Cancer research, including research into gastrointestinal stromal tumors (GISTs), is in an exciting phase, where old paradigms are challenged and the new ones are waiting in the wings. 

Serrano and George, in their study on the challenges and opportunities of treating GIST in a new decade, wrote, “GIST provides a paradigm to evaluate new molecularly targeted therapies and to identify structural and functional mechanisms for drug response and resistance. Drug development in GIST has successfully exploited the high reliance on KIT/PDGFRA oncogenic signaling as a therapeutic vulnerability.” 

In other words, the public should be assured that progress is being made, albeit slowly. 


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However, at present, the mainstay of GIST treatment remains surgical resection, if the tumor is resectable. There has been a concerted move from open surgery toward laparoscopic surgery, which can be observed all around the world. The benefits of laparoscopic surgery are clear: it is minimally invasive, leaving behind only minor scars, and is less risky of a procedure compared to open abdominal surgery in terms of the possibility of infection. 

When I was working as a doctor in a Borneo hospital that wasn’t necessarily equipped with the latest and best medical technology, I was pleasantly surprised that laparoscopic surgery was the default, unless contraindicated. The main drive for taking this approach was to prevent postoperative infection, which during my time was curiously and stubbornly high. The quicker a patient heals from the surgery, the quicker he or she can be discharged and free up another bed for the next patient. 

The Feasibility of Minimally Invasive Options 

Let’s examine a study conducted by Mazer and colleagues on the feasibility of minimally invasive options for GISTs. They aimed to present “a review of our cases, a technical description of the main types of laparoscopic resection for gastric GIST, and some general principles to help surgeons approach these highly variable tumors.” 

The research team conducted a retrospective review of all patients who underwent surgery (both laparoscopic and open resection) for gastric GIST at Stanford Hospital in California. The researchers had access to information such as patient, operative, and tumor characteristics, as well as operative notes and preoperative imaging. 

Among the 77 patients identified, 53 had a laparoscopic resection; 24 had an open resection. Researchers discovered that tumor size was significantly larger among those who had an open resection, with a median size of 7 cm. 

The research identified 4 types of resection: ”(1) non-anatomic stapled wedge resection, (2) non-anatomic full thickness removal of a “disk” of tissue with closure of the resulting gastrotomy, (3) anatomic partial gastrectomy with reconstruction, and (4) transgastric resection.” 

In terms of the locations of tumors within the stomach identified for laparoscopic resection, 34% occurred in the cardia, fundus, or gastroesophageal junction, 23% occurred in the lesser curve, 19% occurred in the greater curve, 17% occurred in the body of the stomach, and 8% at the antrum/pylorus. 

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The researchers also described how a laparoscopic transgastric surgery is performed, something that would be familiar to surgeons.

“Once the stomach was inflated, the abdomen was desufflated to bring the abdominal wall in contact with the gastric wall. Under endoscopic vision, two 5-mm and one 12-mm radially-dilating trocars were placed into the stomach and insufflation in the gastric lumen maintained with the laparoscopic CO2 insufflator“ they wrote. “The lesion was elevated with an endoloop, and a stapler introduced through the 12 mm transgastric port to amputate the stalk. The lesion was then bagged and removed either from the mouth using a snare passed through the endoscope or by enlarging a gastric trocar site.” 

What is the point Mazer et al are attempting to drive home? Well, first is that minimally invasive gastric surgery can take on various forms, depending on the aggressiveness of the tumor and its location. Second, it is well-developed enough that the different types of procedures that can be performed are clearly defined, with associated guidelines. 

Mazer and colleagues concluded, “resection requires creativity and flexibility of technique. By utilizing a combination of methods, including upper endoscopy and laparoscopy, it is technically feasible to resect even large lesions close to the lesser curve, gastroesophageal junction, or pylorus in a minimally invasive fashion.”

An Eye on the Benefits 

Let us keep our focus on what this is all about: minimally invasive surgery is safer, shortens hospital stays, and reduces the risk of intraoperative or postoperative infection.

Ortenzi et al, in their study comparing laparoscopic versus open surgery for GIST, discovered certain benefits of laparoscopic surgery. For example, operation time was significantly lower than with abdominal surgery (82.4 minutes vs 117.8 minutes). In addition, they did not encounter intraoperative or postoperative complications in patients who received laparoscopic surgery, which is contrasted with 4 patients receiving open surgery who needed blood transfusions for anemia. 

Ortenzi and colleagues summed up why laparoscopic surgery is generally safer and more effective than open surgery: “Laparoscopic surgery is a minimally invasive approach to the treatment of GISTs and offers many advantages such as short hospital stay and low morbidity. In the meantime oncological outcomes of laparoscopy for gastric GIST, assessed as tumor free resection margins and recurrence rate, are comparable to traditional open strategy.” 

References

Serrano C, George S. Gastrointestinal stromal tumor: challenges and opportunities for a new decadeClin Cancer Res. 2020;26(19):5078-5085. doi:10.1158/1078-0432.CCR-20-1706

Mazer L, Worth P, Visser B. Minimally invasive options for gastrointestinal stromal tumors of the stomachSurg Endosc. 2021;35(3):1324-1330. doi:10.1007/s00464-020-07510-x

Ortenzi M, Ghiselli R, Cardinali L, Guerrieri M. Surgical treatment of gastric stromal tumors: laparoscopic versus open approachAnn Ital Chir. 2017;88:S0003469X17026112.