Laparoscopic Approaches to Gastric Gastrointestinal Stromal Tumors (gist): An Institutional Experience.

Michael J Pucci, MD, Francesco Palazzo, MD, Pei-wen Lim, BS, Karen A Chojnacki, MD, Ernest L Rosato, MD, Adam C Berger, MD. Thomas Jefferson University Hospital, Department of Surgery, Philadelphia, PA, USA

Introduction: Gastrointestinal stromal tumors (GIST) are uncommon gastric neoplasms that can generally be treated by surgical excision. Over the past eight years, our institution has gained experience in resecting these tumors by minimally invasive methods. As our experience with advanced laparoscopic techniques improves, our treatment algorithm for these tumors has changed. Since 2003, our approach has been to attempt laparoscopic resection as first line treatment for small and medium-sized gastric GISTs (< 7 cm) in any position along the stomach. The purpose of this study is to review our experience with laparoscopic resection, report our outcomes, and offer our perspective on the technical nuances involved in handling these neoplasms via a minimally invasive approach.

Methods: We queried our prospectively maintained, IRB-approved database for laparoscopic gastric GISTs resections. From 2003 to 2011, fifty-seven gastric GISTs were resected via laparoscopy at our institution. We reviewed operative notes for information on the technique employed. Data on tumor location, size, margin status, operative time, and blood loss was collected and reviewed.

Results: Fifty-seven gastric GISTs were resected over 8 years. 37 tumors (65%) were located on the body of the stomach (14 on the posterior body and 23 on the anterior body). Eleven tumors (19%) were positioned in the fundus. Four (7%) GISTs were located at the gastroesophageal junction (GEJ). Five tumors (9%) were located at the antrum of the stomach. The mean tumor size was 3.8cm with a mean estimated blood loss of 39ml. We achieved complete microscopic resection (R0) in 95% of the cases. Most tumors were amenable to local wedge resection. Fundus and GEJ tumors were generally treated with an anterior gastrostomy and transgastric wedge resection. Antral tumors were either resected with local wedge or antrectomy with gastro-enteric reconstruction. Intraoperative endoscopy was utilized in select circumstances; usually to locate a small lesion, confirm completeness of resection, or check luminal patency. Technical approaches varied depending on location of the neoplasm.

Conclusion: As our large, single-institution experience with gastric GISTs has increased, we view laparoscopic resection as first-line treatment in small and moderate sized tumors. Our results confirm the safety of minimally invasive resection and its oncologic efficacy. We have employed several technical variations of laparoscopic wedge resections to treat tumors in difficult anatomic locations. Adequate preoperative planning allows for a proper operative approach in almost all locations of the stomach.