Endoscopic or Laparoscopic Resection for Small Gastrointestinal Stromal Tumors: A Cumulative Meta-Analysis

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the digestive system, predominantly occurring in the stomach (60%–70% of cases). While traditionally managed through surgical resection, advancements in minimally invasive techniques have introduced endoscopic resection (ER) and laparoscopic resection (LAP) as viable alternatives for small GISTs (≤5 cm). This meta-analysis evaluates the comparative efficacy, safety, and outcomes of ER versus LAP and explores the emerging role of laparoscopic and endoscopic cooperative surgery (LECS).

Study Design and Methodology

The meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of medical databases (Medline, EMBASE, Web of Science, and others) up to January 2020 identified 12 cohort studies comparing ER and LAP (1,383 participants) and three studies comparing ER and LECS (167 participants). Inclusion criteria encompassed cohort studies, case-control studies, or randomized controlled trials (RCTs) comparing short- or long-term outcomes between ER and LAP/LECS for GISTs ≤5 cm. Exclusion criteria eliminated studies involving open surgery, non-GIST benign tumors, and low-quality publications.

Data extraction focused on operation time, blood loss, hospital stay duration, hospitalization costs, complications, positive margins, and recurrence rates. Statistical analyses employed fixed- or random-effects models based on heterogeneity levels (assessed via I² statistics and Q-tests). Meta-regression, cumulative meta-analyses, and subgroup analyses were conducted to refine conclusions, while sensitivity analyses evaluated result robustness.

Key Findings

Short-Term Outcomes: ER vs. LAP

Operation Time and Hospital Stay
ER demonstrated significantly shorter operation times compared to LAP (weighted mean difference [WMD] = −27.1 minutes; 95% confidence interval [CI]: −40.8 to −13.4 minutes). Cumulative meta-analysis revealed consistent superiority of ER since 2017, attributed to advancing endoscopic techniques. Similarly, ER reduced hospital stays by 1.43 days (95% CI: −2.31 to −0.56 days), with heterogeneity (I² = 83.1%) reflecting variations in postoperative care protocols across studies.

Blood Loss and Costs
No significant differences were observed in intraoperative blood loss (WMD = −9.19 mL; 95% CI: −20.13 to 1.74 mL) or hospitalization costs (WMD = −1,191.25 RMB; 95% CI: −3,109.51 to 727.01 RMB). High heterogeneity in cost analysis (I² = 97.6%) likely stemmed from regional pricing disparities and differing healthcare systems.

Safety and Complications

The overall complication rate did not differ significantly between ER and LAP (relative risk [RR] = 1.30; 95% CI: 0.88–1.91). Common complications included bleeding, perforation, and infection, with no life-threatening events reported. Subgroup analysis stratified by tumor size (≤2 cm vs. 2–5 cm) showed comparable safety profiles, though ER carried a higher risk of positive margins for tumors 2–5 cm (RR = 5.78; 95% CI: 1.31–25.46).

Long-Term Outcomes: Recurrence and Margins

Recurrence rates were statistically equivalent between ER and LAP (RR = 0.73; 95% CI: 0.28–1.93), with median follow-up periods ranging from 12 to 60 months. Notably, positive margins in ER did not translate to higher recurrence, potentially due to adjuvant therapies (e.g., imatinib) or subsequent remedial surgeries.

ER vs. LECS

Comparisons between ER and LECS, though limited to three studies, highlighted shorter operation times for ER (WMD = −41.03 minutes; 95% CI: −59.53 to −22.54 minutes) but a higher complication risk (RR = 4.03; 95% CI: 1.57–10.34). LECS, combining laparoscopic and endoscopic approaches, showed promise in ensuring margin negativity and preserving gastric function, warranting further investigation.

Subgroup and Sensitivity Analyses

Subgroup analyses stratified by tumor size (≤2 cm vs. 2–5 cm) confirmed ER’s efficacy for smaller tumors, while underscoring caution for larger lesions due to margin concerns. Sensitivity analyses affirmed result robustness, excluding undue influence from individual studies. Cumulative meta-analyses illustrated temporal trends, with ER’s advantages in operation time and hospital stay becoming statistically stable after 2017.

Discussion

Clinical Implications

ER emerges as a safe, efficient alternative to LAP for gastric GISTs ≤5 cm, particularly for lesions ≤2 cm. Its shorter operation times and hospital stays align with patient preferences for minimally invasive procedures. However, the higher incidence of positive margins in ER for tumors 2–5 cm necessitates meticulous patient selection, emphasizing tumor location, accessibility, and operator expertise.

LECS, while requiring longer operative durations, may bridge the gap between ER and LAP by enhancing margin control and reducing complications. Its hybrid approach warrants validation through larger, prospective studies.

Limitations and Future Directions

The absence of RCTs and predominance of retrospective cohort studies (11/12 ER vs. LAP studies) limit evidence strength. Heterogeneity in outcomes, particularly hospitalization costs and blood loss, reflects methodological and regional disparities. Future research should prioritize RCTs, standardized outcome reporting, and long-term survival data. Additionally, the role of adjuvant therapies in mitigating recurrence after margin-positive ER merits exploration.

Conclusion

This cumulative meta-analysis supports ER as a viable first-line option for small gastric GISTs, balancing efficacy and safety. For tumors 2–5 cm, LAP or LECS may be preferable to minimize margin positivity. Continued innovation in endoscopic techniques and collaborative surgical approaches will further refine management strategies for GISTs.

doi.org/10.1097/CM9.0000000000001069

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