10 days). There were no major perioperative complications or mortalities. All lesions had negative resection margins (range, 2-45 mm). Nine patients had 10 or more mitotic figures per 50 high power fields, while 11 had ulceration and/or necrosis of the lesion. At a mean follow-up of 36 months, 46 (92%) patients were disease free, 1 patient was alive with disease, 1 patient with metastases died of a cardiac event, and 2 (4%) patients died of metastatic disease. No local or port site recurrences have been identified. Patient age, tumor size, mitotic index, tumor ulceration, and necrosis were statistically associated with tumor recurrence. The presence of 10 or more mitotic figures per 50 high power fields was an independent predictor of disease progression (P = 0.006). CONCLUSION A laparoscopic approach to surgical resection of gastric GIST is associated with low morbidity and short hospitalization. As found in historical series of open operative resection, the tumor mitotic index predicts local recurrence. The long-term disease-free survival of 92% in our study establishes laparoscopic resection as safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by minimally invasive surgery, a laparoscopic approach may be the preferred resection technique in most patients with small- and medium-sized gastric GISTs.
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Affiliation(s)
- Yuri W Novitsky
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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