Laparoscopic Treatment of Gastric Gastrointestinal Stromal Tumors: Demonstration of Three Different Approaches

Introduction: Approximately 60% of all gastrointestinal stromal tumors (GISTs) are located in the stomach and show a wide variety of histological features and growth pattern.1 Thanks to recent advances in laparoscopic surgery, the majority of gastric GIST can be removed by using minimally invasive techniques. The most appropriate laparoscopic approach to GIST treatment is selected according to the tumor size, growth pattern, and location. A gastric wedge resection or exogastric resection is the treatment of choice for exophytic tumors with extraluminal growth,2 but it cannot be applied easily to submucosal tumors located close to the esophagogastric junction or the pyloric ring because of a high risk of narrowing or obstructing the gastric inlet or outlet. In these cases, a transgastric or intragastric approach with submucosal resection of the tumor can be safely performed.3 This video shows the three different approaches to laparoscopic minimally invasive treatment of gastric GIST (run time: 7 minutes). Materials and Methods: The first case shows a gastric wedge resection for an exophytic 3-cm GIST located on the lesser curvature at the level of the gastric body. The wedge procedure was performed using a linear stapling device. The second case shows the treatment of a 3.5-cm GIST located at the posterior wall of the antrum about 2 cm from the pylorus. A gastrotomy was performed on the anterior gastric wall directly over the lesion. The tumor was delivered through the gastrotomy and resected via a submucosal/muscular dissection. The third case concerns the treatment of a GIST, about 2.5 cm in diameter, located close to the esophagogastric junction. An intragastric approach was performed by inserting three balloon-type ports into the stomach, one for the optical and two for the laparoscopic instruments. The intragastric enucleation was performed by a progressive submucosal/muscular dissection under the guidance of an oral endoscope to confirm a patent lumen around the esophagogastric junction. Results and Conclusions: The operative time was 75 minutes in the first case, 90 minutes in the second case, and 120 minutes in the third case. No intraoperative complications, such as bleeding or leakage along the suture line, were encountered. The time until the patient could begin oral intake was 1 day, and the average postoperative hospital stay was 4 days. Histopathological analysis confirmed a low-grade malignancy GIST with tumor-negative resection margins in all three patients. The laparoscopic approach to gastric GIST is feasible and safe even when the tumors occur in challenging locations, such as close to the esophagogastric junction or the pylorus.