Hybrid Push-Pull Endoscopic and Laparoscopic Full Thickness Resection for the Minimally Invasive Management of Gastrointestinal Stromal Tumors: A Pilot Clinical Study

Abstract

Background. Gastric gastrointestinal stromal tumors (GISTs) that are predominantly endophytic or in anatomically complex locations pose a challenge for laparoscopic wedge resection; however, endoscopic resection can be associated with a positive deep margin given the fourth-layer origin of the tumors. Methods. Patients at two tertiary care academic medical centers with gastric GISTs in difficult anatomic locations or with a predominant endophytic component were considered for enrollment. Preoperative esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA), and cross-sectional imaging were performed. Eligible patients were offered and consented for hybrid and standard management. Results. Over ten months, four patients in two institutions with anatomically complex or endophytic GISTs underwent successful, uncomplicated push-pull hybrid procedures. GIST was confirmed in all resection specimens. Conclusion. In a highly selected population, the hybrid push-pull approach was safe and effective in the removal of complex gastric GISTs. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique manages with a laparoscopic, full thickness, R0 resection. This novel, minimally invasive, hybrid laparoscopic and endoscopic push-pull technique is a safe and feasible alternative in the management of select GISTs that are not amenable to standard laparoscopic resection.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

“…Another advantage of wedge resection is its technical simplicity and lack of requirement for advanced skills[ 3 ]. However, this simplicity easily results in rough resection and oncological inadequacy[ 61 ]. The simple wedge resection technique is associated with both excessive and inadequate resection of the gastric wall, which may lead to postoperative gastric stenosis, gastric dysfunction, and local recurrence[ 62 , 63 ].…”

An innovative laparoscopic and endoscopic technique in an animal model: combined gastric full-thickness tumor resection

“…Another technique described in the literature is hybrid push-pull endoscopic and laparoscopic full-thickness resection 9 . The seromuscular layer is not incised and the tumor is just pushed towards the gastric lumen by the surgeon, while the endoscopist tries to ensnare all the lesion and directly cut it.…”

“…However, during this maneuver, there is a risk of gastric perforation and exposure of the lesion and the gastric contents to the peritoneal cavity. In four reported cases, the margins were compromised, and a complementary wedge resection was necessary, with use of a laparoscopic stapler 9 .…”

Endoscopic Full Thickness Resection: A Systematic Review

“…Most of the earlier reports described endoscopic resection and laparoscopic defect closure. 76,77 Robotic laparoscopyassisted EFTR was described recently. 78 EFTR has similar operating time and R0 resection rates compared with laparoscopy and was shown to be equivalent for GIST <2 cm.…”

“…(►Table 6). 41,42,77,[112][113][114] Modified laparoscopic intragastric surgery in which resection is performed under endoscopic vision by laparoscopic instruments has been described for gastric GIST. 115 NESS-EFTR has the advantage of preventing peritoneal seeding in EGC 114 (►Fig.…”