We found that laparoscopic resection can be safely performed for small intestinal GIST with less than 10 cm in diameter compared with open surgery. Laparoscopic approach showed better early postoperative outcomes than open approach in terms of operation time, estimated blood loss, and postoperative hospital stay, especially for small intestinal GIST. Besides, laparoscopic resection was oncologically comparable to open surgery when it was compared with respect to not only margin status and tumor spillage during operation but also recurrence and survival after surgery.
It has been suggested that large size gastric GIST is not recommended for laparoscopic surgery because of difficulties in manipulating tumor without tumor cell spillage.(15
) Unlike to gastric GIST, laparoscopic operative techniques for small intestinal GIST are diverse and depending on the location of the small bowel.(16
) If there is no adjacent organ invasion, small intestinal GIST can be manipulated without any direct contact to the mass by grabbing the mesentery or nearby normal small bowel segment. With this mobility, most small bowel GIST can be treated by simple segmental resection either by intracorporeal or by extracorporeal anastomosis, except for duodenal and proximal jejunal GISTs. In most of the cases, GISTs are oval shape thus specimen can be delivered through a bit smaller incision size than shortest diameter of the mass. Thus, even with the mass size in 10 cm in diameter, it can be delivered through a much small incision. Thus, small intestinal GISTs have several appealing characteristics for laparoscopic approach.
When we are trying to apply laparoscopic approach for small intestinal GIST, we have to consider long-term outcomes as well as early postoperative results. As small intestinal GIST is regarded as having a more aggressive malignant potential than gastric GIST has, evaluation of long-term oncological outcomes is essential, especially when size of the tumor is large.(17
) While there have been many studies for the oncological safety of LAP group for gastric GIST of larger tumors, studies dealt with long-term outcomes after LAP group for small intestinal GIST compared with open surgery are rare. Our study adds evidence that laparoscopic application for small intestinal GIST can be safely applied.
However, our study has limitations mainly coming from its retrospective nature. Although most baseline characteristics were comparable, patients treated by laparoscopy had smaller tumors. Thus, we analyzed outcomes after size stratification. There were selection bias in selecting operative approaches by the surgeons' preference. Some surgeons have little experience of advanced laparoscopic procedure and some surgeons were expert in LAP group. In addition, patients were also biased based on their information for the types of surgery, thus the selection of the operation type was decided based on their limited knowledge. Other limitation was rather long study duration makes it difficult to evaluate the LAP group. Relatively more patients of the OPEN group was skewed towards early period of study compared to those of the LAP group. This may have introduced biases because of the differences in mastering operational skills and by rapid development and improvement of instruments.
In conclusion, our study demonstrated that laparoscopic approach can be safely adopted for small intestinal GIST. Laparoscopic resection for small bowel GISTs could get favorable short-term postoperative outcomes while achieving comparable oncologic results compared with open surgery. Thus, laparoscopic approach can be regarded as an recommendable treatment modality for patients with small bowel GISTs less than 10 cm in diameter.