Surgical treatment of gastric stromal tumors: laparoscopic versus open approach

Gastrointestinal stromal tumors (GIST) are quite rare tumors, but yet they are the most common mesenchymal lesions of gastrointestinal tract. Their outmost frequent origin site is stomach and presently surgical resection is the mainstay in the treatment of gastric non metastatic GIST. Their peculiar characteristic of growth and poor metastatic tendency make this tumors particularly prone to be managed by minimally invasive technique. Presenting our experience we want show the feasibility and safeness of laparoscopic approach for gastric GIST and its benefits versus traditional open surgery and pointing out short term and long terms outcomes.

In our series we included 60 patients who underwent surgery for gastric GIST from 2004 to 2014 at Clinica Chirurgica of Università Politecnica delle Marche. Patients were divided in two group according with surgical approach (open or laparoscopic). Criteria of exclusion were metastatic disease and palliative purpose of surgical resection. All patients underwent endoscopic ultrasonography, fine needle aspiration, TC/MRI or PET before surgery. However most of the definitive diagnosis were postoperative. CD117 and CD34 immunohistochemical positivity were considered suggestive for GIST. Tumors were classified in four different prognostic groups according with pathological findings (size and mitotic count) as reported in Fletcher classification. None of the patients received Imatinib before surgery. All patients underwent follow-up with Computerized Tomography (TC) and/or Magnetic Resonance (MRI) repeated every year (mean 51.98 ± 35.68 months).

We performed open surgery on 22 patients (36.7%) and laparoscopic wedge resection on 38 patients (63.33%); one of these underwent robotic wedge resection by da the da Vinci® surgical system. The median age at diagnosis was 64 years (range= 45-71). Patients with gastric GIST presented with various symptoms, including fatigue secondary to anemia, intraluminal gastrointestinal bleeding, abdominal pain, abdominal mass, vomiting and syncope. In 26 patients (43.3%) gastric GISTs were detected incidentally during abdominal exploration, endoscopy, or radiologic imaging. Tumor dimensional difference between the two groups was not significant (mean 4.75 cm, range= 2-13). Operation time was significantly lower in laparoscopic approach (82.4 versus 117.8 min). We did not experience of intraoperative or post-operative complications in laparoscopic group. Conversely 4 patients of open group were transfused for anemia. In our series we didn't observe recurrence or metastasis at mean follow up period of (range= 49-120 months).

Laparoscopic surgery is a minimally invasive approach to the treatment of GISTs and offers many advantages such as short hospital stay and low morbidity. In the meantime oncological outcomes of laparoscopy for gastric GIST, assessed as tumor free resection margins and recurrence rate, are comparable to traditional open strategy.

Gastrointestinal stromal tumors, Laparoscopy, Minimally invasive surgery, Stomach.