Minimally invasive surgery for gastrointestinal stromal tumors--pursuing the trivial, or striving for perfection

Abstract

Complete surgical resection is the main treatment for gastrointestinal stromal tumor (GIST). However, GIST is crisp with rich blood supply, and prone to rupture with improper handling, leading to intra-abdominal hemorrhage and tumor cell dissemination. With the development of technology and equipment, minimally invasive surgery is getting mature. However, according to a phase III, multicenter, randomized controlled trial published in the New England Journal of Medicine in November 2018, open surgery was superior to minimally invasive surgery for early cervical cancer, which warned us that the application of minimally invasive surgery in GIST should be understood dialectically. The general principle of minimally invasive surgery of GIST is avoiding tumor rupture, despite the different location and decision-making according to tumor location. For gastric GIST, minimally invasive surgery should be performed with tumor locating at the greater curvature or anterior wall of the stomach, and with a diameter less than 5 cm. Small intestinal GIST is more malignant and not recommended to undergo minimally invasive surgery, but the technique can be used to expose and locate the tumor. Colorectal GIST is rare but highly malignant, therefore open surgery should be the first choice. In fact, minimally invasive surgery for rectal GIST has certain advantages such as better visualization compared to open surgery. GIST in non-appropriate location, such as the esophagogastric junction, pylorus, and duodenum, should be treated with caution because of its close relationship with organ function. The general principle of GIST treatment is to completely remove the tumor while retaining organ function. The application of minimally invasive surgery should not cause extra damage to organ function or increase the risk of tumor rupture. Endoscopic treatment of GIST still lacks high-quality evidence-based studies. The application of minimally invasive surgery should be conservative. The purpose of performing minimally invasive surgery is not the technique itself, but to minimize the injuries to tissue and organs. In conclusion, we should perform minimally invasive surgery for appropriate patients cautiously on the basis of complete resection and function preservation.