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Hybrid Push-Pull Endoscopic and Laparoscopic Full-Thickness Resection for the Minimally Invasive Management of Gastric Gastrointestinal Stromal Tumors (GIST)
Paul T. Reynolds*1, Field F. Willingham1, Shishir K. Maithel1, Melinda M. Lewis1, Andrew S. Ross2, Flavio G. Rocha2
1School of Medicine, Emory University, Atlanta, GA; 2Surgical Oncology, Virginia Mason Medical Center, Seattle, WA
Background: For Gastrointestinal stromal tumors (GISTs) in the mid portion of the stomach, a laparoscopic wedge resection is straightforward and associated with little morbidity. However, tumors arising in the cardia, at the gastroesophageal junction, or in the pylorus may require a total or partial gastrectomy, major surgery with potential life-long quality of life implications. Highly endophytic tumors are difficult to locate laparoscopically, may require additional gastrotomies, and may necessitate large resections of the surrounding gastric wall. Endoscopic resection of tumors arising from the muscularis propria, while well tolerated, may divide across, and not below the tumor, leaving a positive deep margin at the base of the resection site.
Objective: To evaluate a novel, minimally-invasive, hybrid laparoscopic and endoscopic push-pull technique for the management of GISTs not amenable to standard laparoscopic wedge resection.
Design: Retrospective cohort study.
Setting: Two tertiary-care academic medical centers.
Patients: Patients with gastric GISTs in difficult anatomic location or with predominantly endophytic lesions were evaluated for a push-pull resection. Pre-operative esophagogastroduodenoscopy, endoscopic ultrasound with or without fine needle aspiration, and cross sectional imaging were performed. Eligible patients were offered enrollment and were consented for hybrid and standard management.
Interventions: Hybrid endoscopic / laparoscopic resection - the tumor was initially resected endoscopically with surgical assistance; a laparoscopic full thickness resection of the resection site was then performed with endoscopic assistance.
Main outcome measures: Technical success, surgical pathology, complications.
Results: Over ten months, four patients with anatomically complex or endophytic GISTs underwent a push-pull hybrid procedure. The mean operative time was 162 min (range 137 - 209 min). All procedures were successful without complications or conversion to open resection. GIST was confirmed in each endoscopic resection specimen and in each subsequent laparoscopic full thickness resection. The deep margin in each endoscopic resection was positive, while each subsequent full thickness resection had a negative margin.
Limitations: Retrospective design, small sample size.
Conclusion: The hybrid push-pull approach was safe and effective in the management of gastric GISTs that were endophytic or in anatomically difficult locations. This technique allowed patients to avoid an extensive resection. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique managed with a laparoscopic, full-thickness, R0 resection site resection. In highly selected populations, this hybrid push pull technique may represent an improvement over standard endoscopic or laparoscopic management for gastric GISTs.
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