Case Control Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Aug 27, 2023; 15(8): 1629-1640
Published online Aug 27, 2023. doi: 10.4240/wjgs.v15.i8.1629
Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors
Wei-Jung Chang, Lien-Cheng Tsao, Hsu-Heng Yen, Chia-Wei Yang, Hung-Chi Chang, Chew-Teng Kor, Szu-Chia Wu, Kuo-Hua Lin
Wei-Jung Chang, Lien-Cheng Tsao, Hung-Chi Chang, Kuo-Hua Lin, Department of General Surgery, Changhua Christian Hospital, Changhua 50006, Taiwan
Hsu-Heng Yen, Chia-Wei Yang, Department of Gastroenterology, Changhua Christian Hospital, Changhua 50006, Taiwan
Hsu-Heng Yen, General Education Center, Chienkuo Technology University, Changhua 50006, Taiwan
Hsu-Heng Yen, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
Chew-Teng Kor, Big Data Center, Changhua Christian Hospital, Changhua 50006, Taiwan
Chew-Teng Kor, Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua 50007, Taiwan
Szu-Chia Wu, Transplant Medicine & Surgery Research Center, Changhua Christian Hospital, Changhua 50006, Taiwan
Author contributions: Yen HH, Chang HC, and Lin KH designed research; Tsao LC, Yen HH, Yang CW, Chang HC, and Lin KH performed research; Tsao LC, Yen HH, and Kor CT contributed new reagents/analytic tools; Kor CT and Wu SC analyzed the data; Chang WJ and Lin KH wrote the paper.
Institutional review board statement: The study was approved by the Institutional Review Board of Changhua Christian Hospital (approval No. 220117).
Informed consent statement: This retrospective study had a waiver of informed consent due to retrospective nature.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kuo-Hua Lin, MD, Surgeon, Department of General Surgery, Changhua Christian Hospital, No. 135 Nanxiao Street, Changhua 50006, City, Changhua County, Taiwan. khlin120380@gmail.com
Received: April 26, 2023
Peer-review started: April 26, 2023
First decision: May 25, 2023
Revised: June 6, 2023
Accepted: July 4, 2023
Article in press: July 4, 2023
Published online: August 27, 2023
Processing time: 121 Days and 3.3 Hours
Abstract
BACKGROUND

Minimally invasive surgery had been tailored to individual cases of gastric subepithelial tumors (SETs) after comparing the clinical outcomes of endoscopic resection (ER), laparoscopic resection (LR), and hybrid methods.

AIM

To study the use of Goldilocks principle to determine the best form of minimally invasive surgery for gastric SETs.

METHODS

In this retrospective study, 194 patients of gastric SETs with high probability of surgical intervention were included. All patients underwent tumor resection in the operating theater between January 2013 and December 2021. The patients were divided into two groups, ER or LR, according to the tumor characteristics and the initial intent of intervention. Few patients in the ER group required further backup laparoscopic surgery after an incomplete ER. The patients who had converted open surgery were excluded. A logistic regression model was used to assess the associations between patient characteristics and the likelihood of a treatment strategy. The area under the curve was used to assess the discriminative ability of tumor size and Youden’s index to determine the optimal cut-off tumor size.

RESULTS

One-hundred ninety-four patients (100 in the ER group and 94 in the LR group) underwent tumor resection in the operating theater. In the ER group, 27 patients required backup laparoscopic surgery after an incomplete ER. The patients in the ER group had small tumor sizes and shorter procedure durations while the patients in the LR group had large tumor sizes, exophytic growth, malignancy, and tumors that were more often located in the middle or lower third of the stomach. Both groups had similar durations of hospital stays and a similar rate of major postoperative complications. The patients in the ER group who underwent backup surgery required longer procedures (56.4 min) and prolonged stays (2 d) compared to the patients in the LR group without the increased rate of major postoperative complications. The optimal cut-off point for the tumor size for laparoscopic surgery was 2.15 cm.

CONCLUSION

Multidisciplinary teamwork leads to the adoption of different strategies to yield efficient clinical outcomes according to the tumor characteristics.

Keywords: Gastric subepithelial tumors; Endoscopic resection; Laparoscopic resection; Tumor size

Core Tip: Multidisciplinary teamwork leads to the adoption of different strategies for resection of gastric subepithelial tumors: Endoscopic resection (ER) was indicated for a smaller tumor and intraluminal growth, whereas laparoscopic resection was indicated for a larger tumor (optimal cut-off point: 2.15 cm), tumors located in the middle or lower third of the stomach, exophytic growth, and more aggressive malignancy behavior. Backup surgery is preserved for incomplete ER to effectively reduce associated morbidities.