Endoscopic treatment for gastrointestinal stromal tumor: Advantages and hurdles

Abstract

One of the most prominent characteristics of gastrointestinal stromal tumors (GISTs) is their unpredictable and variable behavior. GISTs are not classified as "benign" or "malignant" but are rather stratified by their associated clinical risk of malignancy as determined by tumor size, location, and number of mitoses identified during surgical histology. The difficulty in assessing the malignant potential and prognoses of GISTs as well as the increasing incidence of "incidental GISTs" presents challenges to gastroenterologists. Recently, endoscopic enucleation has been actively performed as both a diagnostic and therapeutic intervention for GISTs. Endoscopic enucleation has several advantages, including keeping the stomach intact after the removal of GISTs, a relatively short hospital stay, a conscious sedation procedure, relatively low cost, and fewer human resources required compared with surgery. However, a low complete resection rate and the risk of perforation could reduce the overall advantages of this procedure. Endoscopic full-thickness resection appears to achieve a very high R0 resection rate. However, this technique absolutely requires a very skilled operator. Moreover, there is a risk of peritoneal seeding due to large active perforation. Laparoscopy endoscopy collaborations have been applied for more stable and pathologically acceptable management. These collaborative procedures have produced excellent outcomes. Many procedures have been developed and attempted because they were technically possible. However, we should first consider the theoretical basis for each technique. Until the efficacy and safety of sole endoscopic access are proved, the laparoscopy endoscopy collaborative procedure appears to be an appropriate method for minimally destructive GIST surgery.

Laparoscopic management of gastric gastrointestinal stromal tumors: A retrospective 10-year single-center experience

“…However, this approach requires facilities for endoscopic submucosal dissection and highly-advanced endoscopic skill, which limits the wide application of a combined laparoscopic-endoscopic approach[17]. In our experience, most cases underwent laparoscopic surgery alone, and diagnostic gastroscopy was used when it was difficult to delineate the tumor’s intraluminal extent and location.…”

How best to manage gastrointestinal stromal tumor

“…Endoscopic enucleation and other related procedures are more feasible for GISTs less than 5 cm[61]. Complete resection of GIST is indicated with endoscopic enucleation in the presence of a pseudo capsule.…”

“…Complete resection of GIST is indicated with endoscopic enucleation in the presence of a pseudo capsule. According to location in the gastric wall, GISTs are classified in to several types such as type 1 [very narrow connection with muscularis propria (MP) layer which protrudes in to the lumen], type 2 (wide based connection with MP layer and protrudes in the luminal side at obtuse angle), type 3 (located in the middle of gastric wall) and type 4 (protrudes into the serosal surface of gastric wall)[61]. This classification is very important when considering endoscopic enucleation.…”

“…Endoscopic enucleation is best suitable for type 1 because of narrow connection to the MP layer and can be attempted for type 2. Type 3 and type 4 cannot be completely resected by endoscopic enucleation and hence endoscopic full-thickness resection (EFTR), laparoscopic and endoscopic cooperative surgery (LECS), laparoscopic-assisted endoscopic full-thickness resection (LAEFR) and non-exposed wall-inversion surgery (NEWS) should be considered[61]. Endoscopic enucleation includes various techniques like endoscopic submucosal dissection (ESD)[62], endoscopic muscularis dissection (EMD)[63] and endoscopic submucosal tunnel dissection (ESTD)[64].…”

“…The best indication for LECS is for gastric GISTs originating from MP layer which are intraluminal[61]. First, Argon plasma coagulation (APC) can be used to mark the periphery of the tumor[67].…”