Procedure of choice for GIST.

W read with interest the recent report “Surgical images: soft tissue. Gastrointestinal stromal tumour of the stomach” (GIST) (Can J Surg 2005;48:237-8). The authors noted a submucosal mass on gastroscopy and performed a distal gastrectomy through a laparotomy. Although the woman undoubtedly tolerated the laparotomy, she may have been better served by a minimally invasive approach. In particular, the anterior location of this lesion would have made it amenable to laparoscopic resection. Several authors have noted the benefits of minimally invasive surgery for benign stomach disease in general, and GIST in particular. Others have described endoluminal surgical procedures, involving a combination of laparoscopic and endoscopic techniques. Certainly, the benefits of shortened hospital stay, earlier return to full activities and improved cosmesis apply as much to these patients as to any others. It is nearly always technically possible to perform laparoscopic resection, even in cases of large intraluminal lesions. In addition to the standard wedge resection, a gastrotomy may be performed with eversion of the mass. An endoscopic stapler may then be passed below the lesion, reducing sacrifice of normal gastric wall to a minimum. Although one must exercise caution in cases of large lesions or suspected malignant disease, a minimally invasive approach seems appropriate for the majority of patients with GIST. It remains a challenge for all surgeons to incorporate minimally invasive principles into general surgery operations beyond cholecystectomy or appendectomy. However, laparoscopic resection may indeed now be the standard procedure for patients with GIST.