Clinical feasibility and safety of third space robotic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumors dissection

Abstract Background Surgical management of gastric gastrointestinal stromal tumors (GISTs) has evolved towards minimal invasiveness. Laparoscopic wedge resection and laparoscopic and endoscopic cooperative surgery had been considered as standard surgical treatments for gastric GISTs > 2 cm. However, stomach deformation and the full-thickness gastric defect caused by these procedures may increase the risk of morbidity. To address these problems, we developed a novel technique, third space robotic and endoscopic cooperative surgery (TS-RECS), which could dissect the tumor entirely while preserving the intact mucosal layer. Here we performed a prospective evaluation of the feasibility and safety of TS-RECS. Methods Patients with gastric GISTs were recruited between April 2018 and April 2019. During the operation, the gastric GIST was located by endoscopic view firstly and the submucosal injection was performed. The tumor was then dissected through robotic surgery. Clinicopathological characteristics, operative data, adverse events, and follow-ups were prospectively collected and analyzed. Results A total of 20 patients with gastric GISTs received TS-RECS. The mean tumor size was 33.0 ± 7.3 mm. R0 resection was achieved in all patients with a median operation time of 115 min and a median blood loss of 20 ml. The integrity of mucosal layer was maintained in 95% (19/20) of the patients. All patients started oral diet on postoperative day 1 or 2, staying in the hospital for a median of 6 days after surgery. There were no major adverse events. Local or distant recurrences were not observed during a median follow-up period of 10 months. Conclusions Our study suggests that TS-RECS appears to be a feasible and safe technique which could be an alternative method for resecting gastric GISTs > 2 cm. Clinical Trials ClinicalTrials.gov NCT03804762.

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Hybrid Push-Pull Endoscopic and Laparoscopic Full Thickness Resection for the Minimally Invasive Management of Gastrointestinal Stromal Tumors: A Pilot Clinical Study

Gastroenterology Research and Practice ◽

10.1155/2015/618756 ◽

2015 ◽

Vol 2015 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Field F. Willingham ◽

Paul Reynolds ◽

Melinda Lewis ◽

Andrew Ross ◽

Shishir K. Maithel ◽

...

Keyword(s):

Minimally Invasive ◽

Endoscopic Resection ◽

Gastrointestinal Stromal Tumors ◽

Wedge Resection ◽

Tertiary Care ◽

R0 Resection ◽

Full Thickness ◽

Stromal Tumors ◽

Gastric Gists ◽

Deep Margin

Background. Gastric gastrointestinal stromal tumors (GISTs) that are predominantly endophytic or in anatomically complex locations pose a challenge for laparoscopic wedge resection; however, endoscopic resection can be associated with a positive deep margin given the fourth-layer origin of the tumors.Methods. Patients at two tertiary care academic medical centers with gastric GISTs in difficult anatomic locations or with a predominant endophytic component were considered for enrollment. Preoperative esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA), and cross-sectional imaging were performed. Eligible patients were offered and consented for hybrid and standard management.Results. Over ten months, four patients in two institutions with anatomically complex or endophytic GISTs underwent successful, uncomplicated push-pull hybrid procedures. GIST was confirmed in all resection specimens.Conclusion. In a highly selected population, the hybrid push-pull approach was safe and effective in the removal of complex gastric GISTs. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique manages with a laparoscopic, full thickness, R0 resection. This novel, minimally invasive, hybrid laparoscopic and endoscopic push-pull technique is a safe and feasible alternative in the management of select GISTs that are not amenable to standard laparoscopic resection.

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Minimally Invasive Resection of Large Gastric Gastrointestinal Stromal Tumors

Digestive Surgery ◽

10.1159/000510386 ◽

2020 ◽

Vol 37 (6) ◽

pp. 441-446

Author(s):

Emma C. Gertsen ◽

Gijs I. van Boxel ◽

Lodewijk A.A. Brosens ◽

Jelle P. Ruurda ◽

Richard van Hillegersberg

Keyword(s):

Minimally Invasive ◽

Gastrointestinal Stromal Tumors ◽

Tumor Regression ◽

Medical Center ◽

Disease Free Survival ◽

Partial Gastrectomy ◽

R0 Resection ◽

Gastric Gist ◽

Intraoperative Complication ◽

Stromal Tumors

Introduction: Gastrointestinal stromal tumors (GISTs) frequently present as a large exophytically growing mass in the stomach, for which open partial gastrectomy is standard of care. The aim of this study was to evaluate the safety and feasibility of minimally invasive gastric resection (MIG) of large (>5 cm) GIST. Methods: All patients who underwent MIG for a GIST in the University Medical Center Utrecht between 2011 and 2019 were included. Postoperative course and oncological outcomes were analyzed. Results: Twenty-two patients with gastric GIST, median size 53 mm [20–175 mm], underwent MIG. In 4 patients, preoperative imatinib was given, aiming for tumor regression. Conversion from laparoscopic to open surgery occurred once (5%). An additional resection was performed in 3 patients (14%). In 2 patients (9%), an intraoperative complication occurred, consisting of tumor rupture in 1 patient (5%), and 6 patients (27%) developed postoperative complications. Median hospital stay was 5 days [3–7 days]. R0 resection was achieved in 96%. In 4 patients, adjuvant treatment was indicated. The median follow-up was 31 months, and 1-, 3- and 5-year disease-free survival were 94, 74 and 74%, respectively. One patient presented with local recurrence 2 years after the index resection. Conclusion: MIG for large GIST up to 17.5 cm in diameter is safe, feasible, and oncologically sound, allowing for a controlled resection and reduced patient morbidity.

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Gastrointestinal Stromal Tumor (GIST) and Synchronous Intra-Abdominal Liposarcoma: A Report of Two Rare Cases and Literature Review

International Journal of Surgical Oncology ◽

10.1155/2021/2626635 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Alexandros Diamantis ◽

Athina A. Samara ◽

Ioannis Baloyiannis ◽

Dimitrios Symeonidis ◽

Andreas-Marios Diamantis ◽

...

Keyword(s):

Literature Review ◽

Gastrointestinal Stromal Tumor ◽

Current Literature ◽

Gastrointestinal Stromal Tumors ◽

Stromal Tumor ◽

R0 Resection ◽

Gastric Gist ◽

Stromal Tumors ◽

Retroperitoneal Liposarcoma ◽

Electronic Search

Introduction. Gastrointestinal stromal tumors (GISTs) quite frequently occur synchronously with other malignancies, with most cases being adenocarcinomas. GISTs and liposarcomas are both of mesenchymal origin, and their coexistence is extremely rare. Methods. We conducted a review of the current literature regarding the synchronous occurrence of GISTs and intra-abdominal liposarcomas. An electronic search of the literature was undertaken using MEDLINE (database provider PubMed). Furthermore, we present the first described case of an 86-year-old male with a GIST and synchronous liposarcoma, both located in the stomach, as well as a 66-year-old male with a gastric GIST and concurrent retroperitoneal liposarcoma. Results. A total of 5 cases of synchronous GIST and intra-abdominal liposarcoma have been reported in the literature to date, with the most recent cases included in the present study. Conclusion. Further research is required to explain any possible correlation in the coexistence of these different neoplasms of the same origin. Meanwhile, R0 resection of both tumors remains the treatment of choice.

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Laparoscopic and Endoscopic Cooperative Dissection for Small Gastric Gastrointestinal Stromal Tumor without Causing Injury to the Mucosa

Gastroenterology Research and Practice ◽

10.1155/2019/7376903 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

Lei Cao ◽

Kunming Zheng ◽

Honglei Wang ◽

Yongjie Zhao ◽

Zhengduo Yang ◽

...

Keyword(s):

Gastrointestinal Stromal Tumors ◽

Postoperative Bleeding ◽

Operation Time ◽

Massive Bleeding ◽

Intraoperative Bleeding ◽

Stromal Tumors ◽

Gastric Gists ◽

Chemotherapy Drugs ◽

Complete Tumor

Objective. To investigate the feasibility of laparoscopic and endoscopic cooperative dissection (LECD) for small gastric gastrointestinal stromal tumors (GISTs) without causing injury to the mucosa, compared with ESD surgery which is widely used now. Methods. A total of 25 patients with small gastric GISTs who underwent LECD and 20 patients with small gastric GISTs who underwent ESD between October 2014 and June 2016 were included in this study. All patients underwent curative resection for pathologically diagnosed small gastric GISTs. Patients’ clinical data were retrospectively analyzed. Results. In LECD group, the operation was successfully performed in all patients. However, in the ESD group, three patients were transferred to laparoscopic surgery due to intraoperative massive bleeding or intraoperative perforation. No additional targeted chemotherapy drugs for interstitial tumors were prescribed in two groups. There was no difference in the complete tumor capsule rate (100% vs. 90%, p=0.11), operation time (80.76±13.86 ml vs. 84.05±15.33 ml, p=0.45), major intraoperative bleeding (0 vs. 5%, p=0.26), postoperative bleeding (0 vs. 10%, p=0.11), and postoperative infection (0 vs. 10%, p=0.11) between the two groups. Compared to ESD (endoscopic submucosal dissection), LECS patients had shorter postoperative indwelling gastric tube (1.04±0.98 d vs. 2.85±0.24 d, p<0.01), earlier postoperative eating (1.96±0.98 d vs. 3.50±1.15 d, p<0.01), shorter average postoperative hospital stay (3.44±1.00 d vs. 7.85±1.18 d, p<0.01), smaller perforation rate (0 vs. 25%, p < 0.05), and fewer surgical supplies. No recurrence or metastasis cases were found between the two groups during the follow-up period, and there were no cases of death due to gastric GISTs. Conclusion. LECD is a novel surgery for small gastric gastrointestinal stromal tumors that leads to satisfactory short-term outcomes and meets the idea of minimally invasive surgery and rapid recovery; compared with ESD, LECD surgery has some advantages in clinical practice. However, further follow-up is needed to confirm.

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Meta-Analysis on the Efficacy and Safety of Laparoscopic Surgery for Large Gastric Gastrointestinal Stromal Tumors

The American Surgeon ◽

10.1177/0003134820951482 ◽

2020 ◽

pp. 000313482095148

Author(s):

Miao Yu ◽

Deng-chao Wang ◽

Jian Wei ◽

Yue-hua Lei ◽

Zhao-jun Fu ◽

...

Keyword(s):

Gastrointestinal Stromal Tumors ◽

Laparoscopic Resection ◽

Meta Analysis ◽

Disease Free Survival ◽

Operation Time ◽

Intraoperative Blood Loss ◽

Open Resection ◽

Free Survival ◽

Stromal Tumors ◽

Disease Free

Background The aim of this study was to conduct a meta-analysis comparing the safety and feasibility of laparoscopic versus open resection for gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm. Method We searched the Cochrane Library, PubMed, and Embase for relevant articles. Randomized and nonrandomized clinical trials were identified and included in this study. Searching for related articles on large GIST (>5 cm) for laparoscopic resection (laparoscopic group [LAPG]) and open resection (open group [OG]), RevMan 5.3 was used for data analysis, comparing 2 groups of operation time, intraoperative blood loss, complications, length of hospital stay, recurrence rate, disease-free survival, and overall survival. Results Seven studies including 440 patients were identified for the meta-analysis. Meta-analysis revealed that LAPG had less bleeding, shorter postoperative hospital stay, and a better 5-year disease-free survival. There was no significant difference between LAPG and OG in operation time, postoperative complications, recurrence rate, and overall survival. Conclusion Laparoscopic resection of large (>5 cm) GIST is safe and feasible and has the advantages of less intraoperative blood loss and fast postoperative recovery, with a good outcome in the recent oncology.

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Endoscopic Removal of Gastrointestinal Stromal Tumors in the Stomach: A Single-Center Experience

Gastroenterology Research and Practice ◽

10.1155/2019/3087298 ◽

2019 ◽

Vol 2019 ◽

pp. 1-9 ◽

Cited By ~ 1

Author(s):

Yingjie Guo ◽

Xue Jing ◽

Jian Zhang ◽

Xueli Ding ◽

Xiaoyu Li ◽

...

Keyword(s):

Tumor Size ◽

Gastrointestinal Stromal Tumors ◽

Average Length ◽

Risk Classification ◽

Low Risk ◽

Efficacy And Safety ◽

Endoscopic Removal ◽

Moderate Risk ◽

Stromal Tumors ◽

Gastric Gists

Background and Aims. Endoscopic removal of GISTs (gastrointestinal stromal tumors) is recently recognized, but less is known about its efficacy and safety. This study is aimed at assessing the feasibility, clinical efficacy, and safety of the endoscopic removal of gastric GISTs. Patients and Methods. Endoscopic removal (ER) of GISTs was performed in 134 patients at our hospital between January 2015 and January 2019. The clinical features, surgical outcomes, complications, pathological diagnosis, and risk classification were evaluated retrospectively. Results. ER was successful in 131 cases (98%), including 58 by ESD (endoscopic submucosal dissection), 43 by ESE (endoscopic submucosal excavation), 25 by EFTR (endoscopic full-thickness resection), and 5 by STER (submucosal tunneling endoscopic resection). In addition, GISTs of two cases were resected using LECS (laparoscopic and luminal endoscopic cooperative surgery) for the extraluminal and intraluminal growth pattern. The average tumor size was 1.89±1.25 cm (range: 0.5-6.0 cm). Of these patients, 26 cases had a large tumor size (range: 2.0-6.0 cm), and endoscopic removal was successful in all of them. During the procedure, endoclips were used to close the perforation in all cases, without conversion to open surgery. The average length of hospital stay was 5.50±2.15 days (range: 3-10 days). In the risk classification, 106 (79.7%) were of a very low risk, 25 (18.8%) of a low risk, and 2 (1.5%) of a moderate risk. The moderate-risk cases were treated with imatinib mesylate after ER. No recurrence or metastasis was observed during the follow-up period of 23±8 months (range: 3-48 months). Conclusions. The endoscopic treatment is feasible, effective, and safe for gastric GISTs, and individualized choice of approaches is recommended for GISTs.

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Outcomes of multivisceral resection of gastric gastrointestinal stromal tumors.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.4_suppl.91 ◽

2012 ◽

Vol 30 (4_suppl) ◽

pp. 91-91

Author(s):

Sabha Ganai ◽

Mitchell Posner ◽

Vivek N. Prachand ◽

John C. Alverdy ◽

Eugene A. Choi ◽

...

Keyword(s):

Tumor Size ◽

Gastrointestinal Stromal Tumors ◽

Disease Free Survival ◽

Multivisceral Resection ◽

Response To Therapy ◽

Hospital Length Of Stay ◽

Free Survival ◽

Stromal Tumors ◽

Gastric Gists ◽

Disease Free

91 Background: Despite the recent introduction of imatinib and laparoendoscopic techniques to the management of gastric gastrointestinal stromal tumors (GISTs), outcomes remain uncertain in the setting of multivisceral involvement. Methods: We conducted a retrospective review of 69 consecutive patients who underwent resection of gastric GISTs from October 2002 through August 2011. Median follow-up was 19 months (interquartile range [IQR] 4-37). Results: Patients were 51% female, with a mean age of 65 ± 13 years and BMI of 30 ± 8 kg/m2. Patients undergoing multivisceral resection (n=13) had a longer interval from diagnosis to surgery (7.4 [IQR 1.9 – 15.0] vs. 1.3 [IQR 0.7-3.5] months, p<0.01), greater use of neoadjuvant imatinib (62% vs. 4%, p<0.001), and greater preoperative tumor size (12 ± 8 vs. 4 ± 3 cm, p<0.001) in comparison to gastric-only resections (n=56). Patients were less likely to be managed laparoscopically (8% vs. 71%, p<0.001), had a longer operative time (286 ± 92 vs. 152 ± 65 min, p<0.001), and were less likely to be R0 (69% vs. 98%, p<0.001). While patients undergoing multivisceral resection were more likely to have a pathological complete response to therapy (23% vs. 0, p<0.01), they were also more likely to have metastatic disease present (31% vs. 0, p<0.01). Hospital length of stay was greater (median 8 [IQR 7-9] vs. 3 [IQR 2-6] days, p<0.001). There were no significant differences in grade or mitotic index between groups, or in the use of adjuvant imatinib (54% vs. 23%). Overall survival was less in patients undergoing multivisceral resection (63% vs. 86% at 3 years, p<0.05), as was disease-free survival (52% vs. 71% at 3 years, p<0.05). Median disease-free survival was 50 and 66 months, respectively (p<0.01). Controlling for tumor size, grade, resection status, and the use of neoadjuvant imatinib, multivisceral resection was an independent predictor of disease-free survival (p<0.05). Conclusions: Multivisceral involvement is associated with tumors of greater size, and despite an increased use of neoadjuvant imatinib, it is associated with poor outcome for patients with gastric GISTs.

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A multinational phase II clinical trial of neoadjuvant imatinib for large gastrointestinal stromal tumor of the stomach.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.4_suppl.130 ◽

2016 ◽

Vol 34 (4_suppl) ◽

pp. 130-130

Author(s):

Han-Kwang Yang ◽

Yukinori Kurokawa ◽

Min-Hee Ryu ◽

Haruhiko Cho ◽

Sook Ryun Park ◽

...

Keyword(s):

Clinical Trial ◽

Adverse Events ◽

Gastrointestinal Stromal Tumor ◽

Neoadjuvant Treatment ◽

Stromal Tumor ◽

Maximal Response ◽

R0 Resection ◽

Gastric Gist ◽

Efficacy And Safety ◽

Resection Rate

130 Background: Neoadjuvant therapy is expected to reduce the risk of primary surgery, such as rupture of the tumor, hemorrhage, and multi-visceral resection, and to improve survivals for patients with a large gastric gastrointestinal stromal tumor (GIST). This study aims to evaluate the efficacy and safety of neoadjuvant imatinib therapy for a large gastric GIST. Methods: Patients with gastric GIST, which is 10cm or larger and without metastasis, received neoadjuvant imatinib (400mg/day) for 6 months, and up to 9 months if maximal response is expected. Postoperative adjuvant imatinib was prescribed for at least 1 year and up to 3 years according to adjuvant treatment guideline. The primary endpoint was complete (R0) resection rate. A primary analysis were performed by the time all the operations were finished, to examine the efficacy and safety of the neoadjuvant treatment. Results: Between Feb 2010 and Sep 2014, 55 patients were enrolled in Japan and Korea. One patient with a jejunal GIST and one patient with PDGFRA-18 D842V mutation were excluded from analysis. Mean tumor diameter was 12cm (10-23). 86.8% of patients (46/53) completed neoadjuvant treatment. Dose reduction of imatinib was performed in 26.4% (14/53). The most frequent Grade 3 or 4 adverse events were G3 rash (5/53, 9.4%) and G3/4 neutropenia (4/53, 7.5%). Disease control rate (PR+SD) and response rate (PR) of neoadjuvant imatinib was 100% and 62.3% by RECIST, and 100% and 98.1% by Choi criteria, respectively. There was no case of CR or PD. 50 patients underwent operation, and R0 resection rate was 90.6% (n = 48, 95% CI 79.3% - 96.9%), which was significantly higher than the threshold value of 70% (p < 0.001). Combined resection of other organs (except gall bladder) was performed in 24.5% (n = 13), and 83.0% of patients (n = 44) could preserve ≥ 50% of the stomach. Postoperative complication occurred in 18.0% (9/50). Conclusions: Neoadjuvant imatinib treatment is effective and safe treatment option for a large primary GIST allowing high R0 resection rate with acceptable incidence of adverse events and postoperative complications. Clinical trial information: UMIN000003114.

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The prognostic value of gender in gastric gastrointestinal stromal tumors: A propensity score matching analysis.

10.21203/rs.3.rs-23931/v1 ◽

2020 ◽

Author(s):

Jian fang Rong ◽

Si hai Chen ◽

Cong hua Song ◽

Huan Wang ◽

Qiao yun Zhao ◽

...

Keyword(s):

Propensity Score ◽

Propensity Score Matching ◽

Gastrointestinal Stromal Tumors ◽

Gastric Gist ◽

Confounding Factors ◽

Cox Regression Analysis ◽

Stromal Tumors ◽

Female Patients ◽

Risk Of Death ◽

Male Patients

Abstract Background Gastrointestinal stromal tumors (GISTs) of the stomach are the most common GISTs. The risk, incidence and outcome of cancer are different between the sexes. Whether gender is related to the prognosis of gastric stromal tumors is unclear. Therefore, this study aims to explore the relationship between gender and gastric GIST prognosis. Methods Data from gastric GIST patients were collected from the Surveillance, Epidemiology, and End Results (SEER) database. After propensity score matching (PSM) was performed to reduce confounding factors, the clinicopathological features and prognosis of GIST patients were comprehensively evaluated. Results There were 512 male patients and 538 female patients with gastric GIST. The gender of gastric GIST patients was associated with marital status, surgical treatment, tumor size, and mitotic index (P < 0.05). The Kaplan-Meier analysis and log-rank test revealed that male patients had a higher mortality rate than female patients (P = 0.0024). After matching all the potential confounding factors, the survival of the female gastric GIST patients was better than that of the male gastric GIST patients (P = 0.042). Cox regression analysis revealed that gender was an independent risk factor for overall survival. The risk of death was higher for males than for females (HR: 1.539, 95% CI: 1.066–2.222, P = 0.021). Conclusion Gender could be a prognostic factor for gastric GIST survival, and male patients had a higher risk of death.

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Gastrointestinal Stromal Tumors: Actin Expression, a New Prognostic Factor?

The American Surgeon ◽

10.1177/000313481007601126 ◽

2010 ◽

Vol 76 (11) ◽

pp. 1244-1250 ◽

Cited By ~ 3

Author(s):

Jaime Ruiz-Tovar ◽

María Diez-Tabernilla ◽

Gada Housari ◽

Enrique Martinez-Molina ◽

Alfonso Sanjuanbenito

Keyword(s):

Prognostic Factors ◽

Small Bowel ◽

Gastrointestinal Stromal Tumors ◽

Abdominal Mass ◽

Disease Free Survival ◽

Gastric Gist ◽

Free Survival ◽

Stromal Tumors ◽

Actin Expression ◽

Disease Free

The aim of this study is to analyze the clinical outcome of gastrointestinal stromal tumors (GISTs) and to determine new prognostic factors. We perform a retrospective study of all the patients diagnosed with GIST in any location and operated on between 2000 and 2008 at our institution. We analyzed 35 patients, 16 males (45.7%) and 19 females (54.3%), with a mean age of 64 ± 13.8 years. The tumors were located in the stomach in 22 patients (62.9%), in the small bowel in 10 (28.6%), and the retroperitoneum in three (8.6%). Referring to gastric GIST, endoscopy revealed an ulceration in the mucosa in five cases, suggesting an epithelial neoplasm. In all these cases, pathology of the biopsy specimen was nonconclusive. Survival rate at 1 and 5 years was 94.3 and 88.6 per cent, respectively. Disease-free survival at 1 and 2 years was 91.4 and 88.6 per cent, respectively. Analyzing prognostic factors, a lower disease-free survival was observed among patients with constitutional syndrome at diagnosis ( P = 0.000), small bowel GIST ( P = 0.037), and tumors not expressing actin ( P = 0.015). A lower global survival was observed among men ( P = 0,036), patients with an abdominal mass ( P = 0.033) or with constitutional syndrome ( P = 0.007) at diagnosis and tumors at a retroperitoneal location ( P = 0.0002). Gastric GIST may be confused with epithelial neoplasms, modifying the surgery. In our patients, masculine gender, constitutional syndrome and abdominal mass at diagnosis, small bowel and retroperitoneal location, and actin negative tumors are bad prognostic factors.

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