When conducting the retrospective study, the ER group (59 patients) was found to have had longer operative times than the LR group (59 patients) at 120 versus 70 minutes; however, the median postoperative time to liquid diet was significantly shorter in the ER group compared with the LR group (4 days versus 5 days), respectively. Furthermore, the ER group, compared with the LR group, had fewer postoperative symptoms, though there was no significant difference in the postoperative hospital stay (both at 7 days) or hospital costs between the groups.
“Both ER and LR are safe and effective treatments for gastric GISTs [gGISTs]. ER is associated with less postoperative pain and faster recovery and is particularly suitable for cases where cosmetic results or preservation of organ function are desired. In contrast, LR is strongly recommended for large tumors [more than 4 cm] due to its high rate of complete resection,” the study authors wrote in their research.
The Safety of Both Treatment Approaches and Long-Term Outcomes
Regarding safety, there were no significant difference in surgery-related complications between the two groups, though, in the ER group, bleeding occurred in three patients and was treated with conservative treatment or endoscopic hemostasis. In the LR group, postoperative anastomotic fistula occurred in one patient but improved after fasting, adequate drainage, and anti-infection. Five cases of postoperative infection were reported in the ER group versus 8 in the LR group; there was no significant difference in the incidence of postoperative infections between the LR and ER groups.
In all tumors in both groups en bloc resection was achieved, and, in the ER group, 43 tumors received en bloc removal from the stomach and complete resection after PS matching; the remaining 16 tumors were temporarily attached to the stomach using clips though they were then removed en bloc with an endoscopic lithotripter on the next day. Looking to the LR group, 1 tumor did not achieve complete resection because of fragmentation, making the rates of complete resection higher in the LR group versus the ER group. Regarding mitotic count or pathological report risk, there were no significant differences between the groups.
When referring to long-term outcomes, the median follow-up times in the LR and ER groups were 54 months and 51.1 months, respectively; the difference was not statistically significant. In the ER group, GIST recurrence occurred in three patients prior to last follow-up and this number of patients was two in the LR group; again, the difference was not statistically significant. However, following PS matching, no GIST recurrence occurred in the ER group versus two in the LR group, still with no significant difference between the two groups. During the follow-up period, no metastases were observed and no significant difference in mortality between the two patient groups before or after matching was noted. In total, nine patients died across both groups, one of which was due to GIST recurrence and the other eight from other GIST-resection-unrelated diseases.
“The matched ER group showed significantly better outcomes than the LR group in terms of the resumption of a liquid diet and postoperative symptoms. The LR group had an advantage over the ER group in terms of the complete resection rate,” the study authors concluded. “There were no statistically significant differences between the two groups in terms of either the incidence of complications or the long-term postoperative outcomes.”
Diving into the Importance of ER and LR Approaches
GISTs are the most common mesenchymal tumors of the gastrointestinal tract with an annual incidence of 10 to 20 cases per million and primarily occur in the stomach. Management strategies for patients with primary gGISTs depend on tumor size and risk factors; however, surgical excision is recommended for localized gGISTs 2 cm or larger, while active surveillance is advised for smaller, low-risk lesions. There have also been advancements made in minimally invasive approaches to this disease, with techniques such as LR and ER offering benefits like faster recovery and less blood loss.
Despite these advancements, the choice between ER and LR remains a debated topic for gGISTs between 2 to 5 cm in size due to inconsistent outcomes. Some studies suggest LR has lower complication rates and shorter hospital stays while others highlight the advantages of ER, including shorter operation times and reduced costs. Therefore, Taizhou Hospital in the Zhejiang Province has conducted research which aims to provide updated guidance on treatment standardization for gGISTs garnering data.
Investigators reviewed and compiled information on patients with gGISTs who underwent ER or LR at the Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, for their retrospective study from Jan. 2014 to Aug. 2022. Patients were included in this review if they were 18 years of age or older; had a longest tumor diameter of 2 to 5 cm; a diagnosis of gGISTs confirmed by postoperative pathological evaluation and immunohistochemical findings; surgery; and a surgical method of ER or LR. Participants were excluded from the investigation if they did not complete surgery; had adjacent organ invasion; or duodenal and small intestinal stromal tumors.
Furthermore, all patients underwent regular postoperative follow-up by endoscopic examination and CT. Additional follow-up data were acquired via telephone interviews or outpatient follow-up after surgery. Notably, follow-up time was defined as the period from the date of surgery to the last follow-up (August 2023) or death.
Prior to PS matching, in the ER group, the tumor size was significantly smaller (3.5 cm) compared with the LR group (4.2 cm), and the distribution of tumor locations differed between the groups. Notably, 63.4% of patients had tumors located in the gastric body in the LR group, as well as 0% in the gastric cardia, 28.2% in the gastric body and 8.4% in the gastric antrum. In the ER group, 48.9%, 3.7%, 42.2% and 5.2% of the tumors were located in the gastric body, cardia, fundus and antrum, respectively.
However, the study authors wrote that, “We performed a PS-matched analysis to eliminate the impact of confounding factors and enhance the credibility of the findings. After PS matching, 59 patients from each group were selected and included in the subsequent analysis. Post-matching, there were no significant differences between the two groups in terms of these factors.”
Reference:
“Comparison of endoscopic and laparoscopic resection of gastric gastrointestinal stromal tumors: A propensity score-matched study.” Gu BB, et al. World J Gastrointest Surg.
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