Laparoscopic wedge resection of the stomach for gastrointestinal stromal tumor (GIST): non-touch lesion lifting method

Background

Laparoscopic surgery for GIST carries a risk of intraoperative tumor dissemination. To avoid tumor dissemination, we have utilized a “non-touch” method for surgical resection of GIST since 2000.

Methods

Forty-two patients with gastric GIST were treated at our institution between 2000 and 2012. Laparoscopic wedge resection of the stomach was used as the standard procedure for tumors that were 2–5 cm in size. Tumors larger than 5 cm were treated with open surgery. Our non-touch procedure included a lesion-lifting method using traction sutures at the normal stomach wall around the tumor. Intraoperative gastroscopy was utilized to confirm the location of the tumor with laparoscopy. After lifting of the tumor, tumors with a clear operative margin were resected using a linear stapler. Tumors located at the posterior wall of the stomach or located near the esophagogastric junction were resected using traction sutures.

Results

Median operative time was 140 min and median blood loss was 0 ml. Postoperative course was uneventful excepting one patient who experienced postoperative bleeding. The median postoperative stay was 7 days. One patient developed liver metastasis after surgery. None of the patients had local recurrence or peritoneal recurrence case.

Conclusion

This non-touch lesion-lifting method was useful for the surgical management of gastric GIST.     

Nonexposure laparoscopic and endoscopic cooperative surgery (closed laparoscopic and endoscopic cooperative surgery) for gastric submucosal tumor

Laparoscopic and endoscopic cooperative surgery (LECS) is increasingly applied for gastric submucosal tumors (SMTs) such as gastrointestinal stromal tumors. However, the conventional LECS procedure has the potential risk that gastric contents and even tumor cells could spread into the abdominal cavity because the gastric wall has to be opened during the resection. To avoid this problem, we have developed a modified LECS procedure named “closed LECS.” Ten patients underwent closed LECS for the resection of gastric SMTs. Closed LECS consists of the following steps: endoscopic submucosal layer dissection around the tumor, laparoscopic marking of a resection line on the serosal surface along submucosal dissection line, seromuscular suturing with the marked lesion inverted into the inside of the stomach, endoscopic circumferential seromuscular dissection, and peroral retrieval. In three of the initial five cases, the closed LECS procedure was not completed as planned because of the tumor size and endoscopic inappropriate seromuscular dissection. After modification of the procedure, the entire procedure was successful in all five cases. The mean resected tumor diameter was 24.1 ± 7.6 mm. The mean operation time was 253 ± 45 min. One patient experienced an intra-abdominal abscess potentially related to delayed perforation as a postoperative complication. The closed LECS procedure for gastric SMTs can theoretically be applied without contamination and tumor cell dissemination into the abdominal cavity.     

腹腔镜胃胃肠间质瘤外翻切除术的临床价值

目的：探讨腹腔镜胃胃肠间质瘤（gastrointestinal stromal tumor,GIST）外翻切除术的临床价值。方法回顾性分析2013年7月至2015年7月在中山大学附属第一医院因胃 GIST 接受腹腔镜下肿瘤切除手术的27例患者临床病例资料,将患者分为两组,其中腹腔镜胃 GIST 外翻切除术（laparoscopic transgastric tumor－everting resection, LTTR）组8例和腹腔镜胃楔形切除术（laparoscopic wedge resection , LWR ）组19例,对比两组手术时间、手术出血量、标本切缘、切除正常胃组织面积、术后并发症发生率、术后肛门排气时间、术后进食半流质时间、术后住院天数和随访情况。结果术中LTTR 组的手术时间较LWR 延长[（70±9）分钟 vs．（56±8）分钟,P＜0．001]。 LTTR 组出血量与LWR组比较无统计学差异[（39±12）ml vs．（38±14）ml,P＝0．942]。LTTR 组的正常胃组织切除面积明显少于LWR 组[（33．0±5．6）cm2 vs．（119．3±41．6）cm2,P＜0．001]。术后两组均无胃出血、胃穿孔、切缘均无肿瘤残留、无胃排空障碍等情况发生。术后两组肛门排气时间[（2．4±0．5）天 vs．（2．3±0．5）天,P＝0．842]、进食半流时间[（3．5±0．5）天vs．（3．0±0．8）天,P＝0．07]比较无明显差异。患者中位随访时间17个月（4～31个月）,两组均无肿瘤局部复发和远处转移,无患者死亡。结论腹腔镜胃肿瘤外翻切除术可以安全有效地运用于无黏膜溃疡改变的胃 GIST 患者,其优点是能够最大限度的保留正常胃壁组织,能有效减少胃腔狭窄、梗阻发生率,是腹腔镜胃楔形切除术的有效补充术式。     

An extraordinary case in whom gastrointestinal stromal tumor and low-grade malignant lymphoma are seen together in the stomach

Introduction Gastrointestinal system (GIS) is the most common site of involvement of all primary extranodal lymphomas. Gastric lymphoma constitutes 3–6% of all primary stomach malignancies. Stomach is also the commonest site of involvement of gastrointestinal stromal tumors (GIST). We would like to report these rare synchronous tumors in the same patient. Case A 68-year-old male was admitted to the internal medicine clinics with the complaints of abdominal distension. Physical examination was normal. On abdominal computed tomography a 12 × 14 × 22 cm sized giant tumoral mass was detected in left hypochondrium. A total gastrectomy was performed. Two distinct neoplasms were detected; one of which was located in the posterior wall of the stomach with the size of 24 × 16 × 13 cm, and the other one was localized in the fundus of the stomach and its size was 6 × 5 × 2 cm. Pathological evaluation revealed the diagnosis of GIST at the posterior wall and low-grade malignant lymphoma from the mass localized in the fundus of the stomach. Discussion Two primary tumors are not seen so often together in the stomach. Adenocarcinoma and associated tumors including gastric lymphoma (especially MALT lymphoma), carcinoid, leiomyosarcoma and rhabdomyosarcoma constitute most of the reported series. Rarely adenocarcinoma and associated GIST cases were reported. It is important to report concurrent gastric lymphoma and GIST case since it is extremely rare in the English literature.     

Greater omentum gastrointestinal stromal tumor with PDGFRA-mutation and hemoperitoneum

Although gastrointestinal stromal tumor(GIST) occurs generally in the digestive tract,omental GIST is very rare.We report the first case of an adult greater omental GIST with a new platelet-derived growth factor receptor α gene(PDGFRA)-mutation with hemoperitoneum.A 43-year-old man was admitted to our hospital complaining of acute abdominal pain.Abdominal contrast-enhanced computed tomography revealed a huge mass in the right abdominal cavity,and a large accumulation of fluid in the pelvic cavity,suggesting hemoperitoneum.We diagnosed the rupture as an intra-abdominal tumor,and an emergency tumorectomy was performed with resection of the greater omentum.This tumor was located in the distal right side ofthe greater omentum,and showed no continuity with the gastric wall.The tumor occurred primarily in the greater omentum.The resected tumor was about 19 cm × 12 cm × 14 cm in diameter,and weighed 1529 g.Histologically,the tumor was composed of epithelioidshaped cells with high cellularity,and was positive for CD117 and CD34,and negative for S-100,α-smooth muscle actin.The mitosis was 6/50 under high power field.This case showed exon 18 mutation of PDGFRA with 846(Asp to Glu) substitution,848(Asn to Lys) substitution.This is the first report of this PDGFRA mutation in omental GIST,and this might play an important role in the tumorigenesis of this case.Based on these findings,the tumor was diagnosed as high risk GIST primarily occurring in the greater omentum.The patient was treated with imatinib at a dose of 400 mg/d as adjuvant chemotherapy,and has been followed up for 24 mo with no evidence of recurrence.     

Spontaneous rupture of the giant gastric stromal tumor (> 35 cm) as a rare cause of acute abdomen:a case report

A case of spontaneous rupture of giant gastrointestinal stromal tumor (GIST) of stomach causing acute abdomen is described below. A male patient with abdominal mass presented with symptoms and signs of acute abdomen after admitting for 1 day. After preoperative management and evaluation, an exploratory laparotomy was performed, where rupture of a huge tumor in the stomach was found. A subtotal gastrectomy including the mass was performed and the final immunohistochemi-cal examination verified that the neoplasm was a high risk GIST. The postoperative period was uneventful and the patient received treatment with imatinib mesylate, and regular fol ow-up without recurrence.     

Isolated abdominal wound metastasis from a gastrointestinal stromal tumor

Background. Gastrointestinal stromal tumors (GIST) frequently recur even after complete resection. The typical pattern of failure from GISTs is both local and distant with hepatic and peritoneal metastases being most common. Isolated abdominal-wall recurrence from GISTs has not been previously described. Aim of the Study. To report an isolated abdominal-wound recurrence in the absence of widespread disease in a patient with GIST. Methods. Case report of a GIST and isolated abdominal-wound recurrence after laparoscopic-assisted en bloc resection. Results. Elderly male patient presented with an isolated abdominal wall incisional recurrence 18 mo after gastric resection and adjuvant imatinib mesylate therapy for a high-grade GIST. Conclusions. Complete resection of gastrointestinal stromal tumors followed by imatinib therapy may alter the extent of recurrence.     

Totally laparoscopic resection for a large gastrointestinal stromal tumor of stomach

A debate is currently ongoing about whether a large gastrointestinal stromal tumor (GIST) should be treated by the laparoscopic approach because of the increased risk of tumor rupture during manipulation of the tumor with laparoscopic instruments and the resultant peritoneal tumor dissemination. Herein, we report a case of a large GIST of the stomach which was successfully treated by the laparoscopic approach. A 57 year old female patient visited our institution complaining of postprandial epigastric discomfort. An esophagogastroduodenoscopy and an abdominal computed tomography scan revealed a 10×8 cm sized submucosal tumor at the greater curvature side of the gastric antrum. The patient underwent laparoscopic distal gastrectomy with intracorporeal Billroth-II reconstruction without any breakage of the tumor. Her postoperative course was uneventful and she was discharged on the 7th postoperative day. Even a large GIST of the stomach can safely be treated by the laparoscopic approach when it is performed with proper techniques by an experienced surgeon.     

甲磺酸伊马替尼治疗胃肠道间质瘤的研究进展

胃肠道间质瘤（GIST）是胃肠道及腹腔最常见的间叶源性肿瘤,对常规的放疗、化疗均不敏感。外科手术是局限性GIST患者的主要治疗方式,但术后复发率较高。对于术前、术后辅助、复发、转移及不能手术切除的患者,酪氨酸激酶抑制剂甲磺酸伊马替尼对其有较好的治疗效果。本文对甲磺酸伊马替尼治疗胃肠道间质瘤的研究进展作一综述。     

Imatinib (STI-571) heals a gastrocutaneous fistula resulting from a malignant gastric stromal tumor

The management of inoperable giant malignant gastrointestinal stromal tumor (GIST) of the stomach sed to be a formidable task. We report our success with the use of STI-571 in treating a patient with huge GIST of the stomach complicated by gastrocutaneous fistula after an unsuccessful laparotomy. The patient was a 49-year-old man who presented to our center with a painful epigastric mass in December 2001. Endoscopy, biopsy, and magnetic resonance scan confirmed that it was a malignant stromal tumor arising from the gastric fundus. Laparotomy with an intention to resect the tumor was performed in view of the obstructing symptoms. However, massive bleeding was encountered during dissection of the tumor and gastrectomy was abandoned. The case was further complicated with the development of a gastrocutaneous fistula in the early postoperative period. The patient ws then managed with naso-duodenal tube feeding and enteral STI-571 was prescribed. The fistula healed up in 20 days and the mass became impalpable 1 month afterwards. Follow-up computed tonography (CT) scan 3 months later confirmed significant tumor reduction, and the patient has experienced no side effects from the treatment     

胃体不典型血管球瘤1例报告及文献复习

Objective

The aim of this study was to analyze the clinical pathological features of the atypical glomus tumor of the stomach, and explore its biological behavior and clinical significance.

Methods

a 43-year-old female was admitted due to passing black stool for 5 months. The melena of the patient occurred after eating the crabs. The endoscopic ultrasonography (EUS) was performed, showing a hypoecho nodule found at the body of the stomach, suggesting the diagnosis of gastric stromal tumor. After onset of disease, no specific clinical symptoms were observed except for the slight feeling discomfort in upper abdominal region. The gastroscopy was performed under the general anesthesia: there was a spheroidal nodule measuring 2.5 cm × 3.0 cm at the anterior wall of the body of stomach near the side of lesser curvature with the focal erosion of gastric mucosa. The DualknifeTM and the snare were used to excise the tumor in full thickness. Grossly, the tumor nodule measured 2.5 cm in diameter. The cut surface was solid, showing moderate consistency and grey red in colour. Microscopically, this tumor presented a well circumscribed nodule. It composed of the rounded neoplastic cells which were mainly arranged in solid pattern. The tumor cells had well-defined cell membranes, centrally placed, round nuclei and amphophilic cytoplasm. Immunohistochemical staining showed the positive expression of smooth muscle actin (SMA), caldesmon and vimentin; meanwhile detecting the negative expression of desmin, pan-cytokeratin, CD34, CD117 and S-100 in tumor cells. The Ki-67 labelling index of tumor was 8%.

Results

Combined with the histopathological features, immunophenotype of the tumor, deep location in abdominal cavity and with greater diameter larger than 2 cm, and the diagnosis of atypical glomus tumor of the body of the stomach in this case was established.

Conclusion

The atypical glomus tumor of the body of the stomach is a rare mesenchymal tumor. The following differential diagnosis should be included as following: gastrointestinal stromal tumor (GIST), paraganglioma, myopericytoma and the angioleiomyoma. The immunohistochemistry exerts an essential role during the diagnosis of this tumor. The deeper location and larger size implicate its undetermined biological behavior.     

Laparoscopic wedge resection for gastric GIST: long-term follow-up results.

AIM: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Recently, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST. However, no study has provided long-term follow up results of laparoscopic surgery for gastric GIST. The aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure. MATERIALS AND METHODS: Between January 1998 and August 2005, 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients' clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively. RESULTS: The mean age of patients was 59.7 years, and 12 patients were women. Twelve patients (47%) presented with epigastric pain. The mean tumor size was 4.2+/-2.1 cm, and most tumors were located in the upper stomach (52.2%). The mean operative time was 104.3 min. No case of open conversion, reoperation and operative mortality occurred in the present study. Most patients had very low and low risk (60.6%), while only two patients had high risk malignancy. During a median follow-up period of 61 months (range, 7-98 months), there have been no recurrences or metastases. CONCLUSION: Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon.     

Behavior of advanced gastrointestinal stromal tumor in a patient with von-Recklinghausen disease: Case report

Gastrointestinal stromal tumors (GISTs) represent a malignant gastrointestinal tumor of neurofibromatosis type 1 (NF1) Von Recklinghausen disease. In the current case, we report a 27-year-old woman with NF1, who presented with a lower abdominal mass, symptomatic anaemia, and significant weight loss. We employed multiple approaches to assess the tumor behavior, including computed tomography (CT) scan, surgical tumor resection, histological and immunohistochemical analysis and gene sequencing. Additionally, the patient was given Imatinib mesylate (Gleevec) as adjuvant therapy. CT scan delineated a large thick wall cavity lesion connecting to the small bowel segment. Resection of the tumor yielded a mass of 17 cm × 13 cm with achievement of safety margins. The diagnosis was GIST, confirmed by immunohistochemical expression of CD117, CD34, and Bcl-2. Sequencing revealed no mutations in either KIT or platelet-derived growth factor receptor-alpha, genes which are mutated in over 85% of sporadic GIST cases. Further, there was no evidence of recurrence, metastasis or metachronous GIST for over three years in our patient. From our analyses, we believe selective genotyping is advisable for high risk patients to predict potential tumor behavior.     

Laparoscopic intragastric resection of melanoma cardial lesion

Background

Gastrointestinal tract involvements of metastatic melanoma are rare; 7% of gastrointestinal tract metastases of melanoma concerns the stomach [1]. Actually, bleeding from gastric melanoma metastasis is very rare. For the first time in Literature, this video shows a laparoscopic intragastric resection [2] of a cardial lesion of melanoma. A 64-year old patient with history of a skin melanoma resection with lung and liver metastatic disease confirmed by FDG PET, stable after repeated cycles of Pembrolizumab, presented anemia with gastrointestinal bleeding signs. Endoscopy and CT scans documented a 4-cm subcardial metastatic melanoma lesion. Endoscopic ultrasound evaluation confirmed no full-thickness involvement of gastric wall. Patient refused blood transfusions because Jehovah's Witness. Since the tumor position so close to the cardias contraindicated both typical endoscopic and laparoscopic approaches, we proposed laparoscopic intragastric solution in order to avoid risk related to a total gastrectomy.

Synchronous adenocarcinoma and gastrointestinal stromal tumors of the stomach treated laparoscopically

Gastric adenocarcinomas account for approximately 95% of primary gastric tumors, and gastrointestinal stromal tumor (GIST) is the most common gastrointestinal mesenchymal tumor, accounting for 1%–3% of primary gastric tumors. However, the synchronous occurrence of GIST and gastric epithelial tumor is rare. We herein report a case of synchronous occurrence of gastric adenocarcinoma and two GISTs of the stomach. All lesions were resected laparoscopically. We discuss this case and review the literature.     

Hand-assisted laparoscopic surgery for a large gastrointestinal stromal tumor of the stomach

We report two cases of large gastrointestinal stromal tumor (GIST) of the stomach that were successfully treated by hand-assisted laparoscopic surgery (HALS). Two patients, a 56-year-old woman and a 60-year-old man, were admitted to our department for the treatment of a large submucosal tumor of the stomach. After gastrointestinal endoscopy, ultrasonography, computed tomography, and magnetic resonance imaging, we suspected that the masses, measuring 7.0 cm and 8.0 cm in diameter, respectively, were GISTs in the stomach. However, preoperatively, we could not rule out the possibility of malignant neoplasms, because they had been bleeding or gradually growing. Hand-assisted laparoscopic wedge resection was safely performed for the diagnosis and treatment of the submucosal tumor of the stomach. The immunohistochemical diagnosis in both patients was GIST of the stomach with intermediate-grade malignancy. HALS may be a good indication for large GISTs of the stomach that are difficult to diagnose preoperatively, whether they are malignant or benign, because it is safe and minimally invasive, promoting rapid recovery.     

Synchronous Tumors: Adenosquamous Carcinoma of Pancreas and GIST of Stomach

We report herein a unique case of an adenosquamous carcinoma (ASC) of the pancreas and a synchronous gastrointestinal stromal tumor (GIST) of stomach in a 75-year-old Caucasian male. He presented with painless jaundice and generalized pruritus and was found to have a pancreatic head mass. Whipple's procedure was performed and yielded the above diagnoses. Ductal pancreatic adenocarcinoma, not a much rarer and more aggressive ASC subtype, has previously been shown to co-exist with GIST in some surgical series. In addition, the incidentally discovered GIST in our patient involved the stomach and not the small intestine, which is the predominant GIST location when concurrently diagnosed with other GI tumors. At the time of this publication, our patient, who received adjuvant chemoradiotherapy, remains disease-free 14?months after the abdominal surgery.     

A case of bleeding giant gastrointestinal stromal tumor of the stomach who achieved partial response by chemotherapy

A 80-year-old female was referred to our hospital for hematomesis. An abdominal CT revealed a heterogeneous giant tumor of about 11 cm, rich in vascularity, extending from the gastric fundus, beyond the upper side of the spleen, to the left thoracic diaphragm. Gastroscopy showed a 5 cm submucosal tumor with a visible vessel at the gastric fundus. After biopsy was performed, she was diagnosed with a c-kit-positive gastrointestinal stromal tumor (GIST)of the stomach. Following endoscopic hemostasis for gastric bleeding, imatinib mesilate was administered. The tumor reduced markedly, and vascularity in the tumor was diminished, the visible vessels of the tumor disappeared. For curative resection, total gastrectomy with a distal pancreato -splenectomy and a left diaphgram resection is necessary, but surgery was high-risk for this patient because she was advanced in age. She is now achieving a good partial response without surgery.     

34例胃肠间质瘤相关急腹症诊治分析

[目的]探讨胃肠间质瘤（GIST）所引起相关急腹症的诊治。[方法]对急诊收治入院且病理证实的34例GIST患者的临床表现、检查资料、手术和生存情况进行分析。[结果]34例患者中有消化道出血18例,腹腔出血4例,肠梗阻8例,肿瘤破裂与穿孔4例。29例行根治性切除（90.6%）。3年生存率为88.1%,5年生存率80.4%。[结论]首诊医师应熟悉GIST相关急腹症,早期诊断与手术切除可显著提高患者生存率。     

A gastrointestinal stromal tumor in the stomach: usefulness of computed tomographic volumetry

We report herein the case of a 70-year-old man who was found to have a gastrointestinal stromal tumor (GIST) in the stomach following sigmoid colon resection. Preoperative gastroscopic and barium examinations revealed a submucosal tumor, measuring 10cm, on the upper part of the stomach. Using computed tomography (CT) images (i.e., computed tomographic volumetry) the doubling time of this tumor was calculated, accurately, as 3.3 months, which suggested a high growth rate and malignancy. A laparotomy and partial gastric resection were performed. Histologically, the tumor consisted of spindle-shaped cells with oval nuclei. In immunohistochemical studies, the tumor cells were positive with respect to c-kit, CD34, and vimentin, but negative with respect to smooth muscle actin and S-100 protein. There were 15–16 mitoses per 50 high-power fields (HPFs), and the Ki-67 antigen (MIB-1) index was 25.5% in the most active areas, which also indicated malignancy. The final pathological diagnosis of this tumor was malignant GIST. The patient was found to have hepatic metastasis 27 months after the surgery, and he subsequently received a hepatic subsegmentectomy. To our knowledge, there are very few reports concerning the growth rate of GISTs. Computed tomographic volumetry is useful for the follow-up of small or irregularly shaped gastric submucosal tumors, and for making decisions regarding surgical intervention.