GISTs, the most common soft tissue sarcomas of the GI tract, most commonly contain KIT- or PDGFRA-activating mutations and are derived from mesenchymal neoplasms in the GI tract [9–11]. The main clinical symptoms are abdominal pain, bloating, and bleeding in the digestive tract. The prognosis is generally good, with a five-year survival rate of over 70% . The main prognostic tools include biopsy, risk stratification, and whether the tumor ruptured during surgery. Complete surgical resection is regarded as the main treatment method for gastric GISTs. Because lymph nodes are not the main location of metastasis, complete resection of the tumor is emphasized. In 1992, Lukaszczry et al. first reported the successful laparoscopic resection of a gastric GIST . In recent years, due to the rapid development of laparoscopic technology, laparoscopic resection has become the main surgical method for the treatment of gastric GISTs [2–4]. However, the space information of the tumor size and scope during surgery is portrayed by the secondary conversion function of laparoscopy, which may affect the surgeon’s accurate assessments. Precise positioning during surgery is particularly important for gastric GISTs requiring local resection. HLS can not only avoid the large trauma caused by open surgery but can allow for manual manipulation of the tumor to achieve accurate resection during the operation. HLS can be used for the surgical treatment of gastric GISTs to maximize the preservation of normal gastric tissue and gastric function, while avoiding esophageal or pyloric stenosis .
Our results confirmed that the operation time of HLS was significantly shorter than that of TLS. Under the same type of operation, the trauma due to HLS was less, resulting in a shorter time to ambulation, a shorter time to first flatus, and a shorter time to first diet compared to TLS. The possible reasons for this include: first, with HLS, the surgeon can directly palpate the tumor, bringing about a more accurate position; and second, HLS can better expose the relevant anatomical structures around the tumor to facilitate tissue separation and tumor resection. In addition, HLS has lower requirements for the surgeon's laparoscopic technology, while TLS has higher requirements and a certain learning curve [14–19]. Consequently, the operation time of HLS was significantly less than that of TLS in our study. For HLS, the maximum margin of the tumor was significantly less than that of TLS, ensuring R0 resection. This is because the stomach wall has a certain ability to contract, so the hand can control the range of tumor resection more precisely. In addition, due to the assistance of the hand, the HLS is more convenient and stable when using the Endo-GIA for surgical stapling. At present, there is still controversy about the laparoscopic resection of gastric GISTs, especially for large tumors and tumors located in the cardia and pylorus. This is because prospective studies are lacking as this type of surgery is difficult to perform, and it sometimes requires a total gastrectomy, a distal gastrectomy, or even a combined organ resection.
Therefore, the guidelines recommend that laparoscopic surgery is mainly used for tumors less than 5 cm and located in the greater curvature of the stomach or in an easy-to-remove location in the lesser curvature [1, 20]. For such patients, there were obvious advantages for HLS. The effect of hand-assisted surgery makes the operation similar to open surgery, where fatal bleeding during the operation can be better controlled [19, 21]. Additionally, the surgeon can successfully complete the tumor resection, reduce the probability of conversion to open surgery, and preserve normal stomach tissue and gastric function. Simultaneously, HLS technology can avoid the esophageal or pyloric stenosis caused by the local resection of tumors in specific areas. Furthermore, there was no statistically significant difference between the two groups in terms of intraoperative bleeding or postoperative complications such as gastric bleeding, postoperative wound infections, or wound leakage. This proved that the effects of HLS were equivalent to those of TLS. However, the operation time was significantly shortened in the HLS, and much of the normal gastric tissue was preserved as much as possible. In the treatment of GISTs located in the cardia or pyloric, HLS can decrease the probability of cardia and pyloric stenosis or the possibility of an expanded surgery.
HLS can better allow surgeons who have experienced open surgery to make sense of the points of laparoscopic technology, which serves as a bridge between open surgery and TLS. In terms of the smooth learning curve of HLS, it is easier for most surgeons to accept . Furthermore, by analyzing nearly 20 cases, we found that HLS has unique advantages in the treatment of gastric GISTs, especially for tumors located in the cardia, pylorus, and other difficult areas. HLS has a significantly shorter operation time than TLS, which indicates that patients may have a better postoperative recovery. Moreover, it is easier for GI surgeons, who start laparoscopy in the initial stage, to learn and master the laparoscopic technology of a GIST resection, which helps improve the self-confidence of the surgeon.
Although this study summarizes the advantages of HLS, it still has the following limitations. First, although the data in this study came from a high-volume institution’s database, the sample size was still small, which makes it impossible to perform statistical methods such as propensity score matching to balance the baseline data of patients, such as whether there was a significant difference in the tumor location. Second, long-term survival analysis was lacking. Finally, although HLS can be an optional transitional stage of TLS for novices, TLS is still the main method of gastric GIST surgery. Prospective randomized studies using multicenter data may be needed before a definite answer could be given concerning the surgical value of HLS compared with TLS.
In conclusion, our results confirmed that HLS in gastric stromal tumor resection has advantages, including a shorter operation time, minimal invasiveness, and maximum preservation of gastric function, especially for patients with gastric cardia GISTs. It is an effective surgical method for GI surgeons who have not fully mastered laparoscopic techniques.