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 Table of Contents     
ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 18-22
 

Transgastric submucosal excision of small- to medium-sized gastrointestinal stromal tumours by pure minimally invasive approach


Department of General Surgery, Sriram Chandra Bhanj Medical College and Hospital, Cuttack, Odisha, India

Date of Submission11-Jun-2016
Date of Acceptance30-Apr-2017
Date of Web Publication11-Dec-2017

Correspondence Address:
Dr. Manash Ranjan Sahoo
Department of General Surgery, Sriram Chandra Bhanj Medical College and Hospital, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_138_16

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 ¤ Abstract 

Aim: The aim of this study is to evaluate the results of a single and common approach for transgastric submucosal excision of small- to medium-sized gastrointestinal stromal tumours (GIST) having different locations in upper two-third of the stomach by pure minimally invasive approach.
Materials and Methods: A retrospective study from February 2012 to January 2015 on 11 patients was conducted including both male and female. Their age ranged from 40 to 65 years. All were subjected to laparoscopic transgastric submucosal excision of GIST in upper two-third of the stomach with 1 cm margin having different locations in stomach. Excised tumours were subjected to histopathological study. These patients were followed for 12 months assessing operative time, post-operative complications, conversion rates, morbidity, hospital stay and recurrence rate.
Results: Duration of surgery was 150.6 ± 20.4 min. Mean hospital stay was 8 (range: 7–10) days. There were no post-operative complications. There were no conversions to open procedure. There were no recurrences. Morbidity was comparable to any other laparoscopic procedures.
Conclusion: We conclude that a single and common approach of transgastric submucosal excision of small- to medium-sized stromal tumours with 1 cm margin having different locations in upper two-third of stomach, by pure minimally invasive approach, has a better outcome and brings a uniformity in laparoscopic management of GIST.


Keywords: Double-layered closure with PDS*II (Polydioxanone 2-0) CRB, no spillage, pure minimally invasive surgery, submucosal excision of gastrointestinal stromal tumours with 1 cm margin, transgastric approach


How to cite this article:
Sahoo MR, Deshpande S, Ahmmed S. Transgastric submucosal excision of small- to medium-sized gastrointestinal stromal tumours by pure minimally invasive approach. J Min Access Surg 2018;14:18-22

How to cite this URL:
Sahoo MR, Deshpande S, Ahmmed S. Transgastric submucosal excision of small- to medium-sized gastrointestinal stromal tumours by pure minimally invasive approach. J Min Access Surg [serial online] 2018 [cited 2020 Oct 22];14:18-22. Available from: https://www.journalofmas.com/text.asp?2018/14/1/18/220355



 ¤ Introduction Top


Gastrointestinal stromal tumours (GIST) are the most common tumours present in GI tract (GIT), but stomach being more common amongst them.[1] They are mostly benign. These tumours originate from submucosa.[1] In stomach, they are present at different locations. Surgical removal is the treatment of choice.[2] It can be done by open procedure, pure laparoscopy, pure endoscopy and hybrid technique i.e., laparoendoscopy.[1] Laparoscopic method is now feasible and safe in the management of GIST.[3] However, the surgical approach is different for tumours located in different sites of stomach.[1] Very few studies have been published regarding transgastric submucosal excision of stromal tumours located in different sites of stomach by a single and common pure minimally invasive approach. We hypothesised that a single and common approach of transgastric submucosal excision of small- to medium-sized of stromal tumours with 1 cm margin having different locations in upper two-third of the stomach, by pure minimally invasive approach, has a better outcome and brings an uniformity in laparoscopic management of GIST.


 ¤ Materials and Methods Top


A case series study was undertaken on 11 patients, both male and female, admitted from the period February 2012 to January 2015. Patients clinically presented with symptoms of abdominal pain, nausea and vomiting. Initially patients were subjected to ultrasonography which revealed heterogeneous reflectivity in all the patients suggestive of stromal tumours in stomach. Upper Gastrointestinal (GI) endoscopy was helpful in locating the site of tumour in stomach wall [Figure 1]. Computerised Tomography (CT) scan findings depicted well marginated and low soft tissue density lesions which were benign. Invasiveness and lymph node metastasis was ruled out. On Contrast enhanced CT they showed features of homogenous enhancements. Patients selected for the study were subjected to all routine work up. Pre-anesthetic evaluation was done and patients were posted for surgery. The patients were subjected to pure minimal invasive surgery with a single and common approach i.e., transgastric submucosal excision of stromal tumours with 1cm margin. Tumours were located at lesser curvature, greater curvature, cardia part (including 2-3 cm below gastroesophageal junction) and the body. All were small to medium sized tumours (range: 2-6 cm). Excised tumours with 1cm margin were subjected to histopathological (HP) study. Perioperative parameters like operative time, intraoperative complications, conversion rates, post-operative complications, hospital stay, morbidity, recurrence rate were studied. All the patients post-operatively were reviewed and followed up for a minimum period of 1 year assessing different follow up parameters.
Figure 1: Polypoid mass seen at lesser curvature of stomach 2–3 cm below gastro-oesophageal junction

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Operative techniques

Patient was put in modified lithotomy position with surgeon standing in the centre on the leg end of the patient, monitors placed at the head end in the centre. Ports were given. One 10 mm telescopic supraumbilical port, one 5 mm epigastric port, one 5 mm port in right hypochondrium, one 5 mm port in left hypochondrium and one 5 mm port between telescopic 10 mm and left hypochondrial 5 mm port. Diagnostic laparoscopy revealed no suspicious metastasis, no ascites and no peritoneal seedings and the procedure was begun. An incision was made with harmonic scalpel on body of anterior part to enter stomach [Figure 2]. The stromal tumour was exposed [Figure 3]. Tumour was submucosally exposed with harmonic scalpel. Submucosal excision of the stromal tumour was done with minimal bleeding and no spillage of the tumour was noted. Defect was closed with PDSII(2'0) in a double layered fashion [Figure 4]. Tumour was delivered out of abdomen through an endobag and ports were closed with port closure.
Figure 2: An incision was made with harmonic scalpel on body of anterior part to enter stomach

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Figure 3: The stromal tumour was exposed

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Figure 4: Defect was closed with PDS II (2'0) in a double-layered fashion

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 ¤ Results Top


During the study period, a total of 11 patients were enrolled in the study with 6 females and 5 males. The median age of the patients was 52.5 years (range 40–65) [Table 1]. Six (54%) patients presented with pain abdomen and five (45%) patients presented with vomiting and none with bleeding [Table 2]. After performing an upper GI endoscopy, two (18%) patients had tumour at greater curvature, two (18%) at anterior wall of stomach, two (18%) at lesser curvature, three (27%) at fundus 2–3 cm below GE junction, one (9%) at posterior wall, one (9%) at cardia region and none found at pylorus and pre-pyloric region [Table 3]. None of the stromal tumours had ulceration and necrosis. CT and CECT were performed on all patients. None had lymph node involvement and metastasis. All were small- to medium-sized tumours ranging from 2 to 6 cm, eight (72%) were of size 2–4 cm and three (27%) were of size 4–6 cm [Table 4]. All the 11 cases underwent pure minimally invasive approach i.e., transgastric submucosal excision of GIST with 1 cm margin, originating from different sites in upper two-third of the stomach. Mean operative time was 150.6 ± 20.4 min. There were no conversions to open procedure. There were no post-operative complications. Nasogastric aspiration was minimal and had no bloody aspirate. Oral feeds were started on 2 ± 1 post-operative day. No complaints of regurgitation, haematemesis, melaena or fullness after meals noted. Patients tolerated solid diet 72 h after surgery. Mean hospital stay was 8 (range: 7–10) days. Histopathology report revealed benign tumour for five (45%) patients which required only surveillance. Three (27%) patients had 4–6 mitotic rate per 50 high-power field (HPF) low-to-moderate grade and three (27%) were suspicious for malignancy were started on imatinib therapy and also patients with C-kit positive tumours were given imatinib therapy. Every patient was subjected to follow-up for a minimum period of 1 year which showed no recurrence after performing an upper GI endoscopy and CT scan with no evidence of metastasis.
Table 1: Age distribution

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Table 2: Symptom distribution

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Table 3: Location

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Table 4: Tumour size

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 ¤ Discussion Top


GIST is the most common sarcomatous tumour of GIT derived from intestinal cells of Cajal.[2] They can occur anywhere in GIT but commonly occurring in the stomach (40%–60%), small intestine (30%) and colon (15%).[2] It can occur in both males and females with equal incidence but slightly having a male predisposition.[2] Most commonly stromal tumours are asymptomatic and are found incidentally during routine workup or when upper GI endoscopy is indicated.[2] Clinical course varies from small benign to massive lesions with necrosis, haemorrhage and metastasis.[2] Symptomatic patients present with bleeding and vague abdominal pain. GIST is rarely associated with paraganglioma syndrome (CAREY TRIAD), von Hippel-Lindau syndrome, neurofibromatosis type 1 but most commonly arise in de novo.[2] Diagnosis is done by CT, CECT, upper GI endoscopy and HP study. HP study may show smooth muscle and neuroendocrine features i.e., leiomyoma, leiomyosarcoma and lipoma.[1] Surgery remains the mainstay treatment with wide local excision, enucleation, sleeve gastrectomy and total gastrectomy with/without en bloc dissection depending on the location and size of tumour in stomach.[2] Low-risk tumours of size <3 cm or >5 mitoses HPF need removal and surveillance whereas tumours of size >3 cm are high risk and need removal with imatinib as adjuvant therapy.[2] Surgical approaches can be done by open procedure, pure laparoscopy, pure endoscopy and hybrid technique i.e., laparoendoscopy.[1] Traditionally, tumours located in anterior wall and curvatures of stomach are treated by wedge resection with endo-GIA stapler which predisposes for more intraoperative stapler line bleeding, stapled anastomotic leak and is not cost effective.[1] Enucleation by laparoendoscopic approach is not suitable for removal of anterior wall stromal tumours.[1] Recommended methods for removal of stromal tumours near the cardia are local excision with 2–4 cm margin, enucleation and stapled resection.[1] Maintaining adequate margins, angle of HIS and muscle reconstruction in cardia region is difficult after wedge resection.[1] Wedge resection causes stapled anastomotic leak, stenosis and GE reflux disease (GERD) leaving a long-term post-operative morbidity.[1] The usage of a gastroscope in distending the stomach causes slippage of trocars and creates unnecessary trauma to the stomach.[1] Laparoendoscopic approach is difficult to deliver out the tumours through oral cavity which are located near cardia. Transgastric submucosal excision with 1 cm margin of the tumour in anterior wall, curvatures and in cardia reduces the risk of stapler line bleeding and anastomotic leak. It is cost effective and prevents long time complications of GERD, stenosis and recurrence.[1],[4] Transgastric submucosal excision avoids the usage of gastroscope and the need to distend the stomach. This method also avoids the insertion of trocars in the stomach for removal of tumours located near cardia.[1] For posterior wall tumours, a gastrostomy is done, and submucosal excision with 1 cm margin is performed. This approach is also useful in removing stromal tumours located near GE junction.[5] A gastrostomy on the anterior wall of stomach and submucosal excision of posterior wall tumours avoids division of lesser sac, gastrocolic omentum and short gastric vessels.[5] Endolaparoscopy is not useful in removing posterior wall tumours. It causes slippage and impaction, and its usefulness is doubted in the setup where the expertise is not available and facilities are inadequate.[5] Endoscopic method is of use for removing stromal tumours of size <2 cm.[5] In inexperienced hands, chances of bleeding and gastric perforation are more in removing stromal tumours by endoscopic method.[5] In general, transgastric submucosal excision with 1 cm margin reduces the risk of spillage, recurrence and disease progression and is feasible for removal of stromal tumours located at difficult places. This method also improves the survival rate. Closure of the defect with PDS II (2'0) in double-layered fashion avoids the use of stapler, reduces the risk of anastomotic leak, reduces the risk of post-operative morbidity and is cost effective.


 ¤ Conclusion Top


A single and common approach i.e., transgastric submucosal excision of stromal tumours with 1 cm margin by pure minimally invasive approach is the treatment modality for small- to medium-sized tumours originating in the upper two-third of the stomach, with less intraoperative, with no conversions to open procedure, less post-operative complications, has a better outcome and brings an uniformity in the laparoscopic management of GIST.

Acknowledgement

The authors would like to thank anaesthetists and all our operation theatre and nursing staff.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Singaporewalla RM, Baladas GH, Lee TD. Laparoendoscopic removal of a benign gastric stromal tumor at the cardia. JSLS 2006;10:117-21.  Back to cited text no. 1
[PUBMED]    
2.
Courtney M. Townsend JR, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 19th ed., Vol. II, Ch. 49, Sec. 10. India Gurgaon: Saunders, an imprint of Elsvier Inc.; 2014. p. 1220.  Back to cited text no. 2
    
3.
Ronellenfitsch U, Staiger W, Kähler G, Ströbel P, Schwarzbach M, Hohenberger P. Clinical study: Perioperative and oncological outcome of laparoscopic resection of gastrointestinal stromal tumour (GIST) of the stomach. Diagn Ther Endosc 2009;2009:7.  Back to cited text no. 3
    
4.
Xu X, Chen K, Zhou W, Zhang R, Wang J, Wu D, et al. Laparoscopic transgastric resection of gastric submucosal tumors located near the esophagogastric junction. J Gastrointest Surg 2013;17:1570-5.  Back to cited text no. 4
[PUBMED]    
5.
Novitsky YW, Kercher KW, Sing RF, Heniford BT. Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors. Ann Surg 2006;243:738-45.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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