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

Abstract

BackgroundSurgical 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.MethodsPatients 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.ResultsA 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.ConclusionsOur 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 TrialsClinicalTrials.gov NCT03804762.Electronic supplementary materialThe online version of this article (10.1007/s00464-019-07223-w) contains supplementary material, which is available to authorized users.

Minimally Invasive Approach to Gastric GISTs: Analysis of a Multicenter Robotic and Laparoscopic Experience with Literature Review

“…The authors described a new surgical cooperation between robotic and endoscopic surgery, where the GG was identified through the endoscopic view and, after a submucosal injection, was dissected through robotic surgery (Table 4) [36].…”

Clinical outcomes and functional analysis of third space robotic and endoscopic cooperative surgery versus laparoscopic wedge resection for gastric submucosal tumours: a propensity score-matched study

“…One might be vagal nerve injury. Given the important role of the vagal nerve in gastric motility and sensation regulation, vagal nerve injury may impair these functions and thereby lead to gastrointestinal symptoms 28 , 29 . Furthermore, several studies have reported that vagal nerve injury is associated with higher gastrointestinal symptom scores 28 , 30 , 31 .…”

“…Given the important role of the vagal nerve in gastric motility and sensation regulation, vagal nerve injury may impair these functions and thereby lead to gastrointestinal symptoms 28 , 29 . Furthermore, several studies have reported that vagal nerve injury is associated with higher gastrointestinal symptom scores 28 , 30 , 31 . In the LWR group, stapler firings caused a considerable amount of wedge-shaped gastric wall to be resected along with the tumour, which could easily lead to unintentional injury to branches of the vagus nerve.…”

A narrative review of surgical management of gastrointestinal stromal tumors

“…The first document about LECS was published by Hiki et al in 2008 and they had proved this method as a safe procedure and especially advantageous in removing the tumor completely without excessive resection of the gastric wall. Recently, several laparoscopic approaches including laparoscopic and endoscopic cooperative surgery (LECS) have been developed for small gastric GISTs near the gastroesophageal junction and pylorus to preserve junctional functions (46).…”

“…An additional advantage of the procedure was low blood loss and quick recovery after the surgery. TS-RECS seems to be a promising treatment for gastric GIST >2 cm but this method requires further research due to the small number of patients included in the study (46,47).…”