Laparoscopic approaches to resection of suspected gastric gastrointestinal stromal tumors based on tumor location

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Abstract
Surgical resection of gastric gastrointestinal stromal tumor (GIST) should be optimized to achieve a negative pathologic surgical margin while limiting the extent of stomach volume loss. Careful identification of exact gastric tumor location using preoperative computed tomography (CT) scans and gastroscopy should allow for selection of a specific operative approach. This retrospective case series involved 12 patients (7 men and 5 women; mean age, 60.5 years) with suspected gastric GIST undergoing tumor resection at Fletcher Allen Health Care, a university medical center, from January 2005 to August 2006. The main outcome measures were pathologic resection margins, operative time, estimated blood loss (EBL), morbidity, and duration of hospital stay. The 12 patients were separated into three groups on the basis of tumor location as follows: type 1 (fundus/greater curvature, n = 5), type 2 (prepyloric/antrum, n = 3), and type 3 (lesser curvature/perigastroesophageal junction, n = 4). Preoperative imaging (CT scan and/or endoscopy) used to identify tumor location accurately predicted the operative approach before surgery for 11 of the12 patients. The surgical approach was selected solely by tumor location as follows: type 1 (laparoscopic partial gastrectomy [LPG]), type 2 (laparoscopic distal gastrectomy [LDG]), and type 3 (laparoscopic transgastric resection [LTG]). Nine patients had a final pathologic diagnosis of GIST. The average tumor size was 4.6 cm, but this did not influence procedure selection. Histologic margins were microscopically negative in all patients. The LPG and LTG approaches had similar outcomes in terms of estimated blood loss (EBL; 80 vs 100 ml) and hospital stay (3.4 vs 3.3 days; p = 0.0198), but LTG had longer operative times (236 vs 180 min). The LDG procedure had longer operative times, greater EBL, and a longer hospital stay. The operative morbidity was 17%, and there was no operative mortality. The selection of an operative technique for resection of gastric submucosal tumors can be based on preoperative identification of tumor location, for better definition of both the extent of gastric resection and the technical complexity of the laparoscopic procedure.