Laparoscopic Surgery for Gastric Gists Over 5cm in Size: Is It Feasible and Safe?

Yasuaki Miyazaki, MD, Kiyokazu Nakajima, MD, Yukinori Kurokawa, MD, Syuji Takiguchi, MD, Hiroshi Miyata, MD, Makoto Yamasaki, MD, Yoshiyuki Fujiwara, MD, Toshirou Nishida*, MD, Masaki Mori, MD, Yuichiro Doki, MD. Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Department of Surgery, Osaka Police Hospital*

Background: Based on the National Comprehensive Cancer Network sarcoma guidelines, laparoscopic surgery has been limitedly indicated for gastric gastrointestinal stromal tumor (GIST)s less than 5 cm in size. If no clinically malignant factors were detected through the preoperative evaluation, laparoscopic approach can theoretically be considered for cases with larger tumors. However, its use for gastric GIST > 5 cm is still controversial, since its feasibility, safety and limitation have not been fully understood. The objective of this study was to assess feasibility, safety and oncologic appropriateness of laparoscopic surgery for gastric GIST over 5 cm in size.
Patients and Methods: Laparoscopic surgery was attempted in 10 patients with gastric GISTs over 5cm in size from January 2000 to August 2010. In principle, a standard 3 – 4 port technique was employed and stapled partial gastrectomy was performed after adequate gastric mobilization. Following three oncologic principles were strictly adhered during each procedure: 1) no direct handling of the lesion, 2) adequate surgical margins at stapling, and 3) full thickness gastric resection. Laparoscopic exposure was also carefully maintained so that the entire extragastric lesion was fully visualized, to prevent any unexpected injury to the pseudocapsule of the tumor outside the laparoscopic vision. Intraoperative gastroscopy was routinely used to confirm exact tumor localization, for gastric calibration, and for leak testing. Hand-sewn gastrectomy via enlarged trocar site, i.e. laparoscopic assisted surgery, was positively adopted in selected patients. Patients’ demographics, tumor characteristics, operative and early postoperative outcome, and long-term follow up results, were retrospectively analyzed using prospectively complied surgical database.
Results: Three male and seven female patients were included in this study. The median age at surgery was 64.0 years (18 – 75 years). GIST was located in the fornix (six cases), the corpus (three cases), and the antrum (one case), with median tumor size of 6.0cm (5.0 – 8.0 cm). Laparoscopic surgery was completed without conversion in all cases. Median operating time was 130 minutes (45 – 200 minutes), and estimated blood loss was 12.5 ml (10 – 150 ml). No clinically malignant factors were noted intraoperatively, and all procedures followed the fore-mentioned oncologic principles. No intraoperative or postoperative complications directly related to the use of laparoscopic approach, were noted. All cases showed positive KIT immunostaining with mitotic count < 5/50 HPF histopathologically, and were categorized into “intermediate risk” group. All patients showed rapid and uneventful postoperative recovery with median hospital stay of 10.0 days (5 – 30 days). No patients showed recurrence or metastasis with median follow up periods of 3.75 years (1.2 – 8.5 years).
Conclusion: Laparoscopic surgery is feasible, safe, and fully complies with oncologic principles, with acceptable oncologic outcome for selected patients with gastric GIST > 5 cm. Even for cases with large tumors, laparoscopic approach can still be considered if no clinically malignant factors are identified.