Laparoscopic Gastric Wedge Resection and Prophylactic Antireflux Surgery for a Submucosal Tumor of Gastroesophageal Junction

A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

Comparison of Clinical Characteristics between Open and Laparoscopic Surgery Groups in Gastric Gastrointestinal Stromal Tumor Patients

PURPOSE: The stomach is the most frequent site of gastrointestinal stromal tumor (GIST). Surgery remains the only curative treatment for GIST. Resection needs to ensure tumor free margin without lymphadenectomy. Thus partial gastric resection is the treatment of choice for gastric GIST. This study aims to review clinical characteristics between open and laparoscopic wedge resection group and evaluate safety and efficacy of laparoscopic wedge resection. METHODS: Between 1997 and 2008, 74 consecutive patients undergoing open or laparoscopic wedge resection of gastric GISTs were identified in a retrospectively collected database. Preoperative and postoperative variables were analyzed. RESULTS: Wedge resection with negative margin was performed in 74 patients. Laparoscopic wedge resection was performed 19 patients. Open wedge resection was performed in 55 patients. Mean tumor size of laparoscopic group was 2.7 cm (range 0.4~6.0) and open group was 4.4 cm (range 0.4~23.0). Mean operation time of laparoscopic group was 150.0 minutes (range 80~240), and open group was 164.6 minutes (range 75~360). Mean hospital stay of laparoscopic group was 7.11 days (range 3~19), and open group was 9.38 days (range 6~20). There were no significant survival differences between groups. CONCLUSION: A laparoscopic wedge resection of gastric GIST is associated with short hospitalization and not inferior to open wedge resection in terms of morbidity and mortality. The long-term outcomes between laparoscopic and open wedge resection group in our study were no significant survival differences. Long-term and prospective randomized study should be performed to confirm oncological safety of laparoscopic wedge resection.

Image-based Approach for Surgical Resection of Gastric Submucosal Tumors

PURPOSE: This study was done to evaluate the usefulness of preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound to facilitate treatment of gastric submucosal tumors. MATERIALS AND METHODS: The feasibility of laparoscopic wedge resection as determined by CT findings of tumor size, location, and growth pattern was correlated with surgical findings in 89 consecutive operations. The role of laparoscopic ultrasound for tumor localization was analyzed. RESULTS: Twenty-three patients were considered unsuitable for laparoscopic wedge resection because of large tumor size (N=13) or involvement of the gastroesophageal junction (N=9) or pyloric channel (N=1). Laparoscopic wedge resection was not attempted in 11 of these patients because of large tumor size. Laparoscopic wedge resection was successfully performed in 65 of 66 (98.5%) patients considered suitable for this procedure. Incorrect interpretation of preoperative CT resulted in a change of surgery type in seven patients (7.9%): incorrect CT diagnosis on gastroesophageal junction involvement (N=6) and on growth pattern (N=1). In 18 patients without an exophytic growth pattern, laparoscopic ultrasound was necessary and successfully localized all lesions. CONCLUSIONS: Preoperative CT and laparoscopic ultrasound are useful for surgical planning and tumor localization in laparoscopic wedge resection.

Image-based Approach for Surgical Resection of Gastric Submucosal Tumors

PURPOSE: This study was done to evaluate the usefulness of preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound to facilitate treatment of gastric submucosal tumors. MATERIALS AND METHODS: The feasibility of laparoscopic wedge resection as determined by CT findings of tumor size, location, and growth pattern was correlated with surgical findings in 89 consecutive operations. The role of laparoscopic ultrasound for tumor localization was analyzed. RESULTS: Twenty-three patients were considered unsuitable for laparoscopic wedge resection because of large tumor size (N=13) or involvement of the gastroesophageal junction (N=9) or pyloric channel (N=1). Laparoscopic wedge resection was not attempted in 11 of these patients because of large tumor size. Laparoscopic wedge resection was successfully performed in 65 of 66 (98.5%) patients considered suitable for this procedure. Incorrect interpretation of preoperative CT resulted in a change of surgery type in seven patients (7.9%): incorrect CT diagnosis on gastroesophageal junction involvement (N=6) and on growth pattern (N=1). In 18 patients without an exophytic growth pattern, laparoscopic ultrasound was necessary and successfully localized all lesions. CONCLUSIONS: Preoperative CT and laparoscopic ultrasound are useful for surgical planning and tumor localization in laparoscopic wedge resection.

The Comparison between Laparoscopic Wedge Resection and Open Wedge Resection for Gastric Gastrointestinal Stromal Tumors / 대한내시경복강경외과학회지

PURPOSE: A laparoscopic wedge resection is increasingly being used for gastrointestinal stromal tumors of the stomach. The aim of this study is to evaluate the safety and the feasibility of laparoscopic wedge resection compared to conventional open wedge resection. METHODS: Fifty-six patients who underwent laparoscopic wedge resection (LW group, n=32) or open wedge resection (OW group, n=24) for gastric submucosal tumor, between January 2005 and December 2007, were enrolled in this retrospective study. RESULTS: here were no significant differences in the patients' clinicopathological datas between the two groups. Although there were no significant difference in the operation time and the postoperative morbidity, the time to the first oral intake (1.2+/-1.5 vs. 1.5+/-0.6 days, p=0.015), the duration of hospital stay (3.4+/-0.7 vs. 5.5+/-0.8 days, p<0.001), and the number of analgesic use (2.2+/-0.9 vs. 4.0+/-1.2 times, p<0.001) were shorter or lower in the LW group than in the OW group. Among the LW group, three patients with endophytic growth pattern underwent intraoperative gastroduodenoscopy to identify the precise location of the tumor. CONCLUSION: Laparoscopic wedge resection is a safe and feasible treatment option for gastrointestinal stromal tumors. In addition, appropriate approach should be utilized according to the size, the location, and the growth pattern of the tumor.

Factors Associated with Operation Time of Laparoscopic Wedge Resection for Gastric Submucosal Tumors / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic gastric wedge resection (LWR) is being increasingly performed as a safe and effective treatment for gastric submucosal tumors (SMTs). However, there are few studies on the factors associated with operation time of LWR for gastric SMTs. The purpose of this study was to determine the factors associated with the operation time of LWR for gastric SMTs. METHODS: Between June 2001 and December 2008, 58 patients with gastric SMTs underwent LWR. We analyzed the clinicopathologic data, perioperative parameters and outcomes, and surgeon's experience retrospectively. We also analyzed the factors associated with the operation time of LWR for gastric SMTs. RESULTS: Among 58 patients that underwent LWR, exogastric wedge resection (n=48) was mainly performed. Transgastric wedge resection (n=8) took the longest amount of time. Intraoperative GFS (n=7) was frequently performed for smaller tumors. When the tumor was located at the cardia and fundus, more time was needed for LWR of the SMTs. There was no correlation of the operation time with the clinicopathologic data and surgeon's experience; however, the tumor location (axis) and the approach used for the resection of the stomach were statistically correlated with the operation time. CONCLUSION: The operation time of LWR for gastric SMTs was related to the tumor location (according to gastric axis) and the approach used for the resection of the stomach. If the tumor location was identified precisely and the proper approach for resection of the stomach was determined preoperatively, the operation time of LWR for gastric SMTs might be reduced.

Gastric Glomus Tumor

Gastric glomus tumors are rare submucosal lesions that originate from the modified smooth muscle cells of the glomus body. They usually present as a submucosal tumor on endoscopy and a heterogeneous hypoechoic tumor in the third or fourth sonographic layer of the gastric wall on endoscopic ultrasonography. So they are often confused with other submucosal tumors such as gastrointestinal stromal tumor, schwannoma, and leiomyoma. Immunohistochemistry helps in differentiating glomus tumors from other submucosal tumors. The treatment of choice for these tumors is complete surgical resection. Most of the gastric glomus tumors are essentially benign in nature, so preoperative recognition of this lesion may spare the patient a more extensive resection. Herein, we present three cases of gastric submucosal tumor that were treated by a laparoscopic wedge resection and confirmed as glomus tumor on final pathology.

Laparoscopic Wedge Resection of GISTs Involving the Second Portion of the Duodenum

The optimal surgical procedure for treatment of gastrointestinal stromal tumors (GISTs) of the duodenum remains undefined. Therefore, various surgical procedures have been introduced as treatment options for duodenal GISTs. Due to the anatomical complexity, the laparoscopic approach has been considered as a contraindication. Especially for GISTs located at the second portion of the duodenum, a laparoscopic wedge resection is technically difficult to perform. We describe the surgical technique of laparoscopic wedge resection with hand-sewn closure for GISTs that involve the second portion of the duodenum.

Laparoscopic Wedge Resection with Hand-Sewing Closure for Gastroduodenal Tumors

PURPOSE: To evaluate the feasibility and efficacy of a laparoscopic wedge resection with hand-sewing closure in gastroduodenal tumors. METHODS: Laparoscopic wedge resections were performed in 16 patients with gastroduodenal tumors between May 2000 and December 2002 at Ewha Womans University Mok-Dong Hospital. Every case, with the exception of one, was performed via an extragastric approach, with a transgastric approach performed in the exception. Excision of lesion was performed manually using electrocautery and ultrasonic coagulating shears and closed by a manual (not use autosuture stapler) intracoporeal running suture. RESULTS: Of the 16 cases, two were performed with a laparoscope-assisted method, but there were no conversion to open surgery. Mean size of lesions was 27.9 mm in diameter and mean operation time was 219 minutes. In all cases, a complete tumor excision with negative surgical margins was obtained. The final pathologic diagnoses were: ectopic pancreas 4 cases, gastrointestinal stromal tumor 3 cases, leiomyoma 2 cases, adenomyoma 2 cases, tubular adenoma 1 case, Brunner's gland hyperplasia 1 case, carcinoid tumor 1 case, eosinophilic granuloma 1 case, and post endoscopic mucosectomy state for early gastric cancer 1 case. The average number of days to the first postoperative oral food intake and hospital stay were 3.1 and 6.0 days, respectively. There were no postoperative complications. CONCLUSION: A laparoscopic wedge resection with hand-sewing closure should be considered as a valid treatment option for selected gastroduodenal tumors, in terms of its feasibility, safety, and cost. A more efficient surgical instrument and technique should be developed in the future.