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Minimal access surgical therapy is the emerging gold standard technique for treatment of gastric gastrointestinal stromal tumours (GISTs). Despite the above there continue to be lack of guidance or standardisation of the techniques.
Objectives: To assess the safety, effectiveness and functional outcomes of a minimal access surgical strategy for gastric GISTs.
Methods: Thirty eight symptomatic gastric GISTs diagnosed during the years 2006-2010 satisfied the inclusion criteria for minimal access surgical resection. All procedures were performed according to an agreed surgical strategy based on the anatomical location of the gastric lesions. The size, site, histology, resection margin, complications, hospital stay, functional outcome, recurrence rate, survival and mutational analysis of the 38 consecutive resections were maintained on a prospective computerised database. All entered data was validated by the operating surgeon and the reporting pathologist.
Results: Twenty nine patients (76%) underwent a laparoscopic extra-gastric tangential resection while seven patients (18%) underwent a posterior trans-gastric resection, and two had a distal gastrectomy (5%). There were no conversions to open, no major intra-operative complications and no episodes of tumour rupture. There were no major immediate or early complications of surgery. Complete resection (R0) was achieved in 100% of cases with a mean lesion size of 44mm (range 20-90mm).
There was no peri-operative (30 day or in-hospital) mortality and the mean post-operative length of stay was 5.6 days. The median follow-up for the surviving population (37/38 or 97.4%) is 24.5 months with a range of 4-77 months without any reported dysphagia, reflux, dumping syndrome or any CT evidence of disease recurrence. 25/26 (96.2%) of the low risk group remain alive with a median follow up of 24.5 months (range 4 -77 months). The 8 patients in the intermediate risk group remain alive (100%) with a median follow-up of 51 months (range 20-77 months) and the 4 high risk group patients remain alive (100%) with a median follow-up of 15 months (range 8-24 months). The only death in this series occurred in the low risk group at 11 months secondary to a dissecting thoracic aneurysm.
Conclusion: Most gastric GISTs are resected by simple tangential excision. Lesions close to gastro-oesophageal junction are best suited for laparoscopic intra-gastric excision to ensure complete resection while maintaining oesophageal patency and sphincteric competency. Juxta-pyloric endophytic lesions are best treated via an anterior gastrotomy or by extra-gastric tangential excision if exophytic. This anatomic and function-based strategy for minimal access surgical resection of gastric GISTs conserve the organ and preserve its function leading to a quicker recovery and a better quality of life without breaching oncological principles.