This study demonstrates the feasibility of laparoscopic partial gastrectomy for gastric GISTs. The large-sized GISTs that are not feasible for laparoscopic resection or may be associated with multi-organ resection may receive neoadjuvant therapy to be downsized, thus making them suitable for resection and avoid intrabdominal spillage and dissemination.
Laparoscopic resection of gastric GISTs has been recently adopted, because the prognosis of GISTs depends mainly on the tumor size and morphological features rather than the wide margins of resection [13].
Laparoscopic surgeries have many advantages over the traditional open surgery. Laparoscopy reduces the intraoperative blood loss, postoperative pain, and allows the early recovery of the patient with the oral intake and shorten the hospital stay [14].
The European Society for Medical Oncology (ESMO), indicated laparoscopic resection of small-sized GISTs. The treatment of large sized tumors with minimally invasive surgeries is not preferred due to the risk of intra-operative spillage [15], which is considered a significant factor for tumor recurrence.
Recent data from the National Comprehensive Cancer Network (NCCN) have indicated laparoscopic or laparoscopic-assisted resection of gastric GISTs larger than 5 cm. [16] Nowadays, there is no cutoff tumor size for safe laparoscopic surgery. It is suggested to be around 4–5 cm.
A study by Melstrom et al. [17], the mean tumor size in 17 patients was 4.3 cm (range 1.5–9.1 cm). In the current study, the mean tumor size was 7.2 cm (range 2.5–13 cm) and all patients underwent total laparoscopic resection without single intra-operative tumor rupture.
Many authors demonstrated their experience of safe laparoscopic resection of large sized GISTs > 5 cm without any complications [12]. Large tumor resection requires longer operative times, and may be associated with more significant blood loss. Tumor size is not the only difficulty with laparoscopic resection of gastric GISTs, but also the tumor location as in the gastroesophageal junction, the gastric antrum or posterior gastric wall. The most common tumor location in our study was in the greater curvature of the stomach (46.7%) which made it easier for resection laparoscopically.
Bischof et al. [18] reported a mean operative time of 157 minutes which is comparable to that in our study (153 minutes). Roggin and Posner presented results from five reports on the laparoscopic resection of GISTs and the conversion rates ranged from 0 to 6.5% [19]. However, we reported no intraoperative complications nor conversion into laparotomy in our study.
Oral intake was started in most of the patients in our study in POD 1, thus the mean hospital stay was 3.53 days. In the study by Chi. et.al, oral intake was 3.5 days but the mean hospital stay was 6.1 days [20]. In our series, patients had a smooth postoperative course apart from blood transfusion for two cases due to anemia and another had pneumothorax necessitating chest tube insertion. We had no postoperative mortality in our study. Gertsen et al [21], reported that 6 patients (27%) had postoperative morbidity. One patient was re-operated for anastomotic leakage. Two patients developed pneumonia, one had postoperative cardiac complications, and another had urologic complication. There was no postoperative mortality.
Most of the tumors in our study were large-sized (5 to 10 cm) and only four patients had a tumor size more than 10 cm. The largest tumor size was 13 cm (2 patients) and the mean tumor size was 7.2 cm. All patients had total laparoscopic resection with delivery of specimens through extension of the infraumbilical port without the need for a mini-laparotomy. Immunohistochemical examination was done for all patients revealing positive CD117, CD34, DOG1 for 96.7%, 93.3% and 100% patients, respectively, and most of the tumors were of intermediate risk. In another study, the tumor size was 4 cm and the largest was 5.5 cm and the immunohistochemical examination was CD 117 (97.1%), CD 34 (70.6%), DOG1 (26.5%). Their NIH tumor risk was low in 50% of the cases. [22]
Adjuvant therapy was given to 23 patients, in our study. These patients were with intermediate and high-risk tumor features. Patients were followed up within a mean period of 32.4 months. Clinical and radiological assessment were done. Local recurrence developed in one patient (3.3%) with hepatic and peritoneal disease after 48 months. This patient had a tumor with high risk features (mitotic index > 5) and received both neoadjuvant and adjuvant therapy (Fig. 3). The recurrence rate after laparoscopic resection of gastric GISTs was reported to be ranged from 4.8 to 18% [23].
Another study found no significant difference in terms of disease-free survival and overall survival between the laparoscopic and the open resections for gastric GISTs. In the laparoscopic group, six patients had either local recurrence or distant metastasis and four of these patients died, while, in the open group, ten had either local recurrence or distant metastasis and five of them died. These results indicate that laparoscopic surgery for gastric GISTs has oncologic outcomes similar to that of open surgery [20].