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Intragastric enucleation of stromal tumors through a combined laparoscopic and endoscopic approach.

Dear Editor, We read with great interest the paper entitled "Laparoscopic organ-preserving gastric resection improves the quality of life in stromal tumor patients: an observational study with 23 patients" written by Ozcan et al. in Ann Ital Chir. 2018 Oct 23;7 1. We agree with the Authors that preserving the stomach after excision of stromal tumors is essential to improve the patients' quality of life. We would like, however, to discuss some issues that the paper published by Ozcan et al. might raise. When feasible, laparoscopic surgery is the best procedure for removal of gastric stromal tumors, since it is associated with all the advantages already recognized to the mini-invasive approach 2,3. Furthermore, it allows reducing the entity of the resected stomach wall and, therefore, it may help maintain the stomach functions and a post-operative excellent quality of life. Besides the standard laparoscopic procedure with wedge resection of the stomach, we would like to draw the attention that other mini-invasive procedures might be performed. The standard surgical treatment of gastric stromal tumors typically involves full-thickness resection of the tumor site stomach wall. Surgical treatment could be technically challenging for proximal gastric lesions located near the gastro-esophageal junction. In the article by Ozcan et al. it is not well defined how they approached iuxta-cardial stromal tumors. A combined endoscopic/laparoscopic intraluminal enucleation technique has been proposed by some Authors, including us, in these cases 4-6. Our technique consisted in inserting two 5-mm radially expandable trocars through the abdominal and gastric walls. Through the 5-millimeter trocar, a laparoscope was introduced into the gastric cavity and with an endoscopic polipectomy snare introduced per mouth, the gastric iuxta-cardial lesion was grasped and tractioned. Through the other 5-mm laparoscopic trocar, the iuxtacardial gastric lesion was then removed with a complete submucosal resection. The excellent exposure of the site of excision allowed by the endoscopic traction was essential in this step. The specimen was then pulled away from the mouth after its introduction into a small plastic bag and the gastric holes were closed with monofilament non-absorbable sutures. In selected cases of submucosal iuxta-cardial gastric stromal tumors, as well as in every small stromal gastric lesions, the laparoscopic-endoscopic technique should be preferred since it allows a complete safe and oncologic resection of submucosal lesions, reducing risk of complications (e.g., perforation) and lowering morbidity when compared to other open or laparoscopic approaches.