Laparoscopic techniques and strategies for gastrointestinal GISTs

Abstract

The laparoscopic approach is widely accepted surgical treatment for gastrointestinal submucosal tumors (SMTs). In this chapter, we will introduce laparoscopic techniques and strategy for gastrointestinal SMTs, in accordance with those for gastrointestinal stromal tumors (GISTs). The indication for a laparoscopic approach has been related to tumor size. The upper limit of tumor size has increased, according to recent trends, and there is no established guideline for a lower limit. All patients undergoing laparoscopic surgery receive preoperative examinations including gastrofiberscopy, upper gastrointestinal radiography, computed tomography (CT), and endoscopic ultrasonography (EUS). Gastric tumors <20 mm in diameter measured by EUS or CT are preoperatively localized by gastrofiberscopic clipping of the mucosa covering the SMT. While maintaining the principle of local resection with a negative resection margin, different surgical techniques are required depending on the location and configuration of the tumor. A single dose of a second-generation cephalosporin is administered to patients as a prophylactic antibiotic before or immediately after operation. If a patient undergoes wedge resection, a semi-bland diet will be provided within 48-72 hours. However, in cases of proximal or distal gastrectomy, the diet will be restricted for several days. A "no-touch" technique, by which the risk of tumor dissemination can be minimized, includes grasping the surrounding tissues, holding the threads sutured at the normal serosa around the tumor, and using a laparoscopic stapler or bag during laparoscopic resection.

Comparison of Safety and Outcomes between Endoscopic and Surgical Resections of Small (≤ 5 cm) Primary Gastric Gastrointestinal Stromal Tumors

“…In our study, among 20 patients underwent subtotal gastrectomies, 8 had concurrent gastric intraepithelial neoplasia, 5 had another submucosal tumor lesion discovered at the operative procedure, and 7 had tumors at difficult regions, such as cardia and pylorus. Many studies showed different surgical techniques are required depending on the tumor location and configuration to ensure a complete resection with a negative resection margin 26-29.…”

EUS-guided gastroenterostomy assisted by extrinsic abdominal compression to treat gastric obstruction after surgical resection of a GI stromal tumor

“… 1 Postoperative stenosis of the gastric lumen is a described adverse event after laparoscopic wedge resection of submucosal tumors located on the lesser curvature. 2 , 3 We describe a case of EUS-guided gastroenterostomy facilitated by extrinsic abdominal compression to treat gastric obstruction resulting from a laparoscopic wedge resection of a gastrointestinal stromal tumor.…”

Successful Laparoscopic Sleeve Gastrectomy in Emergency for a Gastric Gastrointestinal Stomal Tumor (GIST) with Acute Bleeding: A Case Report

“…The limitation of tumor size for laparoscopic surgery has traditionally been considered “diameter not more than 2 cm” but recent published data show the safety and feasibility of laparoscopic resection in large (>5 cm) and giant (>10 cm) gastric GISTs. This limit should increase in the near future and current guidelines do not state an absolute indication regarding tumor size [ 12 ]. Open surgery still plays a fundamental role in GISTs that require complex multivisceral resection, large lesions necessitating delicate tissue handling (to prevent tumor rupture or spill-age), or large abdominal incisions for specimen retrieval [ 9 ].…”