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ORIGINAL ARTICLE
Year : 2014  |  Volume : 10  |  Issue : 8  |  Page : 259-262

Endo-laparoscopic rendezvous approach for pericardia with gastric posterior wall of gastrointestinal stromal tumor: Analysis of 52 consecutive cases


Department of Digestive Disease Institute, Tianjin Peoples' Hospital, Tianjin 300000, China

Date of Web Publication17-Feb-2015

Correspondence Address:
Yongjie Zhao
Digestive Disease Institute, Tianjin Peoples' Hospital, Tianjin 300000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.151478

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 > Abstract 

Background: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor in the gastrointestinal tract and most frequently developed in the stomach, and surgical therapy is limited on removal of the tumor lesion. The aim of this study was to investigate the clinical values of endo-laparoscopic rendezvous approach for pericardial GISTs within gastric posterior wall.
Materials and Methods: Surgical outcome and clinical data of 52 patients with pericardial GISTs within gastric posterior wall treated at Tianjin Peoples' Hospital from January 2004 to October 2013 were analyzed. Endo-laparoscopic rendezvous approach was used as an operative procedure for tumor resection ranged from 10 to 50 mm. Endoscopic ultrasound, computed tomography and microscopic findings all certified the gastric spindle type GIST locating in the submucosa to muscle proper.
Results: Endo-laparoscopic rendezvous approach was attempted in 52 patients (male/female: 31/21) with median age of 51 years (25-71 years). The median operating time was 80 min (range: 40-120 min) and median intra-operative blood loss was 26 ml (range: 10-50 ml). The median hospital stay was 5 days (range: 4-6 days), while the median tumor size was 25 mm (range: 7-50 mm). All operative margins were clear. There were no recurrences or metastases of all patients in a median follow-up of 24 months (range: 6-36 months).
Conclusions: Endo-laparoscopic rendezvous approach is considered to represent the next revolution in surgery. The new technique is reliable and effective in clinical application, due to the advantages of accurate and quick localization for pericardial GIST within gastric posterior wall.

Keywords: Clinical values, endo-laparoscopic rendezvous approach, gastric posterior wall, gastrointestinal stromal tumor, surgery


How to cite this article:
Ding P, Zhao Y. Endo-laparoscopic rendezvous approach for pericardia with gastric posterior wall of gastrointestinal stromal tumor: Analysis of 52 consecutive cases. J Can Res Ther 2014;10, Suppl S4:259-62

How to cite this URL:
Ding P, Zhao Y. Endo-laparoscopic rendezvous approach for pericardia with gastric posterior wall of gastrointestinal stromal tumor: Analysis of 52 consecutive cases. J Can Res Ther [serial online] 2014 [cited 2020 Jun 1];10:259-62. Available from: http://www.cancerjournal.net/text.asp?2014/10/8/259/151478


 > Introduction Top


Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor in the gastrointestinal tract; it originated from the interstitial cells of cajal or their common stem cell. It is written in the National Comprehensive Cancer Network guidelines given the limited intramural extension, extended anatomic resections (such as total gastrectomy) are rarely indicated. Segmental or wedge resection to obtain negative margins is often appropriate. [1] However, partial or total gastrectomy is not infrequently needed depending on the size, location, and configuration of the tumor. [2] 2004-European Society for Medical Oncology, meeting recommended laparoscopic resection only for GISTs ≤2 cm. However, many surgeons suggested even 5 cm can be an indication for laparoscopic wedge resection, and successful results have been reported with this technique. [3],[4]

The aim of this study was to evaluate the feasibility of endo-laparoscopic rendezvous approach for relatively small pericardial GISTs within gastric posterior wall. Clinicopathologic findings and postoperative course were also analyzed retrospectively to gain insight into the clinical values.


 > Materials and methods Top


Patient selection

From January 2004 to October 2013, 52 patients of pericardial GIST within gastric posterior wall of the stomach underwent endo-laparoscopic rendezvous approach. This number represented 41.94% (52 of 124) of all primary GIST treated operatively at the Tianjin Peoples' Hospital in this period. This technique involves an endoscopy and laparoscopic operation device (Storz Endoscopy and Laparoscopy, Germany). The technique is applicable to patients with small tumors (50 mm or less) in the gastric posterior wall of upper body GIST, where especially helpful for preserving cardia is intended. The following situations preclude the use of this endo-laparoscopic technique: Tumors >50 mm in size: Such GISTs are too large to be safely extracted via the endo-laparoscopic operation device; mid or low body GIST, which is indication for laparoscopic wedge resection.

Diagnostic procedure

Endoscopy and abdominal computed tomography scan were performed preoperatively in all patients. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration biopsy examination were performed if necessary. Lesions in which immunohistochemical analyses were positive for CD-117 and/or CD-34 were considered as GIST and included in this study. Tumors were grouped according to the risk assessment classification as very low risk group when the maximum dimension was <20 mm and the mitotic count (MC) was <5 of 50 high-power fields (HPFs); low risk when the size was 20-50 mm and the MC was <5 of 50 HPFs; intermediate risk when the tumor size was <50 mm and the MC was 6-10 of 50 HPFs or tumor size was 50-100 mm and the MC was <5 of 50 HPFs; and high risk when tumor size was >100 mm or the MC was >10 of 50 HPFs or the tumor size was >50 mm and the MC was >5 of 50 HPFs. [5] Mitotic figures were counted in 50 randomly selected HPFs by two pathologists for all samples.

Operative procedure

Endo-laparoscopic rendezvous approach was performed according to a relatively standard procedure as follows. With the patient placed supine with legs apart, the operator and scrub nurse stood on the patient's right side, the first assistant and endoscope physician on the left, and the camera assistant stood between the patient's legs [Figure 1]. Four ports were used, with two operator ports on the right side, a one first assistant port on the left side, an umbilical port for laparoscope insertion, and transoral for endoscope insertion [Figure 2]. Endoscopic cold light source is positioning on the nearby tumor, endoscopic corresponding position in the serosal wall as a tumor-targeting. The needle of laparoscope is fitted into gastric cavity to suture the wound surface such as "8" word [Figure 3]. Suturing at the gastric wall for traction, wedge resection of the gastric wall was performed using endo-GIA laparoscopic stapling devices (Tyco Autosuture, USA). After laparoscopic resection, endoscopy was applied to observe the surgical scar and cardia surrounding normal tissues, and our techniques are illustrated as [Figure 3]. In all cases, our pathologist reported a free margin of normal gastric wall by frozen section biopsy.
Figure 1: Positions of surgeons and physicians. The operator and scrub nurse using monitor 1, and first assistant and camera assistant using monitor 2, whereas the endoscope physicians using endoscope monitor. O: Operator; FA: First assistant; CA: Camera assist; SN: Scrub nurse; EP: Endoscope physician

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Figure 2: Port sites for the endo-laparoscopic limited gastrectomy

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Figure 3: Intra-operative picture-in-picture view. Simultaneous laparoscopic (large frame) and endoscopic (small frame) views. The preoperative gastric tumor and postoperative surgical scar is visible on the endoscopic view only

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 > Results Top


The clinicopathologic data are shown in [Table 1]. The study subjects were 31 men and 21 women, with median age of 51 years (range: 25-71 years), and the median tumor size was 25 mm (range: 7-50 mm). The risk categorizations of these gastric GISTs having an aggressive behavior, based on tumor size and mitotic activity, were: Very low (10 cases); low (30 cases); intermediate (11 cases); and high (1 cases).
Table 1: Clinicopathologic data of the patients

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The median operating time was 80 min (range: 40-120 min) and median intra-operative blood loss was 26 ml (range: 10-50 ml). The median hospital stay was 5 days (range: 4-6 days). No incidence of tumor rupture or spillage occurred intraoperatively, and all the operative margins were clear. No case of open conversion, reoperation, and operative mortality occurred in the present study. A postoperative complication encountered in one patient who experienced anastomotic bleeding. During a median follow-up of 24 months (range: 6-36 months), there have been no recurrences or metastases of all the patients [Table 2].
Table 2: Operative outcomes and follow - up data

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 > Discussion Top


Surgical margins are unnecessary since gastric GISTs usually grow out of the primary organ rather than being diffusely infiltrating, and lymphadenectomy is usually unwarranted because of the rarity of nodal metastasis. Thus, most surgeons agree that the limited gastrectomy may be considered a standard treatment for gastric GISTs. [6] In recent years, minimally invasive surgery has become the mainstream trend of modern surgery with the rapid development of endoscopic and laparoscopic techniques. [7]

However, there are limitations when either technique is used alone. Endo-laparoscopic rendezvous approach, which combines the advantages and makes up the deficiencies of these two techniques, has expanded the application field of minimally invasive surgery. [8],[9] Yasuo et al. described transgastric partial gastrectomy through the laparoscopic approach for excision of GIST tumors of the posterior fundus, and the tumor can be placed within a plastic bag, exteriorized, and then excised limiting the risk of tumor fragmentation and seeding. [10],[11]

Endo-laparoscopic rendezvous approach is simple and can be performed in any institution because no special devices or endoscopic expertise is required. Moreover, it ensures a sufficient tumor margin because the gastric wall is resected while confirming the especially helpful for preserving cardia. [12],[13],[14],[15] Stenosis and deformation are prevented, even for an obstruction because the procedure can be performed for minimal resection. Our study, usually all perform this procedure for GISTs more than 2 cm away from esophageal gastric junction because this distance is necessary for a linear stapler to be used. Deformation of the stomach does not result from our procedure even when it is performed for >5 cm of a large tumor. However, any endo-laparoscopic rendezvous approach for a GIST more than 5 cm in diameter is not recommended.


 > Conclusion Top


Pericardia with gastric posterior wall of GIST ≤ 5 cm in diameter may be a good candidate for minimally invasive surgery. Endo-laparoscopic rendezvous approach for gastric GIST is a quick-located, process optimization, operation time-saving, non-invasive, fast recovery, oncologically and technically feasible and safe, and effective in clinical application, due to the advantages of accurate and quick localization for pericardia with gastric posterior wall of GIST.

 
 > References Top

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NCCN guideline for soft tissue sarcoma; 2012. Available from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#sarcoma. [Last cited on 2013 Feb 01].  Back to cited text no. 1
    
2.
Gold JS, Dematteo RP. Combined surgical and molecular therapy: The gastrointestinal stromal tumor model. Ann Surg 2006;244:176-84.  Back to cited text no. 2
    
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Otani Y, Furukawa T, Yoshida M, Saikawa Y, Wada N, Ueda M, et al. Operative indications for relatively small (2-5 cm) gastrointestinal stromal tumor of the stomach based on analysis of 60 operated cases. Surgery 2006;139:484-92.  Back to cited text no. 3
    
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Ryu KJ, Jung SR, Choi JS, Jang YJ, Kim JH, Park SS, et al. Laparoscopic resection of small gastric submucosal tumors. Surg Endosc 2011;25:271-7.  Back to cited text no. 4
    
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Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol 2002;33:459-65.  Back to cited text no. 5
    
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Joensuu H, Fletcher C, Dimitrijevic S, Silberman S, Roberts P, Demetri G. Management of malignant gastrointestinal stromal tumours. Lancet Oncol 2002;3:655-64.  Back to cited text no. 6
    
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Sasaki A, Koeda K, Obuchi T, Nakajima J, Nishizuka S, Terashima M, et al. Tailored laparoscopic resection for suspected gastric gastrointestinal stromal tumors. Surgery 2010;147:516-20.  Back to cited text no. 7
    
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Ohtani H, Maeda K, Noda E, Nagahara H, Shibutani M, Ohira M, et al. Meta-analysis of laparoscopic and open surgery for gastric gastrointestinal stromal tumor. Anticancer Res 2013;33:5031-41.  Back to cited text no. 8
    
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Matsuhashi N, Osada S, Yamaguchi K, Okumura N, Tanaka Y, Imai H, et al. Long-term outcomes of treatment of gastric gastrointestinal stromal tumor by laparoscopic surgery: Review of the literature and our experience. Hepatogastroenterology 2013;60:2011-5.  Back to cited text no. 9
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Abdalla S, Baton O, Rouquie D, Boulanger T, Chapuis O. Laparoscopic transgastric partial gastrectomy for a posterior fundic gastrointestinal stromal tumor. J Visc Surg 2013;150:407-13.  Back to cited text no. 10
    
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Sakamoto Y, Sakaguchi Y, Akimoto H, Chinen Y, Kojo M, Sugiyama M, et al. Safe laparoscopic resection of a gastric gastrointestinal stromal tumor close to the esophagogastric junction. Surg Today 2012;42:708-11.  Back to cited text no. 11
    
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Jianjun Q, Yin L, Wenqun X, Ming Y, Qingfeng J. Fast track program for esophagectomy patients. Thorac Cancer 2012;3:55-9.  Back to cited text no. 12
    
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Mardin WA, Palmes D, Bruewer M. Current concepts in the management of leakages after esophagectomy. Thorac Cancer 2012;3:117-24.  Back to cited text no. 13
    
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Rana SS, Bhasin DK, Rao C, Gupta R. Intramural pseudocysts of the upper gastrointestinal tract. Endosc Ultrasound 2013;2:194-8.  Back to cited text no. 14
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Kypraios D, Fusaroli P, Artuso S, Poli F, Caletti G. Gastric ulcer penetration into the liver mimicking malignancy on endoscopic ultrasound. Endosc Ultrasound 2013;2:107-8.  Back to cited text no. 15
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