Intragastric SILS for GIST, a New Challenge in Oncologic Surgery: First Experiences

Discussion

GISTs are rare uncommon mesenchymal tumors that arise from the wall of the gastrointestinal tract, accounting for fewer than 3% of all gastrointestinal neoplasms. Local resection with macroscopically-negative surgical margins is the preferred and worldwide-accepted treatment of primary non-metastatic GISTs (1). Laparoscopic resection of gastric GISTs has become a widely accepted technique, with advantages of faster recovery, less postoperative pain, better cosmesis and shorter hospital stay (2-4).

SILS is a further evolution of this minimally invasive technique that has been used for several intra-abdominal surgical procedures such as appendectomy, cholecystectomy, colonic surgery, gastric banding and sleeve gastrectomy (5-8). Only few case reports with use of extragastric gastrectomy by SILS for GIST have been described by Tom Henckens described the use of a Triport trocar (Olympus®) and double-bended instruments for extragastric wedge resection of GIST of the stomach (9). Bruna Esteban described another case with the use of a Covidien® port and endoscopic stapling to perform a wedge resection of an exophytic gastric GIST (10).

When the tumor is located at the esophagogastric junction or near the pyloric ring, the laparoscopic extragastric approach is complicated because the dissection of the stomach along the greater curvature or the formation of a gastrotomy at the anterior wall is necessary. To overcome these limitations, the intragastric approach can be used.

In 1995, Ohashi described the first laparoscopic intraluminal intragastric surgery technique for early gastric cancer using three laparoscopic trocars placed separately in the inflated gastric lumen, penetrating both the abdominal and the stomach wall, in order to perform a laparoscopic removal of a gastric lesion (11). A gastrofibroscope was inserted orally into the stomach in order to visualize the gastric lesion on a monitor and to determine the adequate insertion points for three trocars. The tumor was extracted orally. Since then many case reports and small series have reported placing three or four laparoscopic trocars intragastrically for the resection of gastric submucosal tumors (12-20). The gastrostomies were closed with either intracorporeal sutures or extracorporeally through the abdominal incision. The results of these reported SILAS are described in Table I. Sasaki et al. reported a technique where a 12-mm trocar and three other trocars were placed through the same umbilical skin incision to resect a GIST using an endoscopic linear stapler after the tumor was elevated with a mini loop retractor or laparoscopic grasper. The three trocar sites were joined and closed to avoid incisional hernia (20).

In our case, we used an intragastric position of the SILS port through the anterior wall of the stomach via a 2.5 cm incision. This technique gave us a perfect inner view of the stomach. The specimen was extracted through this extended skin incision without contact with the peritoneum or skin to avoid spilling and recurrence. Extracorporel suturing of the stomach was performed safely and quickly. The operation was carried out in the stomach with currently available laparoscopic instruments and laparoscopic monitoring.

Only one other report was found in the literature using the single incision laparoscopic intragastric wedge resection for gastric submucosal tumor between 2.3 and 3.8 cm by placement of a SILS port (Octoport, Duomed®, Darim, Seoul, Korea) at the umbilicus in seven patients (21). This article reported a complication rate of 14.3%. There was no recurrence or death in this previous series. The follow-up period was not specified.

Our report described this type of surgery for larger lesions (up to 6.8 cm) during a shorter operative time and we also did not report any complication or death. There was no recurrence during follow-up at 12 and 20 months (Table II). The advantage of this single-incision intragastric approach is that the dissemination of tumor cells into the peritoneal cavity is not possible in comparison with the laparoscopic technique, where rupture of the tumor during manipulation can give rise to dissemination in the peritoneal cavity and recurrence of disease. This single incision intragastric access offers a better view during surgery compared to conventional laparoscopy. Comparing our technique with the previously reported SILS techniques (Table I), we have performed this technique for lesions up to 6.8 cm, in a very fast manner, without complications, death or recurrence during follow-up. We need further follow-up to be sure of the long-term results. Based on our experience, the intragastric use of a SILS port into the stomach is safe and feasible, with improved cosmesis (only one incision) and improved pain control due to a reduced number of access ports, and with a greater overall patient satisfaction compared to a conventional laparoscopic procedure. This new technique may encourage development of transgastric SILS devices for other intragastric procedures. We only found one publication in the literature using the same technique. Prospective randomized studies are needed before the universal adoption of this new technique can be considered.