Laparoscopic versus open wedge resection for gastrointestinal stromal tumors of the stomach: a single-center 8-year retrospective cohort study of 156 patients with long-term follow-up

Cai et al. BMC Surgery Laparoscopic versus open wedge resection for gastrointestinal stromal tumors of the stomach: a single-center 8-year retrospective cohort study of 156 patients with long-term follow-up Jia-Qin Cai 0 Ke Chen 0 Yi-Ping Mou Yu Pan Xiao-Wu Xu Yu-Cheng Zhou Chao-Jie Huang 0 Equal contributors Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University , 3 East Qingchun Road, Hangzhou 310016, Zhejiang Province , China Background: The aim of this study was to compared laparoscopic (LWR) and open wedge resection (OWR) for the treatment of gastric gastrointestinal stromal tumors (GISTs). Methods: The data of 156 consecutive GISTs patients underwent LWR or OWR between January 2006 and December 2013 were collected retrospectively. The surgical outcomes and the long-term survival rates were compared. Besides, a rapid systematic review and meta-analysis were conducted. Results: Clinicopathological characteristics of the patients were similar between the two groups. The LWR group was associated with less intraoperative blood loss (67.3 vs. 142.7 ml, P < 0.001), earlier postoperative flatus (2.3 vs. 3.2 days, P < 0.001), earlier oral intake (3.2 vs. 4.1 days, P < 0.001) and shorter postoperative hospital stay (6.0 vs. 8.0 days, P = 0.001). The incidence of postoperative complications was lower in LWR group but did not reach statistical significance (4/90, 4.4% vs. 8/66, 12.1%, P = 0.12). No significant difference was observed in 3-year relapse-free survival rate between the two groups (98.6% vs. 96.4%, P > 0.05). The meta-analysis revealed similar results except less overall complications in the LWR group (RR = 0.49, 95% CI, 0.25 to 0.95, P = 0.04). And the recurrence risk was similar in two group (RR = 0.80, 95% CI, 0.28 to 2.27, P > 0.05). Conclusions: LWR is a technically and oncologically safe and feasible approach for gastric GISTs compared with OWR. Moreover, LWR appears to be a preferable choice with mini-invasive benefits. Gastrointestinal stromal tumor; Laparoscopy; Meta-analysis; Survival - Background Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumor of the gut, are often characterized by high expression of KIT [1,2]. The most common sites for GIST include the stomach (60%) and jejunum or ileum (30%) followed by duodenum (5%), colon and rectum (less than 5%), esophagus (less than 1%), and appendix (less than 1%) [2]. GISTs have malignant potential, and it is reported that recurrence of GISTs often occured at the peritoneal surface or liver [3]. Surgical resection is the mainstay management for primary localized GISTs. As submucosal and lymphatic spread are rare, the surgical principles are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles [2-4]. Since the development of minimally invasive surgical approaches, laparoscopic surgery for gastrointestinal tumors has evolved rapidly over the past decade. Various types of laparoscopic approaches for GISTs have been described, including wedge resection of the stomach, intragastric tumor resection, and combined endoscopiclaparoscopic resection [5-8]. For gastric GISTs, lymph node metastases are rare and localised resection with a clear margin of 1 to 2 cm appears to be an adequate treatment [9,10]. Besides, recent evidence has shown that survival depends on the tumor size and histological features rather than the extent of resection [3]. Therefore, gastric GISTs can be treated without major anatomical resections [11] and are suitable for laparoscopic wedge resection (LWR). Several case series have proved the safety and feasibility of LWR for gastric GISTs, however, the oncologic benefits of LWR have not been widely reported and the sample size of those researches were relatively small. In the current study, we retrospectively reviewed data for GIST patients who underwent LWR and traditional open wedge resection (OWR) at our hospital between 2006 and 2013. The clinical data, benefits of operation, perioperative outcomes, and oncologic outcomes were reviewed. Besides, a rapid systematic review with a meta-analysis was conducted to further assess accurately the current status of LWR for gastric GIST. Methods Patients Between January 2006 and December 2013, 177 consecutive patients with suspected gastric GIST underwent laparoscopic or open wedge resection in the Department of General Surgery at the Sir Run Run Shaw Hospital, China. The exclusion criteria included: (1) patients concomitant with tumors outside stomach; (2) patients with metastatic disease at the time of operation; (3) patients diagnosed as other types of submucosal tumor after immunohistochemical examination. Blood tests, chest X-rays, enhanced computed tomography scans of the abdomen and pelvis, and endoscopic ultrasonography were performed before operation. This study protocol was prospectively approved by ethics committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University and conducted in accordance with the ethical guidelines of the Declaration of Helsinki. Informed consent was signed prior to surgery by each case. Surgical procedure The patient is placed in the supine position under general anesthesia. The surgeon stood on the right side of the patient. One assistant stood on the right side of the patient and held the laparoscope, and another stood on the left side of the patient. Carbon dioxide pneumoperitoneum was established through the Veress needle and set at 15 mmHg. One initial 10-mm trocar was inserted for laparoscopy below the umbilicus and another four trocars (one of 12 mm, three of 5 mm) were inserted into the left upper flank, left flank, right upper flank, and right flank quadrants; a total of five trocars were inserted, and arranged in a V-shape. Mobilizing the tumor before excised were usually as fellows: Tumor in anterior wall of the gastric body and pylorus was excised directly. If tumor was in anterior wall near lesser curvature, the hepatogastric ligament was dissected firstly to free it. If it was in anterior wall near great curvature, parts of gastrocolic ligament and gastrosplenic ligament were dissected firstly. For tumor located in posterior wall, the gastrocolic and gastrosplenic ligament were dissected, then lifted up the stomach to expose the tumor. Those in fundus, the gastrocolic and gastrosplenic ligament was also dissected as well as left gastroepiploic vessels and short gastric vessels, so the fundus can be mobilized and the tumor can be expose. Gastroscopy was used intraoperatively to evaluate tumor localization if necessary. Tumor was excised using ultrasonic scalpel or endoscopic linear stapler with at least 1-2 cm surgical margin. The defect left by excision using ultrasonic scalpel in the gastric wall was reinforced using laparoscopic hand-suturing technique. If th (...truncated)