Safety, effectiveness and the optimal duration of preoperative imatinib in locally advanced gastric gastrointestinal stromal tumors: A retrospective cohort study.

BACKGROUND: The optimal duration of preoperative imatinib (IM) remains controversial. This study aimed to evaluate the safety, therapeutic effectiveness, and optimal duration of preoperative IM in patients with locally advanced gastric gastrointestinal stromal tumors (GIST). METHODS: The clinicopathologic data of 41 patients with locally advanced gastric GIST who received preoperative IM and underwent surgical resection from January 2014 and December 2021 were retrospectively analyzed. RESULTS: After a median of 7.0 (IQR: 4.5-10) months of preoperative IM treatment, 30 patients experienced adverse events (AEs), 80% of which were grade 1/2 AEs. The mean tumor size decreased from 12.71 ± 5.34 cm to 8.26 ± 4.00 cm, with a reduction rate of 35%. Setting 8 months as the cut-off value according to the results of ROC analysis. The proportion of laparoscopic surgery was higher in patients with short-term (≤8 months) versus long-term (>8 months) preoperative IM. Compared with the subtotal/total gastrectomy group, patients in the local gastrectomy group exhibited less intraoperative blood loss, shorter length of postoperative hospital stay, and fewer postoperative complications. The 3-year recurrence-free survival (RFS) and overall survival (OS) rates were 82.9% and 97.6%, and the expected 5-year RFS and OS rates were 75.6% and 90.2% respectively. RFS was better in the short-term than in the long-term preoperative IM treatment group, and it was also better in pre- plus postoperative IM treatment group than that in the preoperative IM alone group. Both univariate and multivariate COX analysis showed that a higher mitotic index and long-term preoperative IM treatment were associated with worse RFS, while postoperative IM treatment could significantly improve RFS. CONCLUSIONS: The study suggests that in patients with locally advanced gastric GIST, preoperative short-term (≤8 months) use of IM is associated with higher RFS than long-term use.

Ligation-assisted endoscopic submucosal resection following unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria.

BACKGROUND: The majority of esophageal subepithelial lesions originating from the muscularis propria (SEL-MPs) are benign in nature, although a subset may exhibit malignant characteristics. Conventional endoscopic resection techniques are time-consuming and lack efficacy for small SEL-MPs. AIM: To evaluate the efficacy and safety of ligation-assisted endoscopic submucosal resection (ESMR-L) following unroofing technique for small esophageal SEL-MPs. METHODS: From January 2021 to September 2023, 17 patients diagnosed with esophageal SEL-MPs underwent ESMR-L following unroofing technique at the endoscopy center of Shenzhen People's Hospital. Details of clinicopathological characteristics and clinical outcomes were collected and analyzed. RESULTS: The mean age of the patients was 50.12 ± 12.65 years. The mean size of the tumors was 7.47 ± 2.83 mm and all cases achieved en bloc resection successfully. The average operation time was 12.2 minutes without any complications. Histopathology identified 2 Lesions (11.8%) as gastrointestinal stromal tumors at very low risk, 12 Lesions (70.6%) as leiomyoma and 3 Lesions (17.6%) as smooth muscle proliferation. No recurrence was found during the mean follow-up duration of 14.18 ± 9.62 months. CONCLUSION: ESMR-L following roofing technique is an effective and safe technique for management of esophageal SEL-MPs smaller than 20 mm, but it cannot ensure en bloc resection and may require further treatment.

Successful modified CLEAN-NET with semicircular seromuscular layer incision for a gastric GIST near the cardia: a case report and video demonstration.

BACKGROUND: The combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET) is a laparoscopic and endoscopic cooperative surgery (LECS). It combines laparoscopic gastric resection and endoscopic techniques for local resection of gastric tumors, such as gastrointestinal stromal tumors (GIST), with minimal surgical margins. A conventional CLEAN-NET surgical procedure is complex, requiring careful techniques to preserve the cardia, particularly in case of nearby lesions. We describe the case of a patient who underwent a modified CLEAN-NET approach with a semi-circular seromuscular layer incision surrounding the base of the tumor, different from a circular shape seromuscular layer in the conventional CLEAN-NET: around the tumor to preserve mucosal continuity, which acts as a barrier to avoid intraoperative tumor dissemination. CASE PRESENTATION: A 43-year-old woman was referred to our hospital because of a gastric submucosal tumor near the cardia, detected on medical examination. The patient was diagnosed with gastric GIST based on the results of endoscopic ultrasound-guided fine-needle aspiration. Modified CLEAN-NET was performed with a semicircular incision of the seromuscular layer on the opposite side of the cardia, making the surgical procedure simple and minimizing partial resection of the gastric wall, including the tumor, while preserving the cardia. The operative time was 147 min, preoperative blood loss volume was 3 mL, and postoperative hospital stay was 9 days. The resected specimen revealed a minimal resection of the gastric wall, including the tumor. The cardia and gastric nerves were preserved, and the postoperative food intake was good. CONCLUSIONS: The modified CLEAN-NET with semicircular seromuscular layer dissection is a simple and reliable surgical procedure for GIST near the cardia.

Gastrointestinal stromal tumours: incidence, recurrence and mortality. A decade of patients from a New Zealand tertiary surgical centre.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. The New Zealand (NZ) population incidence has not previously been documented nor has the potential effect of ethnicity been reviewed. We furthermore wanted to assess the difference between those undergoing a wedge resection versus a more extensive operation which we hypothesised would correlate with recurrence and mortality. METHODS: All patients (n = 103) with a GIST diagnosed and treated at Te Whatu Ora Waitemata (Auckland, New Zealand) between 2012 and 2021 are presented. Patient demographics, method of GIST detection, management approach, index surgery, histological features, use of adjuvant and neoadjuvant imatinib, follow-up, recurrence and mortality rates were analysed. RESULTS: This paper reports the largest NZ GIST cohort to date and estimates an incidence of 17 cases per million per year. Eighty-four patients underwent surgical resection, 58 received a wedge resection and 17 received a more extensive operation. Five-year disease-free survival rates were 100% in the low/very low risk, 90% in the intermediate and 59% in the high risk groups as determined by the modified NIH criteria. Our overall 5-year GIST-specific survival rate was 83%; it was 91% in those who underwent a wedge resection and 60% in the extensive operation group. There is evidence that Maori have higher rates of GIST recurrence compared to non-Maori and are more likely to require an extensive surgical resection.

Follow-up analysis and research of very low-risk and low-risk gastrointestinal stromal tumors after endoscopic resection.

Currently, due to limited long-term evidence, there remains some controversy surrounding the recommended postoperative monitoring strategy for primary low-risk gastrointestinal stromal tumors (GISTs). This study recruited a total of 532 patients diagnosed with very low-risk and low-risk GISTs who underwent endoscopic resection from 2015 to 2021, including 460 very low-risk patients and 72 low-risk patients. Descriptive statistical analysis was used to evaluate the clinical and pathological characteristics of GIST patients, and Kaplan-Meier methods were employed for survival analysis. The results showed that the 5-year recurrence-free survival rates for very low-risk and low-risk patients were 98.5% and 95.9%, respectively. The 5-year disease-specific survival rates for both groups were 100%. Additionally, the 5-year overall survival rates were 99.7% for very low-risk patients and 100% for low-risk patients (P = 0.69). Therefore, it is suggested that routine follow-up monitoring, including endoscopic surveillance and imaging, may not be necessary for very low-risk and low-risk GISTs after endoscopic resection.

Endoscopic Characteristics of Small-Bowel Gastrointestinal Stromal Tumors Detected During Single-Balloon Enteroscopy: A Retrospective Analysis.

BACKGROUND/AIMS:  The endoscopic features of small-bowel gastrointestinal stromal tumors (GISTs) are not well defined. The objective of this study was to describe the endoscopic features of GISTs of the small intestine detected via single-balloon enteroscopy (SBE). MATERIALS AND METHODS:  Patients with surgically confirmed small intestinal GISTs from January 2014 to September 2022 were retrospectively analyzed. The hospital's electronic medical record system was used to retrieve the patients' data, including their demographics, clinical symptoms, hemoglobin on admission, endoscopic and computerized tomography findings, clinicopathological findings, and surgical management data. RESULTS:  In total, 46 GIST patients (23 men and 23 women) with overt bleeding were included, with a mean age of 52 years (23-80 years). The typical duration of the symptoms was 48 hours. Four patients (8.70%) had lesions in the duodenum, 32 (69.56%) had lesions in the jejunum, 8 (17.39%) had lesions in the ileum, and 2 (4.35%) had lesions around the junction of the jejunum and ileum. Out of the 46 patients, 27 underwent SBE, and GISTs were visualized in 25, while the lesions could not be visualized in the remaining 2. Submucosal round (n = 13), submucosal sessile (n = 8), and invasive/penetrating (n = 4) were among the endoscopic tumor features. Twenty patients exhibited submucosal protuberant lesions, with ulceration, vascular nodules/congestion, or erosion on the surface, and 5 patients presented ulcerative infiltrative lesions. The multiple logistic regression analysis indicated that the invasive/penetrating characteristics of GISTs under SBE evaluation are significantly correlated with the risk level of GIST malignancy (P < .05). CONCLUSION:  A variety of endoscopic characteristics could be observed during the preoperative SBE evaluation of small-intestine GISTs.

Long-Term Efficacy of Single-Incision Laparoscopic Intragastric Resection in Treating Gastrointestinal Stromal Tumors.

Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumors in the gastrointestinal tract, are increasingly treated with minimally invasive surgeries. Developed techniques include laparoscopic, endoscopic, and hybrid methods for gastric GIST resection. Our study, focusing on single-incision laparoscopic intragastric resection for gastric GISTs, aims to evaluate its safety, efficacy, and long-term outcomes. In a retrospective study of GIST surgery involving 14 patients who underwent single-incision laparoscopic intragastric resections, we analyzed and compared their preoperative demographics, American Society of Anesthesiologists (ASA) scores, tumor size, neoadjuvant treatment, operation duration, hospital stay, mitotic and Ki-67 indexes, and histological features with those of patients who underwent open and laparoscopic wedge resections, to assess the impact on both survival and disease-free survival. Average operation time was 93.07 minutes (range 81-120 minutes). Average blood loss: 67 ± 20 mL (range 40-110 mL). Postoperative hospital stay averaged 6.79 days (range 4-16 days). Strong correlations were observed between preoperative and pathological tumor sizes (P = .001, P < .001). Survival analysis indicated a significant association with ASA scores (P = .031), but not with mitotic index, Ki-67, or tumor size. Average survival was 80.57 months, with no recurrence or metastasis during follow-up. Based on our experience, the single-incision laparoscopic intragastric resection method emerges as a highly efficient, timesaving, and gentle oncological procedure, providing a safe and minimally invasive alternative resulting in shorter hospital stays and excellent long-term outcomes with minimal recurrence. For more definitive conclusions, larger, multicenter, and prospective studies are recommended.

Gastrointestinal Stromal Tumors of the Stomach: Is There Any Advantage of Robotic Resections? A Systematic Review and Meta-Analysis.

Background: The role of robotic surgery for gastrointestinal stromal tumor (GIST) resection remains unclear. This systematic review and meta-analysis aimed to investigate the outcomes of robotic versus laparoscopic surgery in patients requiring surgery for gastric GISTs. Methods: MEDLINE, EMBASE, and the Cochrane databases were searched from inception to September 4, 2023. Two independent reviewers conducted a systematic review of the literature to select all types of analytic studies comparing robotic versus laparoscopic surgery for GISTs and reporting intraoperative, postoperative, and/or pathological outcomes. Results: Overall, 4 retrospective studies were selected, including a total of 264 patients, specifically 111 (42%) in the robotic and 153 (58%) in the laparoscopic group. Robotic surgery was associated with longer operating time (+42.46 min; 95% confidence interval [CI]: 9.34, 75.58; P=0.01; I2: 85%) and reduced use of mechanical staplers (odds ratio [OR]: 0.05; 95%CI: 0.02, 0.11; P<0.00001; I2: 92%;) compared with laparoscopy. Although nonsignificant, conversion to open surgery was less frequently reported for robotic surgery (2.7%) than laparoscopy (5.2%) (OR: 0.59; 95%CI: 0.17, 2.03; P=0.4; I2: 0%). No difference was found for postoperative and oncological outcomes. Conclusions: Robotic surgery for gastric GISTs provides similar intraoperative, postoperative, and pathological outcomes to laparoscopy, despite longer operative time.

Long-term survival outcomes of endoscopic therapy vs. surgical resection in patients with cardia gastrointestinal stromal tumor.

The ideal surgical approach for treating cardia gastrointestinal stromal tumor (GIST) is not clearly established. This study aimed to assess the long-term survival results among patients who received endoscopic therapy (ET) or surgical resection (SR) for cardia GIST. Cardia GIST patients from 2000 to 2019 were selected from the surveillance, epidemiology, and end result (SEER) database. Multiple imputation (MI) was applied to handle missing data, and propensity score matching (PSM) was carried out to mitigate selection bias during comparisons. Demographic and clinical characteristics' effects on overall survival (OS) and cancer-specific survival (CSS) were assessed using Kaplan-Meier analyses and multivariate Cox proportional hazard models. A total of 330 patients with cardia GIST were enrolled, including 47 (14.2%) patients with ET and 283 (85.8%) patients with SR. The 5-year OS and CSS rates in the ET and SR groups were comparable [before PSM, (OS) (76.1% vs. 81.2%, P = 0.722), (CSS) (95.0% vs. 89.3%, P = 0.186); after PSM, (OS) (75.4% vs. 85.4%, P = 0.540), (CSS) (94.9% vs. 92.0%, P = 0.099)]. Moreover, there was no significant difference between ET and SR in terms of long-term OS (hazard ratio [HR] 0.735, 95% confidence interval [CI] 0.422-1.282) and CSS (HR 1.560, 95% CI 0.543-4.481). Our study found no significant disparity in long-term survival outcomes between ET and SR in cardia GIST patients, implying that ET could be a valid surgical strategy for treating cardia GIST.

Is laparoscopic approach as treatment of large gastric GIST acceptable?

AIM: Laparoscopic surgery is widely used for small gastric gastrointestinal stromal tumors (GISTs) (≤ 5 cm) but remains a controversial approach for larger gastric GISTs (> 5 cm). This study aims to compare short- and long-term outcomes of laparoscopic resection in comparison with open resection for gastric GISTs measuring over 5 cm. METHOD: All patients receiving surgery for gastric GIST > 5 cm between 2000 and 2021 in a single tertiary hospital were included. Data were collected from prospectively maintained records. Kaplan-Meier method and log rank test were used to compare survival outcomes. RESULTS: Among 108 included patients, 59 patients had minimally invasive (MI) surgery (54.6%) whereas 49 patients had open surgery (46.4%). The rate of overall postoperative morbidity was 14.8% and the median length was significantly shorter in the MI group [4 (range 2-30) vs. 7 (range 4-33) days; P = 0.007]. The overall R0 resection rate was 98.2% and the rate of tumor rupture was 13%, not different between the two groups. Recurrence occurred in 24% of the whole population without any difference between groups (20.3% vs. 28.7%, p = 0.31). Minimally invasive surgery was not found as a negative prognostic disease-free survival factor. CONCLUSION: Laparoscopic surgery could be a safe and feasible alternative to open surgery in large gastric GIST, bringing the benefits of minimally invasive surgery without compromising oncologic results.