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Laparoscopic Treatment of Large Gastric GISTs. A Single Institution Experience of 28 cases and Literature Review

Research Article ºÚÁÏÍø
Nicosia S, Spataro C, Bonfiglio G, Tropea A, Biondi A and Roberto Ciuni*
Department of Surgery and Oncology - University of Catania UOC Surgery - University Hospital Policlinico - Vittorio Emanuele, Italy
*Corresponding authors: Roberto Ciuni
Department of Surgery and Oncology - University of Catania UOC Surgery - University Hospital Policlinico - Vittorio Emanuele
Italy
E-mail: Ciuni.r@gmail.com
 
Received April 28, 2012; Published July 26, 2012
 
Citation: Nicosia S, Spataro C, Bonfiglio G, Tropea A, Biondi A, et al. (2012) Laparoscopic Treatment of Large Gastric GISTs. A Single Institution Experience of 28 cases and Literature Review. 1: 157. doi:10.4172/scientificreports.157
 
Copyright: © 2012 Nicosia S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 
Abstract
 
Background: The aim of this study is to investigate the role, the technical feasibility and the oncologic safety of laparoscopic resection for GISTs ≥ 2cm.
 
Methods: Data were collected from the hospital in the patient records as well as a prospective database. We classified patients into two groups using as criteria the tumor size. Their DFS and recurrence rates were analyzed.
 
Results: 28 cases of gastric GISTs were collected and analyzed. We didn’t found any statistically significative difference between our two treated groups.
 
Conclusions: the low morbidity rates and the long-term disease-free interval observed in our retrospective study indicates that laparoscopic resection is safe and effective in treating large gastric GISTs (≥2cm), when proper or experimental laparoscopic techniques are used by an experienced surgeon equipe.
 
Introduction
 
Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. They are thought to be derived from the interstitial cells of Cajal (ICCs), which are pacemaker cells for autonomic motility of the alimentary tract [1].
 
Single lesion is founded in 50-60% and 95% can be completely resected. Rare is multiple clinical presentations of GISTs [2].
 
Surgery is the key therapeutic weapon in the management of localized, non-metastatic primary GISTs. Surgical resection, with a 1~2 cm negative resection margin (R0), is recommended for GISTs because of their malignant potential and is the standard treatment [3].
 
The most important oncologic principle while resection is to avoid rupturing of the tumors, because of their brittleness, during manipulation is possible a peritoneal dissemination of the tumor which can result in poor prognosis of the patients [2].
 
The GISTs commonly metastatize to the liver or the peritoneum but it rarely to lymph nodes, therefore, lymphadenectomy is not needed during surgery [4].
 
Minimally invasive surgery has been asserted in the resection of GISTs, instead evidence-based recommendations lack it, especially in the resection of a GIST larger than 2 cm [5].
 
We report a retrospective study of large GISTs of the stomach which were successfully treated by the laparoscopic approach in order to investigate the role, the technical feasibility and the oncologic safety of laparoscopic resection for GISTs larger than 2cm.
 
Materials and Methods
 
We purpouse a retrospective treatment review of GISTs between January 2002 and December 2011.
 
In our study were included all anathomopatogically recognized primary GISTs in patients who did not recived a neoadiuvant therapy with Imatinib.
 
59 patients with GIST were submitted to surgery treatment in oncologic surgery department of Catania University. In 31 patients (44%), was performed open surgery and in 28 patients (56%) laparoscopic procedure.
 
Aim of this work is a comparative study between laparoscopic procedures (PL) in gastric GISTs ≥2cm and in gastric GISTs<2cm.
 
Results
 
A total of 28 patients (16 women and 12 men) with a mean age of 63,25 ± 12,63 years (range 32–81) underwent laparoscopic resection of gastric GISTs. (Table 2).
 
Table 1: Our Causistry.
 
Table 2: Laparoscopic treated gastric GISTs.
 
First group was characterized by a maximum tumor size of 1,9 cm with a mean size 1,33 ± 0,38 cm (0,8 - 1,9).The median follow-up period was 32,13 ± 14,05 (8 - 56) ; the mean operative time was 102,46 ± 10,76 minutes (range 87 - 122) ; the estimated operative blood loss (EBL) was 79,73 ± 27,43 (35 – 115 min) and mean length of hospital stay 4,87 ± 0,99days (range 4-7). We observed a DFS rate (%) of 73.33% and a recurrence rate of 40%.
 
In the second group we included all laparoscopic treated patients with a minimum tumor size of 2 cm [mean size 3,7 ± 1,5 cm (2 - 7,3)]. The mean follow-up period was 15.3 ± 11,08 (5 - 39) ; the mean operative time was 112,07 ± 20,08 minutes (range 87-140) ; the estimated operative blood loss (EBL) was 96,92 ± 34,67 (40 – 155 min) and mean length of hospital stay 6,15 ± 1,67 days (range 4-9). We observed a DFS rate (%) of 76.92% and a recurrence rate 30.7%.
 
 
We analysed our data using the Fisher’s exact Test. There was no statistically significant differences between our two groups (p>0,05) in the analysis of DFS (%) and Recurrence rate.
 
Discussion
 
Lukaszcryk andPretetz [6] reported the first laparoscopic resection of a gastric GIST in 1992. Sincethen, many investigators have reported successful laparoscopic removal of small GISTs (<2cm), and the longterm safety of the laparoscopic approach to these small GISTs is known yet [7].
 
Laparoscopic procedures for the treatment of GIST afford distinct advantages over open surgery, including early recovery of bowel function, early hospital discharge, and decreased postoperative pain. The development of endoscopic stapling devices has made laparoscopic resections an interesting alternative to the open approach [8].
 
Today different laparoscopic approaches for the resection of gastric GIST have been utilised depending on the location, size and transmural extent of the tumour and recently, due to the advancement of the laparoscpic technique, an increasing number of reports have been presented for safe laparoscopic resection for large GISTs [9].
 
The large size of the GIST is a factor that has previously been considered a contraindication to laparoscopic resection. This is because the size of GIST is considered an important prognostic factor with regard to the risk of recurrence (Table 3) and therefore directly considered an indication for conversion to open surgery, principally because it is postulated that it is more difficult to resect larger tumours radically using a laparoscopic approach. The size of the GIST could also influence the indication for a laparoscopic approach because if the length of the incision for removal becomes more than 10 cm, open surgery could be considered better [10]even if, because of the characteristic of the GIST mass (soft and fragile), a minilaparotomy incision could be minimized to 4 cm in extracting a 10 cm sized mass [11] because there is the possibility of fragmenting the tumour inside the bag as is common for other organs such as the spleen, allowing easy removal of tumours larger than the skin incision.
 
Table 3: Risk of Aggressive Behavior in GISTs (from Fletcher et al, 2002, Human Pathology 33(5):459-65, used with permission of Elsevier).
 
Today, laparoscopic large GISTs resection can also be performed with the eversion technique [12] or endoscopic assistance [13]. A surgical border-free resection is considered mandatory for the oncologically correct treatment of these tumours, with a free border of 1-2 cm [14], but these limits and rules are mainly determined by the rules of standard oncological surgical practice. Preoperative knowledge of the tumour location and the extent of transmural involvement are important for planning the appropriate laparoscopic approach [15]. Wedge resection for tumours on the anterior wall is regarded as an easy procedure, but when the mass is on the posterior wall it is difficult to resect [15]. Laparoscopic wedge resection poses particular problems, such as tumour location and uncertainty in determining the correct extent of the resection, especially because tactile sensation is precluded [12]. To avoid this limitation, hand-assisted laparoscopic resection has also been performed with good outcomes in larger GIST [16].
 
Warsi et al. experimented a new technique for posterior gastric wall GISTs performing an anterior gastrotomy. After introducing an endobag trough a 10-mm port, and after closing the retractable metal ring around the base of the tumor, they resected the tumour with a cuff of normal gastric tissue using an endoscopic linear stapler introduces through a 12-mm port [17].
 
Sun Lee et al., to avoid tumor rupture or its direct manipulation, left an attached fibrosis band on the tumor when resecting around the tumor, and if traction was needed, the fibrous tissue or normal gastric wall around the mass was used [2].
 
More surgical investigators have reported successful and safe resection of larger GISTs of the stomach. Otani et al. [18] and Sexton et al. [19] reported using laparoscopy for lesions up to 5 cm. Catena et al. [20] reported that they used hand- assisted gentle tumor handling and precise placement of endoscopic staplers for GISTs larger than 5 cm. Novitsky et al. [21], and Nguyen et al. [22] described a laparoscopic approach without any difficulty for GISTs of 7, 8.5, and 11 cm, respectively.
 
It is also known that recurrence is more closely related to pathological features that, unfortunately, are not known pre- or intraoperatively since the precise diagnosis is possible only after resection. The recurrence rates of laparoscopically resected GIST are in any case comparable to those reported for open surgery [23]. Recurrence can also not be prevented for small gastric GIST and therefore the risk of possible incomplete resection has to be evaluated intraoperatively by the surgeon. On the contrary, large GIST that grow to a large size without manifesting other seedings should be considered biologically associated with low malignant potential.
 
Conclusions
 
Our retrospective study provide evidence that laparoscopic resection of gastric GIST is safe, feasible, and effective, with an excellent long-term outcome, even for lesions larger than 2cm, although the National Comprehensive Cancer Network Clinical Guidelines for Optimal Management of Patients with GIST suggest that laparoscopic techniques should be limited to tumors less than 2cm [24-25].
 
In fact the low morbidity rates and the long-term disease-free interval observed in our retrospective study indicates that laparoscopic resection is safe and effective in treating large gastric GISTs (≥2cm), when proper or experimental laparoscopic techniques are used by an experienced surgeon equipe.
 
The resection should just be performed whenever possible with a no-touch technique, avoiding breaking the tumour or opening its borders.
 
We think that is the only or the main limiting factor for laparoscopic resection of GIST irrespective of the size of the tumour.
 
However, further study will be needed on the limitation of the size of the tumor in laparoscopic resection of GISTbecause we believe that the relationship between feasibility of laparoscopic resection and the size of the GIST is not based on clear data. Also unsure appears the relationship between the size, malignancy grade and recurrency rates, as the risk tables edited since 2002 put in evidence [25].
 
 
References