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Laparoscopic wedge resection for gastric GIST: Long-term follow-up results
EJSO 33 (2007) 444e447
www.ejso.com
Laparoscopic wedge resection for gastric GIST: Long-term follow-up results* S.-M. Choi a, M.-C. Kim a,*, G.-J. Jung a, H.-H. Kim b, H.-C. Kwon c, S.-R. Choi c, J.-S. Jang c, J.-S. Jeong d a
Department of Surgery, Dong-A University College of Medicine, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan 602-715, Korea b Department of Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Korea c Department of Internal medicine, Dong-A University College of Medicine, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan 602-715, Korea d Department of Pathology, Dong-A University College of Medicine, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan 602-715, Korea Accepted 2 November 2006 Available online 13 December 2006
Abstract Aim: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Recently, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST. However, no study has provided longterm follow up results of laparoscopic surgery for gastric GIST. The aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure. Materials and methods: Between January 1998 and August 2005, 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients’ clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively. Results: The mean age of patients was 59.7 years, and 12 patients were women. Twelve patients (47%) presented with epigastric pain. The mean tumor size was 4.2 2.1 cm, and most tumors were located in the upper stomach (52.2%). The mean operative time was 104.3 min. No case of open conversion, reoperation and operative mortality occurred in the present study. Most patients had very low and low risk (60.6%), while only two patients had high risk malignancy. During a median follow-up period of 61 months (range, 7e98 months), there have been no recurrences or metastases. Conclusion: Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon. Ó 2006 Published by Elsevier Ltd. Keywords: Gastrointestinal stromal tumor; Stomach; Laparoscopic surgery
Introduction Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract.1,2 The cells in GIST have characteristics similar to those of the interstitial cells of Cajal, ‘‘pacemaker cells,’’ which play a neuromotor role in normal gut motility, and which are characterized by the expression of KIT.3 GISTs may arise anywhere in the tubular GI tract, from the esophagus to the rectum more specially, 50e60% of lesions arise * This Paper was supported by the Dong-A University Research Fund in 2006. * Corresponding author. Tel.: þ82 51 240 2643; fax: þ82 51 247 9316. E-mail address: [email protected] (M.-C. Kim).
0748-7983/$ - see front matter Ó 2006 Published by Elsevier Ltd. doi:10.1016/j.ejso.2006.11.003
in the stomach, 20e30% in the small bowel, 10% in the large bowel, 5% in the esophagus, and 5% elsewhere in the abdominal cavity.4 Gastric GISTs are generally associated with better survival than small intestinal GISTs, which have a similar mitotic activity and size.5,6 Gastric GISTs <5 cm are usually benign, and many tumors that measure 5e10 cm with limited mitotic activity also show a good prognosis.7 As a result of rapid advances in diagnostic instrumentation and the increased use of mass screening and individual examinations, submucosal tumors of the stomach are being detected more frequently in Korea, and approximately 58e70% of these lesions are GISTs, leiomyomas or leiomyosarcomas.8,9 Despite the development of a new chemotherapeutic agent, imatinib mesylate, surgery remains
S.-M. Choi et al. / EJSO 33 (2007) 444e447
the only curative treatment for non-metastatic GIST.9 Since Lukaszczyk and Preletz’s first report in 199210, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST, for example, on surgical technique and immediate postoperative outcome.8,9,11,12 However, no study has provided long-term follow up results of laparoscopic surgery for gastric GIST. Thus, the aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure. Materials and methods Between January 1998 and August 2005, a total of 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of these 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients’ clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively. All patients were evaluated every six months during the first two years and every one year thereafter. Abdominal computed tomography (CT), endoscopy, and serum chemistry were carried out. Indications for laparoscopic surgery were a tumor size >2 cm or a tumor with associated symptoms such as bleeding or obstruction, even if the tumor size was <2 cm. Tumors involving the esophagogastric junction or pylorus were excluded. Surgical procedure The surgeon stood on the patient’s right, with the first assistant on the patient’s left and the camera operator on the surgeon’s right. A camera port was inserted into the supraumbilical lesion using an open technique. Under pneumoperitoneum of 10e14 mmHg, two additional ports were inserted into the right upper abdomen to identify the tumor location. After locating the tumor, 1e2 extra assistant’s ports were placed to aid manipulation of the stomach. In cases with extra-luminal GIST, wedge resection of the gastric wall was performed using laparoscopic stapling devices (Endo-GIA laparoscopic stapler, Tyco Autosuture, Norwalk CT, USA), whilst maintaining a safe margin from the tumor, if necessary, after the gastric wall had been devascularized and exposed using ultrasonic shears (Laparoscopic Coagulating Shears: LCS; Ethicon EndoSurgery, Cincinnati, OH, USA). In cases with intra-luminal GIST, the same procedure was performed using Endo-GIA after intraoperatively gastroscopy-guided identification of the tumor location. Resected specimens were placed into an endoscopic retrieval bag and extracted via the umbilical wound. In all cases, our pathologist reported a free margin of normal gastric wall by frozen section biopsy. One closed suction drain was placed around the
445
surgical site at the end of the procedure and trocar wounds were closed. Results The clinicopathologic data are shown in Table 1. The study subjects were 11 men and 12 women, of average age 59.7 8.3 years. Clinical manifestations included epigastric pain (12 cases), melena (4 cases), dyspepsia (2 cases), nausea (1 case) and vomiting (1 case). Three cases were found incidentally during screening. Tumor locations were classified into three types, namely, upper (12 cases), middle (6 cases), lower (5 cases), and mean tumor size was 4.2 2.1 cm. The risk categorizations of these gastric GISTs having an aggressive behavior, based on tumor size and mitotic activity, were: very low (2 cases); low (12 cases); intermediate (7 cases); and high (2 cases). Suggested definitions for these risk categories are shown in Table 2. The mean operation time of all but 3 patients who required additional surgery was 104.3 min (Table 3). It included cholecystectomy, left adrenalectomy, and distal gastrectomy. And average count of Endo-GIA used was 3.6. Intraoperative endoscopy was used to help identify tumor position in 7 patients (30.4%). No incidence of tumor rupture or spillage occurred intra-operatively. Overall, postoperative mean length of hospital stay was 5.2 2.3 days. No case of open conversion, reoperation and operative mortality occurred in the present study. A postoperative complication was encountered in one patient who experienced delayed gastric emptying, however, no major postoperative complications, such as bleeding, leakage, obstruction and intraabdominal abscess occurred. During a median
Table 1 Clinicopathologic data Patients’ number Age (mean SD, year) Sex (male: female) Symptom Epigastric pain Melena Dyspepsia Nausea Vomiting No symptom Tumor location Upper Middle Lower Tumor size (mean SD, cm) Pathologic classification Very low risk Low risk Intermediate risk High risk SD, standard deviation.
23 59.7 8.3 11: 12 11 3 2 1 1 3 13 5 5 4.3 2.1 2 12 7 2
S.-M. Choi et al. / EJSO 33 (2007) 444e447
446
Table 2 Proposed approaches for defining risk of aggressive behavior in GISTs
Very low risk Low risk Intermediate risk High risk
Size
Mitotic count
<2 cm 2e5 cm <5 cm 5e10 cm >5 cm >10 cm Any size
<5/50 HPF <5/50 HPF 6e10/50 HPF <5/50 HPF >5/50 HPF Any mitotic rate >10/50 HPF
HPF, high-power field.
follow-up period of 61 months (range, 7e98 months), there have been no recurrences or metastases. Discussion Gastrointestinal stromal tumors (GISTs) comprise a spectrum of neoplasmas with variable malignant potential, ranging from benign to aggressive. Due to their similar appearance under the light microscope, GISTs were previously thought to be smooth muscle neoplasms, and most were classified as leiomyosarcoma.13 Moreover, the principle of surgical treatment of smooth muscle tumors was local excision with a 2 cm margin of surrounding gastric wall.14 Surgical treatment However, recent advances in understanding the molecular pathogenesis of GIST have brought about rapid improvements in its management. Large margins of this size are unnecessary since gastric GISTs usually grow out of the primary organ rather than being diffusely infiltrating, and lymphadenectomy is usually unwarranted because of the rarity of nodal metastasis.13,15 Thus, most investigators agree that wedge resection of the stomach may be considered a standard treatment for gastric GISTs. Laparoscopic enucleation of the tumor from gastric submucosal space has been recommended for gastric submucosal tumor.16 However, the preoperative diagnostic accuracy of gastric submucosal tumor is unsatisfactory and if gastric GIST is accidentally ruptured during surgery, peritoneal dissemination may occur. Therefore, a gastric GIST should be resected with great care keeping the tumor capsule intact. Table 3 Operative outcomes and follow-up Conversion to open Operation time (mean SD, minute) Mean blood loss (range, ml) Postoperative hospital stay (mean SD, day) Postoperative morbidity (%) Postoperative mortality (%) Follow up period (median, month) Recurrence or Metastasis SD, standard deviation.
0 104.3 42.3 39 (0e300) 5.2 2.3 1 (4.3%) 0 (0%) 61 0 (0%)
However, Aparicio et al. reported that peri-tumoral resection conferred a high risk of local recurrence and should be avoided, and recommended a segmental organ resection for localized, resectable GISTs patients, such as partial or total gastrectomy, small bowel resection, the Whipple procedure or anterior rectal resection.17 Unfortunately, no detailed data were provided on the survival of gastric GIST patients vs. operative procedure. The present study presents the first 5-year survival results of laparoscopic wedge resection for gastric GIST, although the number of enrolled patients was not particularly high. Laparoscopic approach in treatment Currently, gastric GIST is viewed as a good indication for laparoscopic resection. Moreover, the development of laparoscopic stapling devices and surgical techniques have made laparoscopic wedge resection an attractive alternative to conventional open surgery.18 In such early gastric cancer cases, many benefits of laparoscopic distal gastrectomy included faster postoperative recovery, a reduced requirement for additional analgesics, and a smaller wound size. Its only known disadvantage was increased duration of surgery.19,20 Previous studies of laparoscopic wedge resection of gastric submucosal tumor, including gastric GISTs, have demonstrated excellent postoperative outcomes, e.g., a short operation time (78.3e180 min), a low open conversion rate (0e23.3%), short hospital stay (5e7 days), a low complication rate (2.9e25.0%), and modest blood loss (0e196 ml).8,9,11,21 In a comparative study of open and laparoscopic surgery for gastric GIST, tumor size, duration of surgery, and estimated blood loss were not found to be significantly different, although the laparoscopic group had a shorter hospital stay.12 In our institution, we have performed over 80 laparoscopic gastrectomies per annum for gastric cancer since 2003, and we have no experience of open conversion, reoperation and operative mortality for laparoscopic wedge resection for gastric GISTs. One patient developed delayed gastric emptying after gastric GIST excision and intracorporeal suture of gastrotomy site. In this case, the tumor was located on the lesser curvature of the mid-body. Nevertheless, the patient was discharged on postoperative day 5 after conservative management. Prognosis Surgery has been, and continues to be the mainstay of GIST treatment. However, 5-year survival rates after open surgery range from 34 to 76.5%.13,22e24 The prognosis of GIST after surgical treatment is influenced by tumor malignant potential and the completeness of primary resection. Bucher et al. reported that the 5-year actuarial survival of low grade GIST patients was 95% and in high grade GIST, 21%, and recommended adjuvant treatment with imatinib mesylate after surgical resection for patients with high grade GIST.25 Although the primary site was not
S.-M. Choi et al. / EJSO 33 (2007) 444e447
found to be a prognostic factor of disease-free survival by univariate analysis, gastric GIST is considered to have a better survival than small intestinal GIST, which has a similar mitotic activity and size.17,26,27 We have not experienced any recurrence after laparoscopic wedge resection for gastric GIST, although most of our patients were at very low or low risk (60.6%), in fact, only two were at high risk. Furthermore, another single patient received chemotherapy for metachronous cholangiocarcinoma with hepatic metastasis. Conclusion In light of its biologic behavior, GIST may be a good candidate for minimally invasive surgery. Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon. References 1. Hirota S, Isozaki K, Moriyama Y, et al. Gain-of-function mutations of ckit in human gastrointestinal stromal tumors. Science 1998;279:577–80. 2. Sircar K, Hewlett BR, Huizinga JD, Chorneyko K, Berezin I, Riddell RH. Interstitial cells of Cajal as precursors of gastrointestinal stromal tumors. Am J Surg Pathol 1999;23:377–89. 3. O’Leary T, Berman JJ. Gastrointestinal stromal tumors: answers and questions. Hum Pathol 2002;33:456–8. 4. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002;33:459–65. 5. Ueyama T, Guo KJ, Hashimoto H, Daimaru Y, Enjoji M. A clinicopathologic and immunohistochemical study of gastrointestinal stromal tumors. Cancer 1992;69:947–55. 6. Emory TS, Sobin LH, Lukes L, Lee DH, O’Leary TJ. Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site. Am J Surg Pathol 1999;23:82–7. 7. Appelman H, Helwig EB. Cellular leiomyomas of the stomach in 49 patients. Arch Pathol Lab Med 1977;101:373–7. 8. Otani Y, Ohgami M, Igarashi N, et al. Laparoscopic wedge resection of gastric submucosal tumors. Surg Laparosc Endosc Percutan Tech 2000;10:19–23. 9. Mochizuki Y, Kodera Y, Fujiwara M, et al. Laparoscopic wedge resection for gastrointestinal stromal tumors of the stomach: initial experience. Surg Today 2006;36:341–7. 10. Lukaszczyk JJ, Preletz Jr RJ. Laparoscopic resection of benign stromal tumor of the stomach. J Laparoendosc Surg 1992;2:331–4.
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11. Hindmarsh A, Koo B, Lewis MP, Rhodes M. Laparoscopic resection of gastric gastrointestinal stromal tumors. Surg Endosc 2005;19: 1109–12. 12. Matthews BD, Walsh RM, Kercher KW, et al. Laparoscopic vs. open resection of gastric stromal tumors. Surg Endosc 2002;16:803–7. 13. DeMatteo RP, Lewis JJ, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg 2000; 231:51–8. 14. Blanke CD, Eisenberg BL, Heinrich MC. Gastrointestinal stromal tumors. Curr Treat Options Oncol 2001;2:485–91. 15. Joensuu H, Fletcher C, Dimitrijevic S, Silberman S, Roberts P, Demetri G. Management of malignant gastrointestinal stromal tumours. Lancet Oncol 2002;3:655–64. 16. Ludwig K, Weiner R, Bernhardt J. Minimally invasive resections of gastric tumors. Chirurg 2003;74:632–7. 17. Aparicio T, Boige V, Sabourin JC, et al. Prognostic factors after surgery of primary resectable gastrointestinal stromal tumours. Eur J Surg Oncol 2004;30:1098–103. 18. Hyung WJ, Lim JS, Cheong JH, Kim J, Choi SH, Noh SH. Laparoscopic resection of a huge intraluminal gastric submucosal tumor located in the anterior wall: eversion method. J Surg Oncol 2005;89: 95–8. 19. Kim MC, Kim KH, Kim HH, Jung GJ. Comparison of laparoscopyassisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer. J Surg Oncol 2005; 91:90–4. 20. Tanimura S, Higashino M, Fukunaga Y, et al. Respiratory function after laparoscopic distal gastrectomy-an index of minimally invasive surgery. World J Surg 2006;30:1211–5. 21. Choi YB, Oh ST. Laparoscopy in the management of gastric submucosal tumors. Surg Endosc 2000;14:741–5. 22. Bucher P, Villiger P, Egger JF, Buhler LH, Morel P. Management of gastrointestinal stromal tumors: from diagnosis to treatment. Swiss Med Wkly 2004;134:145–53. 23. Boni L, Benevento A, Dionigi G, Rovera F, Dionigi R. Surgical resection for gastrointestinal stromal tumors (GIST): experience on 25 patients. World J Surg Oncol 2005;3:78. 24. Wong NA, Young R, Malcomson RD, et al. Prognostic indicators for gastrointestinal stromal tumours: a clinicopathological and immunohistochemical study of 108 resected cases of the stomach. Histopathology 2003;43:118–26. 25. Bucher P, Egger JF, Gervaz P, et al. An audit of surgical management of gastrointestinal stromal tumours (GIST). Eur J Surg Oncol 2006;32: 310–4. 26. Appelman HD. Mesenchymal tumors of the gut: historical perspectives, new approaches, new results, and does it make any difference? Monogr Pathol 1990;31:220–46. 27. Appelman HD. Smooth muscle tumors of the gastrointestinal tract. What we know now that Stout didn’t know. Am J Surg Pathol 1986; 10:83–99.
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Laparoscopic wedge resection for gastric GIST: Long-term follow-up results* S.-M. Choi a, M.-C. Kim a,*, G.-J. Jung a, H.-H. Kim b, H.-C. Kwon c, S.-R. Choi c, J.-S. Jang c, J.-S. Jeong d a
Department of Surgery, Dong-A University College of Medicine, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan 602-715, Korea b Department of Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Korea c Department of Internal medicine, Dong-A University College of Medicine, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan 602-715, Korea d Department of Pathology, Dong-A University College of Medicine, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan 602-715, Korea Accepted 2 November 2006 Available online 13 December 2006
Abstract Aim: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Recently, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST. However, no study has provided longterm follow up results of laparoscopic surgery for gastric GIST. The aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure. Materials and methods: Between January 1998 and August 2005, 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients’ clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively. Results: The mean age of patients was 59.7 years, and 12 patients were women. Twelve patients (47%) presented with epigastric pain. The mean tumor size was 4.2 2.1 cm, and most tumors were located in the upper stomach (52.2%). The mean operative time was 104.3 min. No case of open conversion, reoperation and operative mortality occurred in the present study. Most patients had very low and low risk (60.6%), while only two patients had high risk malignancy. During a median follow-up period of 61 months (range, 7e98 months), there have been no recurrences or metastases. Conclusion: Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon. Ó 2006 Published by Elsevier Ltd. Keywords: Gastrointestinal stromal tumor; Stomach; Laparoscopic surgery
Introduction Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract.1,2 The cells in GIST have characteristics similar to those of the interstitial cells of Cajal, ‘‘pacemaker cells,’’ which play a neuromotor role in normal gut motility, and which are characterized by the expression of KIT.3 GISTs may arise anywhere in the tubular GI tract, from the esophagus to the rectum more specially, 50e60% of lesions arise * This Paper was supported by the Dong-A University Research Fund in 2006. * Corresponding author. Tel.: þ82 51 240 2643; fax: þ82 51 247 9316. E-mail address: [email protected] (M.-C. Kim).
0748-7983/$ - see front matter Ó 2006 Published by Elsevier Ltd. doi:10.1016/j.ejso.2006.11.003
in the stomach, 20e30% in the small bowel, 10% in the large bowel, 5% in the esophagus, and 5% elsewhere in the abdominal cavity.4 Gastric GISTs are generally associated with better survival than small intestinal GISTs, which have a similar mitotic activity and size.5,6 Gastric GISTs <5 cm are usually benign, and many tumors that measure 5e10 cm with limited mitotic activity also show a good prognosis.7 As a result of rapid advances in diagnostic instrumentation and the increased use of mass screening and individual examinations, submucosal tumors of the stomach are being detected more frequently in Korea, and approximately 58e70% of these lesions are GISTs, leiomyomas or leiomyosarcomas.8,9 Despite the development of a new chemotherapeutic agent, imatinib mesylate, surgery remains
S.-M. Choi et al. / EJSO 33 (2007) 444e447
the only curative treatment for non-metastatic GIST.9 Since Lukaszczyk and Preletz’s first report in 199210, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST, for example, on surgical technique and immediate postoperative outcome.8,9,11,12 However, no study has provided long-term follow up results of laparoscopic surgery for gastric GIST. Thus, the aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure. Materials and methods Between January 1998 and August 2005, a total of 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of these 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients’ clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively. All patients were evaluated every six months during the first two years and every one year thereafter. Abdominal computed tomography (CT), endoscopy, and serum chemistry were carried out. Indications for laparoscopic surgery were a tumor size >2 cm or a tumor with associated symptoms such as bleeding or obstruction, even if the tumor size was <2 cm. Tumors involving the esophagogastric junction or pylorus were excluded. Surgical procedure The surgeon stood on the patient’s right, with the first assistant on the patient’s left and the camera operator on the surgeon’s right. A camera port was inserted into the supraumbilical lesion using an open technique. Under pneumoperitoneum of 10e14 mmHg, two additional ports were inserted into the right upper abdomen to identify the tumor location. After locating the tumor, 1e2 extra assistant’s ports were placed to aid manipulation of the stomach. In cases with extra-luminal GIST, wedge resection of the gastric wall was performed using laparoscopic stapling devices (Endo-GIA laparoscopic stapler, Tyco Autosuture, Norwalk CT, USA), whilst maintaining a safe margin from the tumor, if necessary, after the gastric wall had been devascularized and exposed using ultrasonic shears (Laparoscopic Coagulating Shears: LCS; Ethicon EndoSurgery, Cincinnati, OH, USA). In cases with intra-luminal GIST, the same procedure was performed using Endo-GIA after intraoperatively gastroscopy-guided identification of the tumor location. Resected specimens were placed into an endoscopic retrieval bag and extracted via the umbilical wound. In all cases, our pathologist reported a free margin of normal gastric wall by frozen section biopsy. One closed suction drain was placed around the
445
surgical site at the end of the procedure and trocar wounds were closed. Results The clinicopathologic data are shown in Table 1. The study subjects were 11 men and 12 women, of average age 59.7 8.3 years. Clinical manifestations included epigastric pain (12 cases), melena (4 cases), dyspepsia (2 cases), nausea (1 case) and vomiting (1 case). Three cases were found incidentally during screening. Tumor locations were classified into three types, namely, upper (12 cases), middle (6 cases), lower (5 cases), and mean tumor size was 4.2 2.1 cm. The risk categorizations of these gastric GISTs having an aggressive behavior, based on tumor size and mitotic activity, were: very low (2 cases); low (12 cases); intermediate (7 cases); and high (2 cases). Suggested definitions for these risk categories are shown in Table 2. The mean operation time of all but 3 patients who required additional surgery was 104.3 min (Table 3). It included cholecystectomy, left adrenalectomy, and distal gastrectomy. And average count of Endo-GIA used was 3.6. Intraoperative endoscopy was used to help identify tumor position in 7 patients (30.4%). No incidence of tumor rupture or spillage occurred intra-operatively. Overall, postoperative mean length of hospital stay was 5.2 2.3 days. No case of open conversion, reoperation and operative mortality occurred in the present study. A postoperative complication was encountered in one patient who experienced delayed gastric emptying, however, no major postoperative complications, such as bleeding, leakage, obstruction and intraabdominal abscess occurred. During a median
Table 1 Clinicopathologic data Patients’ number Age (mean SD, year) Sex (male: female) Symptom Epigastric pain Melena Dyspepsia Nausea Vomiting No symptom Tumor location Upper Middle Lower Tumor size (mean SD, cm) Pathologic classification Very low risk Low risk Intermediate risk High risk SD, standard deviation.
23 59.7 8.3 11: 12 11 3 2 1 1 3 13 5 5 4.3 2.1 2 12 7 2
S.-M. Choi et al. / EJSO 33 (2007) 444e447
446
Table 2 Proposed approaches for defining risk of aggressive behavior in GISTs
Very low risk Low risk Intermediate risk High risk
Size
Mitotic count
<2 cm 2e5 cm <5 cm 5e10 cm >5 cm >10 cm Any size
<5/50 HPF <5/50 HPF 6e10/50 HPF <5/50 HPF >5/50 HPF Any mitotic rate >10/50 HPF
HPF, high-power field.
follow-up period of 61 months (range, 7e98 months), there have been no recurrences or metastases. Discussion Gastrointestinal stromal tumors (GISTs) comprise a spectrum of neoplasmas with variable malignant potential, ranging from benign to aggressive. Due to their similar appearance under the light microscope, GISTs were previously thought to be smooth muscle neoplasms, and most were classified as leiomyosarcoma.13 Moreover, the principle of surgical treatment of smooth muscle tumors was local excision with a 2 cm margin of surrounding gastric wall.14 Surgical treatment However, recent advances in understanding the molecular pathogenesis of GIST have brought about rapid improvements in its management. Large margins of this size are unnecessary since gastric GISTs usually grow out of the primary organ rather than being diffusely infiltrating, and lymphadenectomy is usually unwarranted because of the rarity of nodal metastasis.13,15 Thus, most investigators agree that wedge resection of the stomach may be considered a standard treatment for gastric GISTs. Laparoscopic enucleation of the tumor from gastric submucosal space has been recommended for gastric submucosal tumor.16 However, the preoperative diagnostic accuracy of gastric submucosal tumor is unsatisfactory and if gastric GIST is accidentally ruptured during surgery, peritoneal dissemination may occur. Therefore, a gastric GIST should be resected with great care keeping the tumor capsule intact. Table 3 Operative outcomes and follow-up Conversion to open Operation time (mean SD, minute) Mean blood loss (range, ml) Postoperative hospital stay (mean SD, day) Postoperative morbidity (%) Postoperative mortality (%) Follow up period (median, month) Recurrence or Metastasis SD, standard deviation.
0 104.3 42.3 39 (0e300) 5.2 2.3 1 (4.3%) 0 (0%) 61 0 (0%)
However, Aparicio et al. reported that peri-tumoral resection conferred a high risk of local recurrence and should be avoided, and recommended a segmental organ resection for localized, resectable GISTs patients, such as partial or total gastrectomy, small bowel resection, the Whipple procedure or anterior rectal resection.17 Unfortunately, no detailed data were provided on the survival of gastric GIST patients vs. operative procedure. The present study presents the first 5-year survival results of laparoscopic wedge resection for gastric GIST, although the number of enrolled patients was not particularly high. Laparoscopic approach in treatment Currently, gastric GIST is viewed as a good indication for laparoscopic resection. Moreover, the development of laparoscopic stapling devices and surgical techniques have made laparoscopic wedge resection an attractive alternative to conventional open surgery.18 In such early gastric cancer cases, many benefits of laparoscopic distal gastrectomy included faster postoperative recovery, a reduced requirement for additional analgesics, and a smaller wound size. Its only known disadvantage was increased duration of surgery.19,20 Previous studies of laparoscopic wedge resection of gastric submucosal tumor, including gastric GISTs, have demonstrated excellent postoperative outcomes, e.g., a short operation time (78.3e180 min), a low open conversion rate (0e23.3%), short hospital stay (5e7 days), a low complication rate (2.9e25.0%), and modest blood loss (0e196 ml).8,9,11,21 In a comparative study of open and laparoscopic surgery for gastric GIST, tumor size, duration of surgery, and estimated blood loss were not found to be significantly different, although the laparoscopic group had a shorter hospital stay.12 In our institution, we have performed over 80 laparoscopic gastrectomies per annum for gastric cancer since 2003, and we have no experience of open conversion, reoperation and operative mortality for laparoscopic wedge resection for gastric GISTs. One patient developed delayed gastric emptying after gastric GIST excision and intracorporeal suture of gastrotomy site. In this case, the tumor was located on the lesser curvature of the mid-body. Nevertheless, the patient was discharged on postoperative day 5 after conservative management. Prognosis Surgery has been, and continues to be the mainstay of GIST treatment. However, 5-year survival rates after open surgery range from 34 to 76.5%.13,22e24 The prognosis of GIST after surgical treatment is influenced by tumor malignant potential and the completeness of primary resection. Bucher et al. reported that the 5-year actuarial survival of low grade GIST patients was 95% and in high grade GIST, 21%, and recommended adjuvant treatment with imatinib mesylate after surgical resection for patients with high grade GIST.25 Although the primary site was not
S.-M. Choi et al. / EJSO 33 (2007) 444e447
found to be a prognostic factor of disease-free survival by univariate analysis, gastric GIST is considered to have a better survival than small intestinal GIST, which has a similar mitotic activity and size.17,26,27 We have not experienced any recurrence after laparoscopic wedge resection for gastric GIST, although most of our patients were at very low or low risk (60.6%), in fact, only two were at high risk. Furthermore, another single patient received chemotherapy for metachronous cholangiocarcinoma with hepatic metastasis. Conclusion In light of its biologic behavior, GIST may be a good candidate for minimally invasive surgery. Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon. References 1. Hirota S, Isozaki K, Moriyama Y, et al. Gain-of-function mutations of ckit in human gastrointestinal stromal tumors. Science 1998;279:577–80. 2. Sircar K, Hewlett BR, Huizinga JD, Chorneyko K, Berezin I, Riddell RH. Interstitial cells of Cajal as precursors of gastrointestinal stromal tumors. Am J Surg Pathol 1999;23:377–89. 3. O’Leary T, Berman JJ. Gastrointestinal stromal tumors: answers and questions. Hum Pathol 2002;33:456–8. 4. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002;33:459–65. 5. Ueyama T, Guo KJ, Hashimoto H, Daimaru Y, Enjoji M. A clinicopathologic and immunohistochemical study of gastrointestinal stromal tumors. Cancer 1992;69:947–55. 6. Emory TS, Sobin LH, Lukes L, Lee DH, O’Leary TJ. Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site. Am J Surg Pathol 1999;23:82–7. 7. Appelman H, Helwig EB. Cellular leiomyomas of the stomach in 49 patients. Arch Pathol Lab Med 1977;101:373–7. 8. Otani Y, Ohgami M, Igarashi N, et al. Laparoscopic wedge resection of gastric submucosal tumors. Surg Laparosc Endosc Percutan Tech 2000;10:19–23. 9. Mochizuki Y, Kodera Y, Fujiwara M, et al. Laparoscopic wedge resection for gastrointestinal stromal tumors of the stomach: initial experience. Surg Today 2006;36:341–7. 10. Lukaszczyk JJ, Preletz Jr RJ. Laparoscopic resection of benign stromal tumor of the stomach. J Laparoendosc Surg 1992;2:331–4.
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