Combined laparoscopic and endoscopic excision of a gastric gist

Abstract

We read with interest the article by K. De Vogelaere, Laparoscopic resection of gastric gastrointestinal stromal tumors (GIST) is safe and effective, irrespective of tumor size, published in Surgical Endoscopy 2012;26:2339–2345. We agree with the authors that the laparoscopic approach can be safely and effectively used to remove gastric stromal tumors irrespective of tumor size. Data from the literature show that the long-term results of the laparoscopic procedure are comparable with those reported after traditional open resection of gastric GIST [1–6]. Concerning the technique described by the authors, we think that for tumor located in the anterior wall, the wedge resection is the best technique to be used. For tumors located in the posterior wall, the technique described in the article is a good option for large tumors. For endophitic small tumors of the posterior stomach wall, however, another laparoscopic approach can be used. We have experienced and published an endoscopic–laparoscopic approach that allowed us to perform a mini-invasive surgery for tumors smaller than 2 cm in diameter located in the posterior wall of the stomach. By our proposed technique, laparoscopic removal of GIST was performed also for a patient with a tumor located close to the esophagogastric junction, which the authors ruled out in their series, probably because these tumors are technically challenging with the laparoscopic approach they reported. The technique we have published was performed using two 5-mm radially expandable trocars inserted through the abdominal and gastric walls to have very small incisions in the gastric wall. An endoscopic polipectomy snare introduced per mouth was maneuvered by an endoscopist, who grasped and tractioned the gastric iuxtacardial lesion. A harmonic scalpel device inserted through the 5-mm laparoscopic trocar was used to remove the gastric tumor with a submucosal resection. The resection of the lesion was accomplished thanks to the traction made by the endoscopist through the polipectomy snare, which allowed an excellent exposure of the dissection site. The specimen then was pulled away from the mouth after its introduction into a small plastic bag. After withdrawal of the expandable trocars, the gastric holes were closed with monofilament nonabsorbable sutures. A nasogastric tube was left in place for 2 days. The postoperative phase was uneventful. This laparoscopic–endoscopic technique made possible a complete resection of the submucosal GIST, which otherwise could have been more challenging with marked intraoperative risk of complications (e.g., perforation), considering the iuxtacardial location of the tumor. Our technique allows all the advantages of the laparoscopic surgery, avoids the gastrotomy, and at the same time satisfies the principles of oncologic surgery. In addition, GIST located in the iuxtacardial region may be resected safely and with less morbidity than with other laparoscopic or open approaches.