Endoscopic treatment for gastrointestinal stromal tumor: Advantages and hurdles

Abstract

One of the most prominent characteristics of gastrointestinal stromal tumors (GISTs) is their unpredictable and variable behavior. GISTs are not classified as “benign” or “malignant” but are rather stratified by their associated clinical risk of malignancy as determined by tumor size, location, and number of mitoses identified during surgical histology. The difficulty in assessing the malignant potential and prognoses of GISTs as well as the increasing incidence of “incidental GISTs” presents challenges to gastroenterologists. Recently, endoscopic enucleation has been actively performed as both a diagnostic and therapeutic intervention for GISTs. Endoscopic enucleation has several advantages, including keeping the stomach intact after the removal of GISTs, a relatively short hospital stay, a conscious sedation procedure, relatively low cost, and fewer human resources required compared with surgery. However, a low complete resection rate and the risk of perforation could reduce the overall advantages of this procedure. Endoscopic full-thickness resection appears to achieve a very high R0 resection rate. However, this technique absolutely requires a very skilled operator. Moreover, there is a risk of peritoneal seeding due to large active perforation. Laparoscopy endoscopy collaborations have been applied for more stable and pathologically acceptable management. These collaborative procedures have produced excellent outcomes. Many procedures have been developed and attempted because they were technically possible. However, we should first consider the theoretical basis for each technique. Until the efficacy and safety of sole endoscopic access are proved, the laparoscopy endoscopy collaborative procedure appears to be an appropriate method for minimally destructive GIST surgery.

Keywords: Gastrointestinal stromal tumor; Endoscopy; Laparoscopy; Efficacy; Safety

Core tip: Several endoscopic approaches have recently been investigated for removing gastrointestinal stromal tumors. Endoscopic enucleation has several advantages. However, there is the possibility of peritoneal seeding when accidental perforation occurs. Furthermore, the rate of R0 resection is not yet acceptable. While endoscopic full-thickness resection has a more solid theoretical basis than endoscopic enucleation in terms of R0 resection, the possibility of tumor cell shedding into the peritoneum would increase when capsule injury results from the procedure. Compared with endoscopy only procedures, laparoscopy endoscopy cooperative surgery and LAFTR provide a higher complete resection rate and a more stable process, which are accordant with the purpose of minimally destructive surgeries.