Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

Wei-Jung Chang; Lien-Cheng Tsao; Hsu-Heng Yen; Chia-Wei Yang; Hung-Chi Chang; Chew-Teng Kor; Szu-Chia Wu; Kuo-Hua Lin

doi:10.4240/wjgs.v15.i8.1629

Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

World J Gastrointest Surg. 2023 Aug 27;15(8):1629-1640. doi: 10.4240/wjgs.v15.i8.1629.

Authors

Wei-Jung Chang¹, Lien-Cheng Tsao¹, Hsu-Heng Yen^{2

3

4}, Chia-Wei Yang², Hung-Chi Chang¹, Chew-Teng Kor^{5

6}, Szu-Chia Wu⁷, Kuo-Hua Lin⁸

Affiliations

¹ Department of General Surgery, Changhua Christian Hospital, Changhua 50006, Taiwan.
² Department of Gastroenterology, Changhua Christian Hospital, Changhua 50006, Taiwan.
³ General Education Center, Chienkuo Technology University, Changhua 50006, Taiwan.
⁴ School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
⁵ Big Data Center, Changhua Christian Hospital, Changhua 50006, Taiwan.
⁶ Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua 50007, Taiwan.
⁷ Transplant Medicine & Surgery Research Center, Changhua Christian Hospital, Changhua 50006, Taiwan.
⁸ Department of General Surgery, Changhua Christian Hospital, Changhua 50006, Taiwan. khlin120380@gmail.com.

Abstract

Background: Minimally invasive surgery had been tailored to individual cases of gastric subepithelial tumors (SETs) after comparing the clinical outcomes of endoscopic resection (ER), laparoscopic resection (LR), and hybrid methods.

Aim: To study the use of Goldilocks principle to determine the best form of minimally invasive surgery for gastric SETs.

Methods: In this retrospective study, 194 patients of gastric SETs with high probability of surgical intervention were included. All patients underwent tumor resection in the operating theater between January 2013 and December 2021. The patients were divided into two groups, ER or LR, according to the tumor characteristics and the initial intent of intervention. Few patients in the ER group required further backup laparoscopic surgery after an incomplete ER. The patients who had converted open surgery were excluded. A logistic regression model was used to assess the associations between patient characteristics and the likelihood of a treatment strategy. The area under the curve was used to assess the discriminative ability of tumor size and Youden's index to determine the optimal cut-off tumor size.

Results: One-hundred ninety-four patients (100 in the ER group and 94 in the LR group) underwent tumor resection in the operating theater. In the ER group, 27 patients required backup laparoscopic surgery after an incomplete ER. The patients in the ER group had small tumor sizes and shorter procedure durations while the patients in the LR group had large tumor sizes, exophytic growth, malignancy, and tumors that were more often located in the middle or lower third of the stomach. Both groups had similar durations of hospital stays and a similar rate of major postoperative complications. The patients in the ER group who underwent backup surgery required longer procedures (56.4 min) and prolonged stays (2 d) compared to the patients in the LR group without the increased rate of major postoperative complications. The optimal cut-off point for the tumor size for laparoscopic surgery was 2.15 cm.

Conclusion: Multidisciplinary teamwork leads to the adoption of different strategies to yield efficient clinical outcomes according to the tumor characteristics.

Keywords: Endoscopic resection; Gastric subepithelial tumors; Laparoscopic resection; Tumor size.