Transgastric laparoendoscopic approach to tumours of the stomach

Abstract

Background: There is currently limited data to reassure the technical efficacy, particularly in attaining clear margins, through a transgastric laparo-endoscopic approach to resecting tumours located near the gastroesophageal junction (GOJ) or the pylorus. Methods: Single institution retrospective analysis of all cases from 1 April 2008 to 31 Dec 2019. Results: Overall, 34 patients (38 tumours) underwent transgastric laparo-endoscopic resection. Of these, 27 (71.1%) and 5 (14.7%) cases were located close to the GOJ and pylorus respectively. Three (8.0%) cases were converted to conventional laparoscopic excision. No anatomical gastric resection was required. The mean (SD) operative time was 167.5 (64.2) minutes and reduced with increasing experience. The median (IQR) length-of-stay was 3.0 (3.0-4.5) days. Major post-operative complication (Clavian-Dindo ≥3) occurred in 1 (2.9%) patient, which required surgical control of staple line bleeding. The most common pathology was gastrointestinal stromal tumour (71.1%), followed by leiomyoma (10.5%), schwannoma (5.2%), dysplastic polyp (5.2%), and neuroendocrine tumour (2.6%). The mean (SD) tumour diameter was 3.9 (2.1) cm (largest 10.1 cm, 10 cases >5 cm). Resection margins were clear in all cases. We found no evidence of tumour recurrence or gastric stenosis at a median follow-up of 88 months. Conclusion: Transgastric laparo-endoscopic resection of junctional and pyloric tumours with low metastatic potential is technically feasible. This approach achieved clear resection margins in all our cases, with acceptable perioperative and longer-term outcomes.

Laparoendoscopic assisted surgery for a gastrointestinal stromal tumor (GIST): A case report

“…Initially, the NCCN established that the use of laparoscopy in GISTs should be limited to tumors that were <2 cm in size because of the risk of tumor rupture, seeding of the peritoneum, and the ability to achieve clear oncologic margins [11] . A retrospective review of 34 patients who had a laparo-endoscopic resection for their tumors by Yahya et al [17] , pointed out that laparo-endoscopic resection of junctional and pyloric tumors with low metastatic potential is technically feasible and that this approach shows great results, with clear margins and acceptable perioperative and longer-term outcomes, which is consistent with our results [17] . The surgical technique described in this case report is comparable to the one described in this retrospective review; with gastrostomies made on the greater curvature with ample room for closure without compromising the GEJ, by being entirely self-contained, minimizing the risk of tumor cell spillage into the abdominal cavity compared to other approaches, and by using intragastric insufflation, flattening the rugal folds, and allowing precise localization and resection of the target site [17] .…”

“…A retrospective review of 34 patients who had a laparo-endoscopic resection for their tumors by Yahya et al [17] , pointed out that laparo-endoscopic resection of junctional and pyloric tumors with low metastatic potential is technically feasible and that this approach shows great results, with clear margins and acceptable perioperative and longer-term outcomes, which is consistent with our results [17] . The surgical technique described in this case report is comparable to the one described in this retrospective review; with gastrostomies made on the greater curvature with ample room for closure without compromising the GEJ, by being entirely self-contained, minimizing the risk of tumor cell spillage into the abdominal cavity compared to other approaches, and by using intragastric insufflation, flattening the rugal folds, and allowing precise localization and resection of the target site [17] . Choi et al [10] proposed that in lesions located in the lesser curvature near the pylorus or the GEJ a laparoscopic-assisted proximal or distal gastrectomy should be done carefully, so as not to compromise the lumen of the stomach.…”

“…However, some concerns were raised about GISTs located near the gastroesophageal junction (GEJ) because of the high risk of causing deformity and complications such as leakage of the staple line [14] , [15] . Yahya et al [17] , reported that in their series of 34 cases 5 patients presented complications. The principal risk of this surgical approach was post-operative bleeding, which presented in 4 of these patients and a minor leak with post-operative collection, which occurred in one patient [17] .…”

“…Yahya et al [17] , reported that in their series of 34 cases 5 patients presented complications. The principal risk of this surgical approach was post-operative bleeding, which presented in 4 of these patients and a minor leak with post-operative collection, which occurred in one patient [17] . These complications need to be taken into account when considering this approach, individualizing each patient, evaluating specially their risk of bleeding, and taking meticulous care and inspection intraoperatively ensuring hemostasis.…”