Goldilocks principle of minimally invasive surgery for gastric subepithelial tumors

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.

Unusual association of Axenfeld-Rieger syndrome and wandering spleen:A case report

BACKGROUND Axenfeld-Rieger syndrome(ARS)is an autosomal dominant genetic disease characterized by ocular developmental disorders and its association with torsion of wandering spleen(WS)has not been reported to date to the best of our knowledge.This study aimed to describe a rare case of ARS observed at our emergency department.CASE SUMMARY A 25-year-old female presented with a constant lower abdominal pain of increasing severity.Diagnostic computed tomography with intravenous contrast material showed a non-homogenously enhanced splenic parenchyma with a twisted vascular pedicle.Further,an emergent laparoscopic exploration was performed,and an ischemic spleen without its normal ligamentous attachments was noted.Notably,the spleen did not regain its normal vascularity after detorsion;thus,we performed the laparoscopic total splenectomy.The postoperative course was uneventful,and the patient was discharged on the 5th postoperative day.This case demonstrates a rare association of WS and ARS.CONCLUSION Early diagnosis of WS in the emergency department is important to prevent pedicle torsion or splenic necrosis and to avoid splenectomy.