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Invited Critique
June 16, 2008

Laparoscopic Gastric Gastrointestinal Stromal Tumor Resection—Invited Critique

Arch Surg. 2008;143(6):591. doi:10.1001/archsurg.143.6.591

The technological development of necessary instruments (eg, roticulating linear staplers, ultrasonic dissectors, and flexible retractors) for the conduct of minimally invasive surgery has greatly facilitated the implementation of laparoscopic procedures within the field of surgical oncology. Although often technically feasible, until the oncologic safety of minimally invasive surgical resections is proven, such procedures should not be broadly implemented. There is increasing evidence supporting minimally invasive surgical resection of malignant tumors of the colon, with early reports in tumors of the lungs, kidneys, prostate, and stomach.1 However, unlike these tumor sites, GISTs are uncommon; their classification is based primarily on histopathologic criteria (spindle cell neoplasm arising from the intestinal pacemaker cell of Cajal) and molecular biologic behavior (frequent mutational activation of the receptor tyrosine kinase c-kit) rather than anatomic site of origin. Huguet et al report the outcome of 33 patients who underwent attempted laparoscopic resection of GISTs, with 31 successfully completed laparoscopically. Although the series is small, the following aspects are notable: (1) laparoscopic resection of GISTs is feasible, has acceptable morbidity and mortality, and is associated with a reasonably short postoperative hospital stay duration; (2) patient selection is essential because these tumors were small (mean size, 3.9 cm), with preoperative CT accurately demonstrating the extent of disease; and (3) there have been no local recurrences during a mean follow-up of 13 months. Despite the observation that only half of the patients had a preoperative histopathologic diagnosis of GIST, the radiologic appearance of these tumors should allow the surgeon reasonable confidence in proceeding to resection. Although a direct comparison with an open approach was not given, the experience presented by the Mayo Clinic supports the feasibility and oncologic safety of laparoscopic resection of GISTs in selected patients by experienced minimally invasive surgeons.

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