Commentary on Brief Clinical Report: Laparoscopic Intragastric Resection

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As patients undergo cross-sectional imaging and upper endoscopy with ever-increasing frequency, the incidental findings that result often require evaluation by a surgeon. Gastric submucosal tumors are typical examples of this. At least half of these will be gastrointestinal stromal tumors (GISTs). We generally recommend excision of these lesions in fit patients because they do have some (albeit often low) malignant potential. Resection often involves a relatively straightforward wedge gastrectomy. However, when these tumors are inconveniently located, for example, close to the gastroesophageal (GE) junction or adjacent to the pylorus, a substantially more morbid procedure may be involved. A wedge gastrectomy gone wrong may narrow the GE junction or gastric outlet. Subjecting a patient with a small, likely indolent, proximal gastric GIST to a total gastrectomy is an unappealing prospect.
In an effort to avoid these more morbid operations for gastric submucosal tumors, Boulanger-Gobeil et al have developed a laparoscopic intragastric approach to resection of such lesions, which they have applied to 8 patients over 3 ½ years. Most were performed with the assistance of upper endoscopy. Most involved the use of a stapler to resect an intragastric lesion on a stalk (an “innie”), although 2 involved submucosal dissection of a tumor in the wall of the stomach. The authors are clear about the limitations of the technique, which is poorly suited to lesions extending beyond the submucosa and exophytic lesions (“outies”). Lesions for which microscopic margins are of concern or for which a formal lymphadenectomy is indicated (notably suspected or proven gastric adenocarcinoma) should be an absolute contraindication to this approach.
Is this a technique that can or should be widely adopted? Clearly, the intragastric approach has significant advantages for tumors that are not amenable to endoscopic resection or straightforward laparoscopic wedge gastrectomy. For very proximal or very distal tumors, this approach may avoid the need for distal or total gastrectomy. However, we should distinguish the advantages of the intragastric technique from those of its laparoscopic application as described by the authors. I am not convinced that a laparoscopic intragastric approach through an anterior gastrotomy is substantially more morbid than making 3 smaller gastrotomies for intragastric ports, although the angles involved may be awkward for some tumors. In hands that are not as laparoscopically skilled as the authors’, a small midline laparotomy may still be the best approach to still allow for an intragastric approach. However, for those surgeons with the laparoscopic skills to apply the laparoscopic intragastric technique safely, it provides one more operative strategy to avoid a more extensive, morbid resection.

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