Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

doi:10.4240/wjgs.v15.i8.1629

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World Journal of Gastrointestinal Surgery

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World J Gastrointest Surg. Aug 27, 2023; 15(8): 1629-1640
Published online Aug 27, 2023. doi: 10.4240/wjgs.v15.i8.1629

Table 1 Characteristics of patients undergoing endoscopic submucosal dissection and laparoscopic surgery

	ESD with/without backup surgery (n = 100)	Laparoscopic surgery (n = 94)	OR (95%CI)	P value
Age, yr, median (range)	56 (49-62)	62 (52-70)	1.04 (1.02-1.07)	0.001^a
Male gender, n (%)	46 (46)	47 (50)	1.17 (0.67-2.06)	0.577
Tumor size, n (%)
≤ 2 cm	72 (72)	15 (16)	1
3-5 cm	26 (26)	54 (57.4)	9.97 (4.82-20.62)	< 0.001^a
> 5 cm	2 (2)	25 (26.6)	60 (12.81-281)	< 0.001^a
Tumor location, n (%)
Upper	81 (81)	61 (64.9)	1
Middle	6 (6)	14 (14.9)	3.1 (1.13-8.53)	0.029^a
Low	13 (13)	19 (20.2)	1.94 (0.89-4.23)	0.096
Layer of tumor origin, n (%)
Submucosa	6 (6)	3 (3.2)	1
Muscularis propria	94 (94)	91 (96.8)	1.94 (0.47-7.97)	0.36
Exophytic growth, n (%)	11 (11)	53 (56.4)	10.46 (4.95-22.08)	< 0.001^a
Pathology, n (%)
Benign	55 (55)	14 (14.9)	1
Malignant or malignant potential	45 (45)	80 (85.1)	6.98 (3.5-13.94)	< 0.001^a
Procedure time, min, median (IQR)	75 (40-138)	130 (100-169)	-	< 0.001^a
Length of stay, d, median (IQR)	5 (4-7)	6 (4-6)	-	0.923
Clavien ≥ III complication, n (%)	5 (5)	3 (3.2)	-	0.527

^aP < 0.05.

ESD: Endoscopic submucosal dissection; OR: Odds ratio; CI: Confidence interval; IQR: Interquartile range.

Table 2 Characteristics of endoscopic submucosal dissection with backup surgery and laparoscopic surgery

	ESD with backup surgery (n = 27)	Laparoscopic surgery (n = 94)	OR (95%CI)	P value
Age, yr, median (range)	56 (50-64)	62 (52-70)	1.03 (1.00-1.06)	0.053
Male gender, n (%)	9 (33.3)	47 (50)	2.00 (0.82-4.90)	0.13
Tumor size, n (%)
≤ 2 cm	16 (59.3)	15 (16)	1
3-5 cm	11 (40.7)	54 (57.4)	7.66 (2.98-19.72)	< 0.001^a
> 5 cm	0 (0)	25 (26.6)	7.66 (2.98-19.72)	< 0.001^a
Tumor location, n (%)
Upper	23 (85.2)	61 (64.9)	1
Middle	1 (3.7)	14 (14.9)	3.11 (0.99-9.76)	0.052
Low	3 (11.1)	19 (3.2)	3.11 (0.99-9.76)	0.052
Layer of tumor origin, n (%)
Submucosa	0 (0)	3 (3.2)	-	1
Muscularis propria	27 (100)	91 (96.8)	-
Exophytic growth, n (%)	10 (37)	53 (56.4)	2.20 (0.91-5.3)	0.08
Pathology, n (%)
Benign	11 (40.7)	14 (14.9)	1
Malignant or malignant potential	16 (59.3)	80 (85.1)	3.93 (1.51-10.21)	0.005^a
Procedure time, min, median (IQR)	185 (150-245)	130 (100-169)	-	< 0.001^a
Length of stay, d, median (IQR)	7 (7-8)	6 (4-6)	-	< 0.001^a
Clavien ≥ III complication, n (%)	0 (0)	3 (3.2)	-	0.347

^aP < 0.05.

ESD: Endoscopic submucosal dissection; OR: Odds ratio; CI: Confidence interval; IQR: Interquartile range.

Table 3 Factors affecting procedure time and length of stay in endoscopic submucosal dissection with backup surgery and laparoscopic surgery

Factors	Without matched data			Propensity score matching
Factors	Adjusted mean difference	SE	P value	Adjusted mean difference	SE	P value
Procedure time
Surgery type
ESD with backup surgery	Reference			Reference
Laparoscopic surgery	-63.42	14.70	< 0.001^a	-56.40	18.60	0.005^a
Age	-0.43	0.42	0.304	-	-	-
Tumor size 2	22.04	13.35	0.101	-	-	-
Tumor location: middle or low	33.58	12.54	0.008^a	-	-	-
Exophytic growth	-4.54	10.98	0.680	-	-	-
Pathology with malignancy	-13.81	15.59	0.378	-	-	-
Length of stay
Surgery type
ESD with backup surgery
Laparoscopic surgery	-1.215	1.089	0.267	-2.00	0.516	0.001^a
Age	0.081	0.031^a	0.009^a	-	-	-
Tumor size 2	-0.348	0.988	0.726	-	-	-
Tumor location: middle or low	0.457	0.928	0.624	-	-	-
Exophytic growth	-0.218	0.813	0.789	-	-	-
Pathology with malignancy	-0.268	1.154	0.817	-	-	-

^aP < 0.05.

ESD: Endoscopic submucosal dissection.

Table 4 Malignant pathology and clinical outcomes after endoscopic submucosal dissection and laparoscopic surgery

	ESD with/without backup surgery (n = 100)	Laparoscopic surgery (n = 94)	P value
Malignant pathology in the group, n (%)	45 (45)	80 (85.1)	< 0.001^a
Malignant pathology
GIST, n (%)	43 (43)	78 (83.1)	< 0.001^a
High risk	0 (0)	11 (14.1)	0.001^a
Intermediate risk	5 (11.6)	20 (25.6)	0.002^a
Low risk	12 (27.9)	36 (46.2)	< 0.001^a
Very low risk	26 (60.5)	11 (14.1)	0.019^a
Neuroendocrine tumor, n (%)	1 (1)	1 (1)	1.000
Lipoleiomyosarcoma, n (%)	0	1 (1)	0.485
Recurrence, n (%)	0	6 (6.4)	0.012^a
Disease related mortality, n (%)	0	2 (2.1)	0.233

^aP < 0.05.

ESD: Endoscopic submucosal dissection; GIST: Gastrointestinal stromal tumors.

Citation: Chang WJ, Tsao LC, Yen HH, Yang CW, Chang HC, Kor CT, Wu SC, Lin KH. Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors. World J Gastrointest Surg 2023; 15(8): 1629-1640
URL: https://www.wjgnet.com/1948-9366/full/v15/i8/1629.htm
DOI: https://dx.doi.org/10.4240/wjgs.v15.i8.1629