SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital lengths of stay compared with those who underwent open resection, according to results from a single-center study.
"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.
Dr. Sabha Ganai
"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).
Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."
To evaluate patient selection for a minimally invasive approach to resection, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.
The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m2, and 57% were male.
There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).
Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).
There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."
Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the amount of estimated blood loss (a mean of 364 mL vs. 35 mL).
Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).
Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (a mean of 3.3 days) than in the open group (a mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).
Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.
On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.48), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-power fields (OR, 4.68). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.