Laparoscopic Transgastric Resection of Gastric Submucosal Tumors Located Near the Esophagogastric Junction

Background

Laparoscopic wedge resection is widely accepted as a choice of treatment for gastric submucosal tumors (SMTs). But it cannot easily be applied to tumors located near the esophagogastric junction (EGJ) due to the high risk of causing deformity or stenosis in the gastric inlet. We evaluated our laparoscopic transgastric surgical technique for gastric SMTs located near the EGJ and clinical outcomes.

Methods

Twelve consecutive patients with gastric intraluminal SMTs located 3 cm or less from the EGJ underwent laparoscopic transgastric resection at our institution from June 2010 to November 2012. The clinicopathological results of these 12 cases were analyzed.

Results

Laparoscopic transgastric resection was successfully performed on all the patients. The mean operation time was 125?±?25 min (range, 85–160 min) and the mean blood loss was 53?±?32 mL (range, 10–120 mL). There was no death in our series. One patient experienced a postoperative complication of upper gastrointestinal tract bleeding due to the errhysis along the staple line treated with an endoscopic hemostatic clip. The mean postoperative length of hospital stay was 5.1?±?1.2 days (range, 3–7 days). All patients received complete resection with a negative margin. Histopathologic diagnoses were gastrointestinal stromal tumor in seven cases, leiomyoma in four, and heterotopic pancreas in one. There was no tumor recurrence or evidence of stenosis of the EGJ during a mean follow-up of 15.3?±?9.6 months (range, 1–30 months).

Conclusions

Laparoscopic transgastric resection is simple, safe, and effective for gastric intraluminal SMTs located near the EGJ.     

腹腔镜与开腹胃间质瘤楔形切除的临床对比研究

目的探讨腹腔镜胃楔形切除治疗胃间质瘤的可行性。方法回顾性分析我院2002年9月~2009年4月腹腔镜胃间质瘤楔形切除术32例（腹腔镜组）和1999年10月~2009年1月开腹胃间质瘤楔形切除术20例（开腹组）的临床资料,比较2组围手术期的情况和预后。结果与开腹组相比,腹腔镜组手术时间短[120 min（23~210 min）vs 145 min（75~400 min）,Z=-2.960,P=0.003],术中出血量少[20 ml（5~100 ml）vs 50 ml（10~200 ml）,Z=-3.580,P=0.000],术后进食时间早[3 d（1~4 d）vs 3 d（3~21 d）,Z=-3.032,P=0.002],术后住院时间短[6 d（4~15 d）vs 8.5 d（6~26 d）,Z=-4.202,P=0.000]。腹腔镜组29例随访6~79个月（中位随访时间25个月）,开腹组16例随访9~120个月（中位随访时间58个月）,均无复发或转移。结论腹腔镜胃间质瘤楔形切除术安全、有效,具有可行性。     

Long-term Outcomes of Laparoscopic Resection of Gastric Gastrointestinal Stromal Tumors

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.     

Predictors of Unsuccessful Laparoscopic Resection of Gastric Submucosal Neoplasms

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.     

Significance of the Inflammation-Based Glasgow Prognostic Score for Short- and Long-Term Outcomes After Curative Resection of Gastric Cancer

Background

The Glasgow prognostic score (GPS) is a patient-related measure to determine long-term outcomes in cancer patients. This study examined the impact of GPS on outcomes including postoperative complications after curative resection of gastric cancer.

Methods

The systemic inflammatory response was assessed by GPS, and the severity of postoperative complications was evaluated according to the Clavien?CDindo classification. Survival analysis was performed by the Kaplan?CMeier method and the log rank test. Multivariate analysis was performed to determine significant associations with complications by a logistic regression model and the independent prognostic values by Cox??s proportional hazards model.

Results

Study patients (n?=?1017) were allocated as follows: 904 (88.9?%) to GPS 0, 92 (9.0?%) to GPS 1, and 21 (2.1?%) to GPS 2. One hundred sixty-three patients (16.0?%) had postoperative complications of ?? grade 2. Multivariate logistic analysis identified gender, body mass index, tumor location, tumor depth, blood transfusion, and comorbidity as significantly correlated with postoperative complications. However, GPS was not associated with the incidence of complication. On the other hand, multivariate analysis for overall survival identified GPS as an independent prognostic factor.

Conclusions

GPS is a significant predictor of long-term survival in curable gastric cancer surgery but not of short-term outcomes.     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

Successful Gastric Submucosal Tumor Resection Using Laparoscopic and Endoscopic Cooperative Surgery

Background  

Laparoscopic wedge resections are increasingly utilized to treat gastric submucosal tumors (SMTs). However, laparoscopic wedge resection is not applicable for tumors located near the gastric inlet or outlet and requires resection of relatively large sections of healthy stomach, particularly if laparoscopic linear staplers are used.     

Short- and Long-Term Outcomes of Vertical Banded Gastroplasty Converted to Roux-en-Y Gastric Bypass

Background

Vertical banded gastroplasty (VBG) often necessitates revisional surgery for weight regain or symptoms related to gastric outlet obstruction. Roux-en-Y gastric bypass (RYGB) is considered as the revisional procedure of choice. However, revisional bariatric surgery is associated with relatively higher rates of complications. The aim of the current study is to analyse our single-centre experience with patients requiring revisional RYGB following primary VBG.

Methods

Retrospective review of the prospectively collected database identified 153 patients who underwent RYGB as a revisional procedure after VBG from Feb 2004–Feb 2011. Early and late complications, weight data and resolution of symptoms related to gastric outlet obstruction were analysed.

Results

One hundred twenty-three females and 30 males underwent revisional RYGB post VBG. Mean age was 44.4 (15–74) years with a mean pre-operative body mass index (BMI) of 34.2 (23.5–65.5) kg/m². Mean hospital stay was 4.3 days. Early complication rate was 3.9 % with a 30-day re-operation rate of 1.3 %. Mortality and leak rate were zero. After a mean follow-up of 48 months, the mean BMI decreased significantly to 28.8 kg/m² and a complete resolution of the obstructive symptoms was achieved in nearly all patients. Late complications developed in 11 (7.7 %) of the patients of which seven (4.9 %) required surgery.

Conclusions

Revisional RYGB following VBG is technically challenging but safe with low rates of morbidity and mortality, comparable to primary RYGB. It produces a significant reduction in body weight and in symptoms resolution. We recommend RYGB as the procedure of choice in patients requiring revisional surgery following VBG.     

Laparoscopic Wedge Resection for Gastrointestinal Stromal Tumors of the Stomach: Initial Experience

PURPOSE: Surgery for gastrointestinal stromal tumors (GIST) of the stomach is now frequently performed using a laparoscopic approach. We investigated the feasibility and effectiveness of laparoscopy in the management of GIST of the stomach. METHODS: We reviewed the records of 12 consecutive patients who underwent laparoscopic surgery for GIST between April 2000 and April 2004, and compared their short-term outcomes with those of patients who underwent open surgery. All laparoscopic wedge resections were done using stapling devices and 3-4 trocars, often with the aid of intraoperative gastroscopy. We examined all patients preoperatively using various diagnostic modalities, including endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA). A laparoscopic approach was not indicated if the tumor was located near the cardia or pylorus or if it was >=5 cm in diameter. RESULTS: A specific diagnosis of GIST was obtained preoperatively by EUS-FNA in 10 of the 12 patients. The median diameter of the lesion was 2.7 cm (range, 1.5-4.8 cm). Although intraoperative complications were encountered in two patients, conversion to open surgery was not required, and we were able to perform complete tumor excision with negative surgical margins in all patients. The median operative time was 100 min (range, 65-180 min), similar to that for open surgery. First flatus was passed earlier, and the interval to resuming oral intake was shorter than after open surgery. No major postoperative complications such as leakage developed, and the median postoperative hospital stay was 7 days (range, 5-12 days). All diagnoses made by EUS-FNA were confirmed by immunohisto-pathological evaluation of resected specimens. CONCLUSION: Laparoscopic wedge resection is a feasible treatment option for GISTs of the stomach if the lesion is <5 cm in diameter.     

腹腔镜胃间质瘤切除术23例

目的:探讨腹腔镜下胃间质瘤切除术的可行性及临床应用价值。方法:回顾分析23例腹腔镜下胃间质瘤切除术的手术方式、术中处理原则以及术后相关指标。结果:23例手术全部成功,平均手术时间(133±68)min,平均出血量40mL,术后平均肠道功能恢复时间(36.6±16.2)h,平均住院(8.1±3.0)d。结论:腹腔镜下胃切除术治疗胃间质瘤是安全、可行的,不同位置手术难易程度相差较大,位于后壁及近贲门部较大的间质瘤应格外慎重。     

Outcomes and Use of Laparoscopic Versus Open Gastric Resection

Background and Objectives:

The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes.

Methods:

The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0–151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors.

Results:

A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preoperative risk factors, complications were significantly fewer in laparoscopic versus open gastric resection (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.45–0.82; P = .001). After adjusting for preoperative risk factors, there was no statistically significant difference in mortality with laparoscopic compared to open gastric resection (OR 0.74; 95% CI = 0.32–1.72; P = .481).

Conclusions:

Laparoscopy is underused in the treatment of gastric cancer. Given that laparoscopic gastric resection has a lower morbidity in comparison to open resection, steps should be made toward advancing the use of laparoscopy for gastric cancer.     

Robotic Techniques in Esophagogastric Cancer Surgery: An Assessment of Short- and Long-Term Clinical Outcomes

Annals of Surgical Oncology - Robotic esophagogastric cancer surgery is gaining widespread adoption. This population-based cohort study aimed to compare rates of textbook outcomes (TOs) and...     

Expanding the Indications for Laparoscopic Gastric Resection for Gastrointestinal Stromal Tumors

Objective:

Laparoscopic resection of large gastric gastrointestinal stromal tumors (GIST) has been controversial. This generally has been limited to small lesions. We hypothesize that laparoscopic mobilization and resection using, in some cases, extracorporeal anastomosis of the gastrointestinal (GI) tract is an oncologically safe alternative to open surgery even when tumors are large.

Methods:

Four patients underwent a laparoscopic approach for gastric GIST tumors >2 cm at Methodist Dallas Medical Center over a 6-month period. Patient demographics, operative findings, postoperative course, and pathologic characteristics were examined.

Results:

The mean age in this patient group was 58 years (range, 36 to 77). Gastrointestinal bleeding and dyspepsia were the most common symptoms. Seventy-five percent of the patients were females. Mean tumor size was 10 cm (range, 2.5 to 20) with distribution in the stomach as follows: 75% greater curvature and 25% antrum. Tumors were removed by wedge, sleeve, and partial gastrectomies. Two of these tumors showed a high grade and the other 2 a moderate grade of differentiation. The number of mitoses was <5/50 HPF in all the tumors. No intraoperative spillage occurred in any patients, even with the largest tumor (20 cm). Importantly, all tumors were excised with a negative gross and microscopic margin. Average length of stay was 4 days. No patients required reoperation, and there were no complications postoperatively.

Conclusion:

Minimally invasive assisted approaches may be an option to treat large GIST tumors. Obeying principles of minimal touch, no spillage, and obtaining a negative margin, a safe operation with a laparoscopic approach is feasible, even in giant tumors. The large size of diagnosed GIST tumors should not preclude a minimally invasive approach.     

Multicenter Study of Short- and Long-Term Outcomes of Laparoscopic Palliative Resection for Incurable, Symptomatic Stage IV Colorectal Cancer in Japan

Background

This Japanese multicenter retrospective study evaluated short- and long-term outcomes of palliative laparoscopic procedures for symptomatic stage IV colorectal cancer compared with conventional open procedures.

Methods

Of 968 eligible patients with stage IV colorectal cancer enrolled during January 2006–December 2007 from 41 participating surgical units (Japan Society of Laparoscopic Colorectal Surgery Group), we studied 409 patients who underwent palliative resection of symptomatic primary colorectal tumor.

Results

Data from patients with laparoscopic resection (n?=?98) and open colorectal resection (n?=?311) were analyzed. Eleven (11.2 %) laparoscopic operations were converted to an open procedure. Fewer complications were reported for laparoscopic resections than for open procedures (13.3 vs. 26.7 %; p?=?0.0042). Postoperative hospital stay was significantly shorter in the laparoscopic vs. open resection group (median, 14 vs. 17 days; p?=?0.0242). Postoperative chemotherapy treatment was administered to 245 (78.9 %) patients in the open and 78 (79.6 %) patients in the laparoscopic resection group. Time from surgery to start of postoperative chemotherapy was significantly shorter in the laparoscopic vs. open resection group (median, 32 vs. 27 days; p?=?0.0487). Median survival time between the two groups was not significantly different (22.0 vs. 22.2 months; p?=?0.948).

Conclusions

Laparoscopic palliative resection results in reduced postoperative complications and earlier recovery with acceptable long-term outcomes comparable with open surgery. When performed by experienced surgeons in selected patients, it may be a safe and feasible option. Because of the potential of significant bias arising from the included studies, further randomized controlled trials should be undertaken to confirm this bias.     

Short- and Long-Term Outcomes of Liver Resection for Intrahepatic Cholangiocarcinoma Associated with the Metabolic Syndrome

World Journal of Surgery - While the metabolic syndrome (MS) is being recognized as an important risk factor for intrahepatic cholangiocarcinoma (ICC), the outcomes of liver resection in this...     

Long-Term Outcomes of Laparoscopic Roux-en-Y Gastric Bypass in US Veterans

Background  

The objective of this study is to evaluate the long-term outcomes following laparoscopic Roux-en-Y gastric bypass (LREYGB) in veteran patients. The VA bariatric population differs from its counterpart in the private sector by the predominance of a male population, a higher percentage of patients from a lower socioeconomic background, a higher mean age, and a higher rate of obesity-related comorbidities.     

Wedge Resection Offers Similar Survival to Segmentectomy for Typical Carcinoid Tumors

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