Endoscopic Cooperative Surgery Research Articles

Thoracoscopic and endoscopic cooperative surgery for esophageal gastrointestinal stromal tumor: a case report

BackgroundEsophageal gastrointestinal stromal tumors (GISTs) are relatively rare, accounting for 2–5% of all GISTs. Typically, the treatment is surgery in nature. However, no standard procedure established for esophageal GISTs, and in many cases, subtotal esophagectomy or local resection via thoracoscopy or mediastinoscopy is performed. Thoracoscopic and endoscopic cooperative surgery (TECS) is a surgical approach similar to laparoscopic and endoscopic cooperative surgery used for gastric GIST; however, no reports of its use for esophageal GIST have been published to date. We herein report such a case along with a review of past literature.Case presentationThe patient was a 60-year-old man. Upper gastrointestinal contrast imaging revealed a subepithelial lesion in the esophagus. An 18 × 17 mm subepithelial lesion was identified in the left wall, 35 cm from the upper incisors, during upper gastrointestinal endoscopy, and was diagnosed as a GIST through endoscopic ultrasound-guided fine needle biopsy. TECS was therefore performed. The patient was placed in a prone position with his face to the left. After confirming the lesion under endoscopy and left thoracoscopy, the periesophageal area of the lesion was dissected under thoracoscopy. Subsequently, an endoscopic full-layer resection was performed. Finally, the excision site of the lesion was sutured under thoracoscopy. The operation took a total of 3 h and 22 min, with a blood loss of 50 mL.ConclusionsThe appropriate surgical procedure for esophageal GIST should be considered according to the location and size of the lesion. TECS ensures that the resection margins are secured using an endoscopic or thoracoscopic approach. Furthermore, TECS is minimally invasive, avoiding esophagectomy and reconstruction, which makes it a potential surgical option for esophageal GISTs.

Laparoscopic endoscopic cooperative surgery for gastric subepithelial lesion during laparoscopic sleeve gastrectomy for severe obesity

BackgroundThe frequency of pathologies detected incidentally before, during, and after a bariatric surgery, such as subepithelial lesion (SEL) of the stomach, is likely to rise as bariatric surgery becomes more common.Case presentationA 49-year-old female patient presented with severe obesity, for which laparoscopic sleeve gastrectomy (LSG) was planned. During a preoperative examination, endoscopy revealed a 10 mm SEL in the posterior wall of the upper body of the stomach. Excision of the SEL was performed simultaneously with the LSG. Endoscopy demonstrated that the SEL was situated on the remnant side of the stomach. Endoscopic resection using laparoscopic endoscopic cooperative surgery was performed for the SEL, and the thinned gastric wall was closed by hand-sewing. Thereafter, LSG was performed. Pathological analysis of the SEL led to a diagnosis of leiomyoma. The patient was discharged on postoperative day 6.ConclusionSurgeons should be prepared to manage incidentally detected pathologies before, during, and after bariatric surgery and to choose the surgical method most suitable to the individual patient.

Successful modified CLEAN-NET with semicircular seromuscular layer incision for a gastric GIST near the cardia: a case report and video demonstration

BackgroundThe combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET) is a laparoscopic and endoscopic cooperative surgery (LECS). It combines laparoscopic gastric resection and endoscopic techniques for local resection of gastric tumors, such as gastrointestinal stromal tumors (GIST), with minimal surgical margins. A conventional CLEAN-NET surgical procedure is complex, requiring careful techniques to preserve the cardia, particularly in case of nearby lesions. We describe the case of a patient who underwent a modified CLEAN-NET approach with a semi-circular seromuscular layer incision surrounding the base of the tumor, different from a circular shape seromuscular layer in the conventional CLEAN-NET: around the tumor to preserve mucosal continuity, which acts as a barrier to avoid intraoperative tumor dissemination.Case presentationA 43-year-old woman was referred to our hospital because of a gastric submucosal tumor near the cardia, detected on medical examination. The patient was diagnosed with gastric GIST based on the results of endoscopic ultrasound-guided fine-needle aspiration. Modified CLEAN-NET was performed with a semicircular incision of the seromuscular layer on the opposite side of the cardia, making the surgical procedure simple and minimizing partial resection of the gastric wall, including the tumor, while preserving the cardia. The operative time was 147 min, preoperative blood loss volume was 3 mL, and postoperative hospital stay was 9 days. The resected specimen revealed a minimal resection of the gastric wall, including the tumor. The cardia and gastric nerves were preserved, and the postoperative food intake was good.ConclusionsThe modified CLEAN-NET with semicircular seromuscular layer dissection is a simple and reliable surgical procedure for GIST near the cardia.

Comparative Assessment of Laparoscopic and Endoscopic Cooperative Surgery with Laparoscopic Wedge Resection for the Treatment of Gastric Submucosal Tumors

Abstract Background The most commonly performed surgical resection technique for gastric submucosal tumors (gSMTs) is laparoscopic wedge resection (LWR). Notably, laparoscopic and endoscopic cooperative surgery (LECS) is a surgical procedure that combines laparoscopic gastric resection with an endoscopic submucosal dissection for the local resection of gastric tumors, which provides appropriate and minimal surgical resection margins. Methods Seventy-nine gSMT patients who underwent surgical resection at our department between January 2004 and January 2023 were retrospectively assessed. LWR and LECS were performed in 61 and 18 patients, respectively. Clinicopathological features and short-term surgical outcomes were assessed between the two groups. A 2:1 propensity score matching was performed to mitigate the effects of selection biases. Regardless of the surgical procedure, all the patients underwent curative resection with negative margins. Results The LWR and LECS groups included 24 and 12 patients, respectively. The mean operative duration was significantly shorter in the LWR group than in the LECS group (LWR, 131.1 min; LECS, 195.2 min; p < 0.05). The mean ratio of tumor diameter to resected specimen diameter was significantly higher in the LECS group than in the LWR group (LWR, 60.3%; LECS, 78.9%; p < 0.05). The mean ratio of tumor area to resected specimen area was significantly higher in the LECS group than in the LWR group (LWR, 44.7%; LECS, 66.3%; p < 0.05). Conclusion LECS was performed safely with a minimal and optimal safety margin compared with LWR. The findings suggest that LECS can be a feasible option for the treatment of gSMTs.

Retrospective observational cohort study of laparoscopic surgical strategies for gastrointestinal stromal tumors

Laparoscopic surgery has been used to treat gastric submucosal tumors (SMTs). Laparoscopic and endoscopic cooperative surgery (LECS) has been used when subtotal resection has been difficult, which enabled resection of these tumors. In this study, we reviewed the medical records of patients with gastric SMTs who underwent laparoscopic surgery in our hospital with the aim of reporting the surgical indications, procedures (especially for LECS), and outcomes of surgery. This study involved 55 patients who underwent laparoscopic surgery between April 2014 and March 2021. We classified the patients into two groups: laparoscopy-assisted surgery group (non-LECS group, n = 30) and LECS group (n = 25). LECS was performed in the upper stomach, in the greater curvature of the lower stomach, and in both intraluminal and intramural locations in the middle stomach. Non-LECS was selected for extraluminal and intramural tumors in the greater curvature of the upper stomach. There were no severe complications associated with the operation. There was one postoperative complication in the LECS group. The length of postoperative hospital stay did not significantly differ between the LECS and non-LECS groups. We reported the surgical procedures for gastric SMTs in our hospital. It is essential to make full use of the multiple techniques reported in this article and examine the location of the tumor to avoid excess or insufficient resection. Our review of the present case series allowed us to select the appropriate surgical approach for gastric SMTs based on the lesion location and type of development.

Gastric inflammatory myofibroblastic tumor: a case report

BackgroundInflammatory myofibroblastic tumor (IMT) of the stomach is an uncommon mesenchymal neoplasm. We present a case of gastric submucosal tumor (SMT) where the final diagnosis was IMT.Case presentationA 69-year-old man presented with a 24-mm SMT on the posterior wall of the middle third of the stomach that was detected by screening upper gastrointestinal endoscopy. Abdominal contrast-enhanced computed tomography showed that the tumor was well-enhanced. Although endoscopic ultrasonography-guided biopsy was performed, the histological diagnosis was not confirmed preoperatively. Since the tumor was clinically suspected to be a gastrointestinal stromal tumor, we performed gastric wedge resection by laparoscopic–endoscopic cooperative surgery. Pathologically, proliferative spindle cells with a positive reaction for smooth muscle actin, negativity for c-kit, desmin, s-100, CD34, STAT-6, β-catenin and anaplastic lymphoma kinase 1 were identified. Hence, the tumor was finally diagnosed as an IMT originating from the stomach.ConclusionsWhen an SMT of the stomach is identified, the possibility of gastric IMT should be considered.

Outcomes of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors: A retrospective multicenter study at 21 Japanese institutions.

We conducted a multicenter study on classical laparoscopic and endoscopic cooperative surgery (LECS) and LECS-related procedures to retrospectively clarify the safety, problems, and mid-term outcomes of these methods after their coverage by the national health insurance. A total of 201 patients who underwent classical LECS/LECS-related procedures for gastric submucosal tumors (G-SMTs) in 21 institutions affiliated with the Laparoscopy Endoscopy Cooperative Surgery Study Group from April 2014 to March 2016 were included. Data was retrospectively obtained from the patients' charts. The most common surgical procedure was classical LECS (155 patients, 77.1%), non-exposed endoscopic wall inversion surgery (22 patients, 11.4%), a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (16 patients, 8%), and closed LECS (two patients, 1%). Only six (3%) patients underwent LECS with gastrostomy. The mean operative time and blood loss were 188.4 (70-462) minutes and 23.3 (0-793) g, respectively. Ten (5%) patients developed postoperative complications (Clavien-Dindo classification grade II or higher). Two patients needed reoperation due to postoperative bleeding or anastomotic leakage. All tumors were resected with negative margins. A total of 127 (63.2%) patients underwent follow-up observations for over 36 months, one of whom had a recurrence of peritoneal dissemination and one had poor oral intake. Classical LECS and LECS-related procedures for G-SMTs have favorable short/mid-term outcomes.

Short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors.

This retrospective study aimed to compare the short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery in patients with superficial non-ampullary duodenal epithelial tumors. We investigated consecutive patients with SNADETs > 10mm in size who underwent ESD (ESD group) or LECS (LECS group) between January 2015 and March 2021. The data was used to analyze the clinical course, management, survival status, and recurrence between the two groups. A total of 113 patients (100 and 13 in the ESD and LECS groups, respectively) were investigated. The rates of en bloc resection and curative resection were 100% vs. 100% and 93.0% vs. 77.0% in the ESD and LECS groups, respectively, with no significant difference. The ESD group had shorter resection and suturing times than the LECS group, but there were no significant difference after propensity score matching. There were also no differences in the rates of postoperative adverse event (7.0% vs. 23.1%; P = 0.161). The 3-year overall survival (OS) rate was high in both the ESD and LECS groups (97.6% vs. 100%; P = 0.334). One patient in the ESD group experienced recurrence due to liver metastasis; however, no deaths related to SNADETs were observed. ESD and LECS are both acceptable treatments for SNADETs in terms of a high OS rate and a low long-term recurrence rate, thereby achieving a comparable high rate of curative resection. Further studies are necessary to compare the outcomes of ESD and LECS for SNADETs once both techniques are developed further.

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor with tumor diameter of >5 cm.

Laparoscopic and endoscopic cooperative surgery (LECS) is an effective treatment for gastric gastrointestinal stromal tumors (GISTs). The utility of LECS for gastric GISTs of > 5 cm remains controversial. This study was performed to investigate the feasibility of LECS for gastric GISTs with a tumor diameter of >5 cm. We analyzed 43 patients with gastric GISTs who underwent LECS or laparoscopic partial gastrectomy (Lap-Partial Gx). We compared the surgical outcomes of LECS versus Lap-Partial Gx and of LECS for a tumor diameter of > 5 versus ≤ 5 cm. In the comparison of LECS versus Lap-Partial Gx, there were no significant intergroup differences in the operative time or blood loss volume. The morbidity rate was similar between the groups. No postoperative mortality occurred in either group. In the comparison of LECS for a tumor diameter of > 5 versus ≤ 5 cm, there were no significant intergroup differences in operative time, or blood loss volume. The morbidity rate was similar between the > 5-cm and ≤ 5-cm groups (0.0% vs. 4.5%, respectively ; p = 0.56). Additionally, no recurrence or death occurred during follow-up in either group. LECS is a feasible option for gastric GISTs with a tumor diameter of > 5 cm. J. Med. Invest. 71 : 148-153, February, 2024.

Endoscopic Treatment for Gastric Subepithelial Tumor.

Most gastric subepithelial tumors (SETs) are asymptomatic and are often incidentally discovered during endoscopic procedures conducted for unrelated reasons. Although surveillance is sufficient for the majority of gastric SETs, certain cases necessitate proactive management. Laparoscopic wedge resection, although a viable treatment option, has its limitations, particularly in cases where SETs (especially those with intraluminal growth) are not visualized on the peritoneal side. Recent advances in endoscopic instruments and technology have paved the way for the feasibility of endoscopic resection of SETs. Several promising endoscopic techniques have emerged for gastric SET resection, including submucosal tunneling endoscopic resection, endoscopic full-thickness resection (EFTR), laparoscopic and endoscopic cooperative surgery (LECS), and non-exposure EFTR (non-exposed endoscopic wall-inversion surgery and non-exposure simple suturing EFTR). This study aimed to discuss the indications, methods, and outcomes of endoscopic therapy for gastric SETs. In addition, a simplified diagram of the category of SETs according to the therapeutic indications and an algorithm for the endoscopic management of SET is suggested.

Eleven-year follow-up of duodenal hemangiolymphangioma treated with duodenal-laparoscopic endoscopic cooperative surgery.

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A rare case of inflammatory myofibroblast tumor of the stomach successfully treated by inverted laparoscopic and endoscopic cooperative surgery

BackgroundAn Inflammatory myofibroblastic tumor (IMT) is a rare intermediate malignancy characterized by myofibroblast proliferation and inflammatory cell infiltration. Various organs are the primary sites of origin. However, primary tumors originating in the stomach tend to be extremely rare, making the diagnosis difficult. Herein, we present a case of IMT originating in the stomach that was effectively managed using inverted laparoscopic endoscopic cooperative surgery (LECS).Case presentationA 47-year-old male who was admitted to the hospital because of a submucosal tumor that was discovered during upper gastrointestinal endoscopy. The diameter of the tumor was approximately 20 mm. A KIT-negative gastrointestinal stromal tumor was suspected based on the biopsy findings. Therefore, partial resection of the stomach was performed using inverted laparoscopic and endoscopic cooperative surgery. Histopathological examination revealed collagen fiber proliferation from the submucosal layer to the muscular layer, accompanied by infiltration of spindle-shaped cells, lymphocytes, and numerous inflammatory cells. Immunohistochemistry results were positive for SMA and negative for CD34, desmin, and c-kit. IgG4-positive cells were observed with an IgG4/IgG ratio > 50%, and specific nuclei were positive for ALK. Therefore, IMT was diagnosed. This condition may be difficult to diagnose both before and after surgery because of its rarity and submucosal tumor-like morphology.ConclusionWhen a submucosal tumor originating in the stomach is observed, IMT should be considered. Partial resection of the stomach with LECS and immunohistochemical diagnosis may be useful.

Progress in the application of laparoscopic and endoscopic cooperative surgery in gastrointestinal stromal tumors

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor among gastrointestinal tumors, with an inherent potential for malignancy. The primary approach to addressing GIST remains surgical intervention. Laparoscopic and endoscopic cooperative surgery (LECS) has emerged as an innovative treatment approach for GIST. LECS includes various techniques, such as classic LECS, inverted LECS, and laparoscopic-assisted endoscopic full-thickness resection, all of which aim to combine the advantages of laparoscopy and endoscopy. This treatment offers benefits such as accurate localization, complete lesion removal, and a good prognosis. Generally, LECS can be used for GIST with a tumor diameter less than 50 mm, which cannot be completely removed through traditional endoscopic surgery. The clinical application of LECS deserves further exploration and expansion in the future, ultimately benefiting patients.

Use of inducible and limiting fluorescence in laparoscopic endoscopic cooperative surgery

Video 1Demonstration of the special use of the near-infrared fluorescent clip in laparoscopic endoscopic cooperative surgery.

Endoscopic Resection of Gastrointestinal Stromal Tumors.

Surgical resection is regarded as the main modality for the treatment of gastrointestinal stromal tumors (GISTs). With the advancement of endoscopic techniques and the concept of super minimally invasive surgery (SMIS), endoscopic resection has been an alternative option for surgery. Recently, various endoscopic resection techniques have been used for the treatment of GISTs, including endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFR), submucosal tunneling endoscopic resection (STER), and laparoscopic and endoscopic cooperative surgery (LECS). Studies on the safety and efficacy of endoscopic treatment of GISTs have emerged in recent years and have demonstrated that endoscopic resection techniques are effective and safe for the treatment of GISTs. However, there is currently no consensus on the optimal follow-up strategy and the appropriate tumor size cutoff value for ER treatment. This review aims to discuss the indications, preoperative preparation, procedures, efficacy, safety, postoperative evaluation, follow-up, and perspectives of ER for GISTs. This article is protected by copyright. All rights reserved.

Endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors: A review.

The surface of the small bowel mucosa is covered more than any other section of the digestive canal; however, the overall prevalence of small bowel tumors of the whole gastrointestinal tract is evidently low. Owing to the improvement in endoscopic techniques, the prevalence of small bowel tumors has increased across multiple countries, which is mainly due to an increase in duodenal tumors. Superficial non-ampullary duodenal epithelial tumors (SNADETs) are defined as tumors originating from the non-ampullary region in the duodenum that share similarities and discrepancies with their gastric and colorectal counterparts in the pathogenesis and clinicopathologic characteristics. To date, white light endoscopy (WLE) remains the cornerstone of endoscopic diagnosis for SNADETs. Besides, narrow-band imaging (NBI) techniques and magnifying endoscopy (ME) have been widely used in the clinic and endorsed by multiple guidelines and consensuses for SNADETs' evaluation. Confocal laser endomicroscopy (CLE), endocytoscopy (ECS), and artificial intelligence (AI) are also up-and-coming methods, showing an exceptional value in the diagnosis of SNADETs. Similar to the endoscopic treatment for colorectal polyps, the choices for SNADETs mainly include cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and laparoscopic endoscopic cooperative surgery (LECS). However, owing to the narrow lumen, rich vascularity, weak muscle layer, abundant Brunner's gland, and the hardship of endoscope control, the duodenum ranks as one of the most dangerous operating areas in the digestive tract. Therefore, endoscopists must anticipate the difficulties in endoscopic maneuverability, remain aware of the increased risk of complications, and then select the appropriate treatment according to the advantages and disadvantages of each method.

Progress in the treatment of early gastric cancer with Laparoscopic and endoscopic cooperative surgery

With the introduction of minimally invasive methods into the field of surgery, the concept of early gastric cancer (EGC) treating has gradually changed from the pursuit of standardized traditional surgical methods to precise, individualized, interdisciplinary collaborative management. Both endoscopic therapy and laparoscopic surgery have their limitations for early gastric cancer treatment. Meanwhile, Laparoscopic and endoscopic cooperative surgery (LECS) combines the advantages of endoscopy and laparoscopy to perform local gastric resection and regional lymph node dissection, providing a more effective surgical approach for radical resection of early gastric cancer. The application of LECS in the treatment of early gastric cancer has been increasing, from the initial laparoscopy-assisted endoscopic full-thickness resection to the evolvement of a variety of improved procedures such as combined laparoscopic and endoscopic approach for neoplasia with a non-exposure technique, non-exposed endoscopic wall-inversion surgery, and the possibility of combined (sentinel lymph node drainage area) regional lymph node dissection or sentinel lymph node navigation surgery, which expands the indications for endoscopic surgery and maximizes the preservation of normal gastric tissue structure and function while ensuring radical treatment, and will certainly become an important development direction in the treatment of early gastric cancer in the future.

Progress of laparoscopy and endoscopy cooperative surgery for early colorectal tumors

Cooperative laparoscopic or robotic-endoscopic surgery has emerged as a promising approach for the treatment of early-stage colorectal cancers that are difficult to treat with endoscopic techniques alone. Cooperative surgery allows organ and function preservation by complementing the advantages of each modality, providing minimally invasive, precise and personalized treatment options. Laparoscopic-endoscopic cooperative surgery includes laparoscopic-assisted endoscopic resection, combined laparoscopic-endoscopic full-thickness resection, endoscopic-assisted laparoscopic wedge resection, endoscopic-assisted laparoscopic segmental resection, and laparoscopic-endoscopic cooperative surgery with sentinel lymph node dissection. Nearly three decades of clinical research and practice have demonstrated the safety and efficacy of laparoscopic and endoscopic cooperative surgery in the treatment of colorectal tumors. With the progress of the minimally invasive concept, the development of minimally invasive technology and the innovation of minimally invasive equipment, laparoscopy and endoscopy cooperative surgery is expected to have a proper place in the treatment of colorectal tumors.

Laparoscopic endoscopic cooperative surgery for the duodenal neuroendocrine tumor: a single-center case series (How I Do It).

Duodenal neuroendocrine tumors (D-NETs) are uncommon. The surgical treatment for D-NETs was in debate. Laparoscopic and endoscopic cooperative surgery (LECS) is a promising approach for treating gastrointestinal tumors. The study aimed to evaluate the feasibility and safety of LECS for D-NETs. Meanwhile, the authors described the details of the LECS technique. All patients diagnosed with D-NETs underwent LECS between September 2018 and April 2022 were retrospectively reviewed. The endoscopic procedures were performed with endoscopic full-thickness resection. The defect was manually closed under the surveillance of the laparoscopy. A total of seven patients were enrolled, including three men and four women. The median age was 58 years (ranging from 39-65). Four tumors were located in the bulb and three in the second portion. All cases were diagnosed as NET with grade G1. The tumor depth was pT1 in two cases and pT2 in five cases. The median specimen size and the tumor size were 22mm (ranging from 10-30) and 8.0mm (ranging from 2.3-13.0), respectively. En-bloc resection and curative resection rates are 100 and 85.7%, respectively. There were no severe complications. Until 1 June 2022, there was no recurrence. The median follow-up was 9.5 months (range, 1.4-45.1). LECS with endoscopic full-thickness resection is a reliable surgical procedure. The minimally invasive advantages of LECS enable more individualized treatment options for a specific group. Limited by the length of observation, the long-term performance of LECS for D-NETs requires additional investigation.

A vanished gastric gastrointestinal stromal tumor

BackgroundLocal resection is the standard treatment for gastrointestinal stromal tumors (GISTs). Laparoscopic and endoscopic cooperative surgery (LECS) is a minimally invasive surgery used to resect GISTs. Herein, we report an extremely rare case of a gastric GIST that grossly vanished during LECS.Case presentationA 50-year-old Japanese female was referred to our hospital after an abnormality was detected during an esophagogastroduodenoscopy (EGD) at her annual health checkup. Based on EGD, endoscopic ultrasound (EUS), and computer tomography (CT) findings, the patient was diagnosed with a 50-mm submucosal tumor (SMT) with intraluminal growth on the anterior wall of the lesser curvature of the upper body of the stomach. We routinely use LECS to treat the intraluminal growth type of GISTs. During the intraoperative endoscopy, the intraluminal submucosal tumor, which was detected preoperatively, had vanished. A red-white scar was observed in the regressed tumor region. LECS was performed by resecting at a distance away from the scar tissue and closing the gastric wall with intracavitary sutures. In the evaluation from the tumor section view of the original resected specimen, a 22 × 14 × 8 mm lobular neoplasm was observed that was predominantly located in the gastric submucosa to the muscularis propia. Pathological findings confirmed the diagnosis of GIST with intermediate risk indicated by the Fletcher classification. The patient continued postoperative adjuvant chemotherapy with imatinib and no recurrence was detected over 12 months after surgery.ConclusionLECS was performed on the vanished gastric GIST, providing the best surgical treatment and leading to an accurate diagnosis and optimal postoperative care.