Commentary on “A Novel Technique to Minimize Deformation of the Stomach in Laparoscopic Partial Gastrectomy for Intraluminal Gastric GISTs”

Laparoscopic techniques for removing primary gastrointestinal stromal tumors (GISTs) have been well described in the literature, and multiple size-matched comparisons between laparoscopic and open surgery show that laparoscopic resection of primary GISTs results in shorter hospital stays and has less morbidity than the open surgical technique.^1,2 Furthermore, these studies suggest the laparoscopic approach has similar long-term oncologic results. ³ In one of the most extensive reviews of laparoscopic resection of gastric GISTs, Karakousis et al. ¹ identified that tumor location at the gastroesophageal (GE) junction or on the lesser curve prevented laparoscopic resection.

The technique described by Hirahara et al. ⁴ in the accompanying article is a technique that may be useful to allow laparoscopic resection of tumors near the GE junction and pylorus. Hirahara et al. ⁴ make an incision in the serosa right over the tumor, which allows the tumor to bulge out so that ultimately it looks and acts more like a pedunculated serosal GIST, which allows stapler resection of the GIST with minimal serosal resection. It is one of those techniques that once you look at it, you are kicking yourself saying, “I should have thought of that,” because of its simplicity and obvious ability to assist in the resection of GISTs in areas that might otherwise be difficult because of the amount of serosa that has to be taken using standard resections. The illustrations and photographs are very descriptive of the technique, which appears to have really significant advantages over the standard resection. Not only do Hirahara et al. ⁴ give an excellent description and show very illustrative pictures, but their success in performance of this procedure is nicely demonstrated and reported in 5 patients. All the tenets of complete margin negative resection with intact pseudocapsule should be followed by surgeons adopting this technique as breaks in the capsule have the theoretical risk of tumor seeding in the peritoneal cavity. ⁵

Although I have not performed the technique in my own patients, it appears to be straightforward enough that it can be easily adopted by the experienced laparoscopic surgeon. Although right now the technique is limited to GISTs smaller than 5 cm and the surgeon has to pay attention to handling of the tumor without breaking the pseudocapsule, the advantages of the laparoscopic approach are such that I would highly recommend this technique for surgeons approaching these types of tumors at the GE junction or near the pylorus or other vital structures.