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 ¤ Introduction
 ¤ Methods
 ¤ Results
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 Table of Contents     
REVIEW ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 147-152
 

The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis


1 Department of General Surgery, Xintai City People's Hospital, Xintai, Shandong Province, China
2 Department of Intensive Care Unit, Xintai City People's Hospital, Xintai, Shandong Province, China
3 Chinese Center for Disease Control and Prevention, Key Laboratory of Trace Element Nutrition of National Health Commission, National Institute for Nutrition and Health, Beijing, China

Date of Submission28-Dec-2019
Date of Decision20-Jan-2020
Date of Acceptance07-Feb-2020
Date of Web Publication28-Mar-2020

Correspondence Address:
Dr. Hu Zhang
Department of General Surgery, Xintai City People's Hospital, No. 1329, Xinfu Road, Xintai 271200, Shandong Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_294_19

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 ¤ Abstract 

Background and Objectives: The objective was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery.
Methods: The randomised controlled trials (RCTs), which are about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours were searched from the PubMed (1998–1990–2018.6), Wanfang Data (1990–2018.6), China National Knowledge Infrastructure (1979–2018.6) and International Statistical Institute (1998–2018.6). The data were extracted from these trials, and the meta-analysis was made through from RevMan 5.3 software.
Results: Six RCTs involving 451 patients were included in the study (227 patients in the laparoscopy combined with gastroscopy positioning group and 224 patients in laparoscopic surgery group). Compared with laparoscopic surgery group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could shorten the post-operation hospital stay (P < 0.05) and reduce the intraoperative blood loss (P < 0.05). However, there was no significant difference in others between the two groups, such as operation time (P > 0.05), post-operative time of recovery of intestinal peristalsis (P > 0.05) and the total hospital stay (P > 0.05).
Conclusion: Compared with laparoscopic surgery group, the better total effect occurs in laparoscopy combined with gastroscopy positioning group for the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.


Keywords: Efficacy, gastric stromal tumours, gastroscopy meta-analysis, laparoscopy, safety, system review


How to cite this article:
Zhang H, Chen J, Chen C. The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis. J Min Access Surg 2021;17:147-52

How to cite this URL:
Zhang H, Chen J, Chen C. The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis. J Min Access Surg [serial online] 2021 [cited 2021 May 12];17:147-52. Available from: https://www.journalofmas.com/text.asp?2021/17/2/147/281501



 ¤ Introduction Top


Gastrointestinal stromal tumour (GIST) is the most common mesenchymal neoplasm of the alimentary tract, and the stomach is the most frequently affected site, accounting for roughly of 60%–70% of all patients with a GIST.[1],[2],[3] It is known that gastric GIST rarely metastasizes to perigastric lymph nodes. In particular, the diameter of the tumour was <5 cm, and at that time, gastric local resection without lymphadenectomy is acceptable as a standard treatment. Laparoscopic local resection has been acceptable. Minimally invasive surgery has the characteristics of less trauma, less post-operative complications and quicker recovery than conventional surgery and is widely used in clinic. At present, the minimally invasive methods for the treatment of gastric stromal tumours include endoscopic therapy, laparoscopy, endoscopic combined laparoscopic combined resection, among which endoscopy is mainly aimed at small diameter and limited growth tumours; the first choice of surgical intervention is needed for patients with larger diameter and malignant potential. Clinical practice shows that compared with open surgery, laparoscopic surgery has the advantages of minimal invasion and quick post-operative recovery,[4] but it has its limitations. We can easily use laparoscopic wedge resection with adequate margins to treat extragastrictype submucosal tumours. Due to the difficulty of accurately judging the tumour's location under laparoscopic examination, hence it is more problematic for the resection of intragastrictype submucosal tumours. Moreover, it induces removing relatively large sections of the stomach during removing the tumour, and it could lead to post-operative deformity of the stomach.[4] In 2008, it was first reported about the laparoscopic endoscopic cooperative surgery by Hiki,[5],[6] and it was designed to resect submucosal tumours originating by a minimally invasive surgical technique. Now, various surgical operations have been carried out both in China and abroad. Colour Doppler ultrasound, computed tomography, gastroscopy and other related examinations should be used to determine the location, diameter and risk grade of the lesion, so as to provide a basis for the formulation of the surgical plan before the surgery. Conventional endoscopy to the small gastric stromal tumour location is poorer, easy to misdiagnosis and gastroscope can accurately judge the location of tumour, positioning is easier, and it could provide a theoretical basis for the minimally invasive treatment of gastric stromal tumour.

Laparoscopy combined with gastroscopy positioning has been gradually matured for the patients with gastric stromal tumours,[6],[7],[8] but compared with the laparoscopy group, it is more controversial that whether the efficacy and safety of laparoscopy combined with gastroscopy positioning for gastric stromal tumours has the existence of the treatment, prognosis, recurrence and follow-up.

In this research, we could provide reliable evidence for the gastric stromal tumours by the efficacy and safety of patients between laparoscopy combined with gastroscopy positioning and laparoscopic for gastric stromal tumours.


 ¤ Methods Top


In this study, six randomised controlled trials (RCTs) were included in standard experimental. The objective of the research was patients with gastric stromal tumours, who were preoperative ultrasonography and gastroscopy performed, and were confirmed by the first biopsy. The articles were all related to laparoscopy combined with gastroscopy positioning and laparoscopic for gastric stromal tumours. The observed indexes include the operation time, the intraoperative blood loss, the post-operative time of recovery of intestinal peristalsis, the post-operation hospital stay and the total hospital stay.

Exclusion criteria

These include the combination of other malignant tumours and organ metastases. The research included patients with non-perforated gastric stromal tumours. This study did not compare two surgicals. The incomplete information is unacceptable. It is not in conformity with the inclusion criteria.

Data retrieval

We got the information with included and exclusion standards by reading the abstract. The searched information retrieval was published from January 1979 to June 2018 and compared the efficacy of the patient by laparoscopy and endoscopic combined laparoscopic combined resection in randomised controlled studies. Specific retrieval methods: we searched from the PubMed (1998–1990–2018.06), Wanfang Data (1990–2018.06), China National Knowledge Infrastructure (1979–2018.06), International Statistical Institute (1998–2018.06), Chinese keywords of 'gastric stromal tumours; laparoscopy; gastroscopy and RCTs', English keywords of 'RCTs, laparoscopy, laparoscopic and gastric stromal tumours'.

Quality assessment of selected literature

Quality assessment used the description of the concealment and blinding from RCT quality standards of Cochrane Reviewer' Handbook 5.3.

Data extraction and statistical processing

The basic data included the first author, the year of publication, the operation mode and the number of cases. The observation index included the operation time, intraoperative bloodless, post-operative time of recovery of intestinal peristalsis, the post-operation hospital stay and the total hospital stay. The statistical data were extracted by RevMan 5.3 software package Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014. The relative risk and 95% confidence intervals (CIs) are used to the binary data, and the standardized mean difference and 95% CI are used to continuous data, the test level was α = 0.05. We used the funnel plots to assess whether there is the publication bias. Due to the small number of RCTs studies involved, the fundibular maps cannot be used to assess publication bias.


 ¤ Results Top


According to the predefined retrieval strategy, there were six randomised controlled studies[9],[10],[11],[12],[13],[14] with 451 cases to review authors' judgement across the included studies from the risk of bias summary [Figure 1] and [Figure 2]. The test group was treated with gastroscopy combined with laparoscopy for gastric stromal tumours with 227 cases, and the control group was treated with laparoscopic surgery for gastric stromal tumours with 224 cases.
Figure 1: Risk of bias summary

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Figure 2: Risk of bias graph

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Comparison of the efficacy and safety

The operative time in this research, six studies had the comparation of the operation time between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours. The difference was statistically significant in the difference test for heterogeneity between studies (P < 0.00001; I2=96%), Hence, we analysed it by a random effects model. It is showed that the difference was not statistically significant between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours. (standardised mean differences [SMD] = −0.89%; 95% CI = [−1.18, 0.10]; P = 0.08) [Figure 3].
Figure 3: The operation time between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours

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The intraoperative blood loss in this research, six studies had the comparation of the intraoperative blood loss between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours. The difference was statistically significant in the difference test for heterogeneity between studies (P < 0.00001; I2=9%), therefore, we used a random effects model to analysis it. It has been shown that the difference was statistically significant between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours (SMD = −1.51; 95% CI = [−2.33, −0.68]; P = 0.0004) [Figure 4].
Figure 4: The intraoperative blood between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours

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The post-operative time of recovery of intestinal peristalsis in this research, two studies had the comparation of the post-operative time of recovery of intestinal peristalsis between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours. The difference was statistically significant in the difference test for heterogeneity between studies (P < 0.00001; I2=98%), so that, we could analysis it by a random effects model. It is showed that the difference was no statistically significant between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours (SMD = −2.46; 95% CI [−5.59, 0.67]; P < 0.00001) [Figure 5].
Figure 5: The post-operative time of recovery of intestinal peristalsis between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours

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The post-operation hospital stay in this research of three studies had the comparation of the post-operation hospital stay between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours. The difference was statistically significant in the difference test for heterogeneity between studies (P = 0.03; I2=72%), therefore, we used a random effects model to analysis it. It is showed that the difference was statistically significant between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours (SMD = −0.85; 95% CI = [−1.40, −0.30]; P = 0.002) [Figure 6].
Figure 6: The post-operation hospital stay between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours

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The total hospital stay in this research for four studies had the comparation of the total hospital stay between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours.

The difference was statistically significant in the difference test for heterogeneity between studies (P < 0.00001; I2=94%), so that, we could analysis it by a random effects model. It has been shown that the difference was no statistically significant between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours (SMD = −0.82; 95% CI = [−1.89, 0.24]; P = 0.13) [Figure 7].
Figure 7: The total hospital stay between laparoscopy combined with gastroscopy positioning and laparoscopy for gastric stromal tumours

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 ¤ Discussion Top


In recent years, minimally invasive treatment has become a major mean for gastric stromal tumours, mainly including gastroscopy treatment, laparoscopic surgery and laparoscopy combined with gastroscopy positioning, such as endoscopic therapy can be used for smaller diameter, growth limited tumours. However, compared with laparoscopy combined with gastroscopy positioning, gastroscopy therapy has obvious deficiencies: intraoperative blood loss, integrity of surgical resection and tumour recurrence rate are not as good as laparoscopic surgery. Laparoscopic surgery is characterized by small trauma and rapid post-operative recovery. Successful laparoscopic wedge resection has been reported for 2–5 cm gastric GISTs and confirmed by studies examining long-term surgical outcomes.[15],[16],[17] However, it has certain limitations in the treatment of gastric stromal tumours. When tumours are located intragastrically, it is hard to decide the appropriate resection line from the outside of the stomach. Laparoscopic vision is limited, and complete tumour resection cannot be guaranteed. Tumours near cardiac and pylorus are treated with simple laparoscopic surgery, which is easy to cause cardiac stenosis or pyloric stenosis.[18]

With the continuous development of endoscopic and laparoscopic technique, laparoscopic combined endoscopic treatment of gastric stromal tumour is increasing, so we can effectively play the advantages of laparoscopic and endoscopic and make up for the inadequacy of pure laparoscopic surgery.

Laparoscopy combined with gastroscopy positioning has become a major mean for gastric stromal tumours.[7],[19],[20] Laparoscopy combined with gastroscopy positioning for gastric stromal tumours, accurate endoscopic localization reduces the time for finding the gastric stromal tumours and marks the tumour under gastroscopy. In addition, tumour resection is more complete with double lens combined therapy.

The bleeding was the most frequent complication post-operatively at the staple line of the tumour resection for gastric stromal tumours.[21],[22] A technical failure in the staple device caused the bleeding so that at the time of the terminal staple fire, we used a white load instead of blue load to reduce the risk of bleeding. It was researched that using staple line reinforcement with a bioabsorbable matrix – Seamguard may reduce the rates of bleedings and leaks at the resection site.[23]

In this study, meta-analysis showed that compared with laparoscopic surgery group, laparoscopy combined with gastroscopy positioning group could reduce the post-operation hospital stay and reduce the intraoperative blood loss. It may be associated with the tumour' fast and accurate location by laparoscopy combined with gastroscopy. Pure laparoscopic treatment of some patients is difficult, and much tissue which was near the stomach has been removed, and at the same time, the wedge resection of stomach is overmuch, laparoscopic exploration time is too long and to increase the intraoperative blood loss.

Since the inclusion of this study is affected by time and the number of cases, the long-term effect analysis has not been conducted from the follow-up of patients.

With the leap development of modern technology, full-thickness local excision using laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours is a promising procedure for these cases.[24] Our experience with laparoscopy combined with gastroscopy positioning surgery has confirmed that this procedure is safely, feasible.


 ¤ Conclusion Top


Because of the difficulty of accurately judging the tumor's location under laparoscopic examination,so it's more problematic for the resection of intragastrictype submucosal tumors. And it induces removing relatively large sections of stomach during removing the tumor, and it could lead to postoperative deformity of the stomach. Laparoscopy combined with gastroscopy positioning has been gradually matured for the patients with gastric stromal tumors and gastroscope can accurately judge the location of tumor, positioning is easier, and it could provides a theoretical basis for the minimally invasive treatment of gastric stromal tumors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
Joensuu H, Vehtari A, Riihimäki J, Nishida T, Steigen SE, Brabec P, et al. Risk of recurrence of gastrointestinal stromal tumour after surgery: An analysis of pooled population-based cohorts. Lancet Oncol 2012;13:265-74.  Back to cited text no. 1
    
2.
Miettinen M, Lasota J. Histopathology of gastrointestinal stromal tumo. J Surg Oncol 2011;104:865-73.  Back to cited text no. 2
    
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4.
Tsujimoto H, Yaguchi Y, Kumano I, Takahata R, Ono S, Hase K. Successful gastric submucosal tumor resection using laparoscopic and endoscopic cooperative surgery. World J Surg 2012;36:327-30.  Back to cited text no. 4
    
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Hiki N, Nunobe S, Matsuda T, Hirasawa T, Yamamoto Y, Yamaguchi T. Laparoscopic endoscopic cooperative surgery. Dig Endosc 2015;27:197-204.  Back to cited text no. 5
    
6.
Hiki N, Yamamoto Y, Fukunaga T, Yamaguchi T, Nunobe S, Tokunaga M, et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008;22:1729-35.  Back to cited text no. 6
    
7.
Hoteya S, Haruta S, Shinohara H, Yamada A, Furuhata T, Yamashita S, et al. Feasibility and safety of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors, including esophagogastric junction tumors. Dig Endosc 2014;26:538-44.  Back to cited text no. 7
    
8.
Kawahira H, Hayashi H, Natsume T, Akai T, Uesato M, Horibe D, et al. Surgical advantages of gastric SMTs by laparoscopy and endoscopy cooperative surgery. Hepatogastroenterology 2012;59:415-7.  Back to cited text no. 8
    
9.
Ming J, Haining C. Efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumors. China J Endosc 2014;20:8436.  Back to cited text no. 9
    
10.
Yu Z, Xiang SS, Ping C, Lei S, Hao W, Xin XL. A comparative study of laparoscopy endoscopy and cooperative surgery in treating gastric stromal tumors. Clin Surg 2015;23:750-2.  Back to cited text no. 10
    
11.
Xu H. Efficacy of laparoscopy combined with gastroscopy positioning and compared with laparoscopy alone in treating gastric stromal tumors gastric stromal tumors were. Contemp Med 2017;23:110-11.  Back to cited text no. 11
    
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Qiang S, Jian-Min Z, Fu-Wen C, Xiao-Biao S, Ji-Jun W. Clinical comparative study of laparoscopic, endoscopic and double endoscopic surgery for gastric stromal tumors. J Clin Med 2017;4:14172.  Back to cited text no. 12
    
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Dong-Chu X, Yun-Hu G, Wei-Xuan Y, Yong-Jian L, Hai-Wen Y. Effects of endoscopic and laparoscopic resection of gastric stromal tumors. J Laparosc Surg 2017;22:63-5.  Back to cited text no. 13
    
14.
Xing W, Xiao-Feng L, Wei-Dong. Clinical analysis of laparoscopic surgery combined with laparoscopy for gastric stromal tumors. Cardiovasc Dis J Integ Tradit Chin Western Med 2018;6:26.  Back to cited text no. 14
    
15.
Honda M, Hiki N, Nunobe S, Ohashi M, Kiyokawa T, Sano T, et al. Long-term and surgical outcomes of laparoscopic surgery for gastric gastrointestinal stromal tumors. Surg Endosc 2014;28:2317-22.  Back to cited text no. 15
    
16.
Kakeji Y, Nakanoko T, Yoshida R, Eto K, Kumashiro R, Ikeda K, et al. Laparoscopic resection for gastrointestinal stromal tumors in the stomach. Surg Today 2012;42:554-8.  Back to cited text no. 16
    
17.
Hwang SH, Park DJ, Kim YH, Lee KH, Lee HS, Kim HH, et al. Laparoscopic surgery for submucosal tumors located at the esophagogastric junction and the prepylorus. Surg Endosc 2009;23:1980-7.  Back to cited text no. 17
    
18.
Yu-Chang L, Hao H, Xiaojun Z, Zhong-Qi M, Zhi-Long H, Han H, et al. Value of endoscopy laparoscopy and its combined application in the treatment of gastric stromal tumor. Jiangsu Med 2012;13:1588-90.  Back to cited text no. 18
    
19.
Wilhelm D, von Delius S, Burian M, Schneider A, Frimberger E, Meining A, et al. Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses – Analysis of 93 interventions. World J Surg 2008;32:1021-8.  Back to cited text no. 19
    
20.
Walsh RM, Ponsky J, Brody F, Matthews BD, Heniford BT. Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors. J Gastrointest Surg 2003;7:386-92.  Back to cited text no. 20
    
21.
Li ZY, Tang L, Li SX, Shan F, Bu ZD, Ji JF. Imatinib mesylate in clinically suspected gastric stromal tumors. Chin J Cancer Res 2013;25:600-2.  Back to cited text no. 21
    
22.
Qiu WQ, Zhuang J, Wang M, Liu H, Shen ZY, Xue HB, et al. Minimally invasive treatment of laparoscopic and endoscopic cooperative surgery for patients with gastric gastrointestinal stromal tumors. J Dig Dis 2013;14:469-73.  Back to cited text no. 22
    
23.
Mari FS, Masoni L, Cosenza UM, Favi F, Berardi G, Dall'Oglio A, et al. The use of bioabsorbable staple-line reinforcement performing stapled hemorrhoidopexy to decrease the risk of postoperative bleeding. Am Surg 2012;78:1255-60.  Back to cited text no. 23
    
24.
Namikawa T, Hanazaki K. Laparoscopic endoscopic cooperative surgery as a minimally invasive treatment for gastric submucosal tumor. World J Gastrointest Endosc 2015;7:1150-6.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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