Nisan 14, 2023

Laparoscopic Transgastric Resection of Gastrointestinal Stromal Tumor and Simultaneous Sleeve Gastrectomy: A Case Report

Posted by opdrmesutcaynak11357981 in

The aim of this case report is to show that simultaneous laparoscopic transgastric resection (LTGR) of a gastrointestinal stromal tumor (GIST) located close to the esophagogastric junction can be performed safely and effectively in a patient who is scheduled for sleeve gastrectomy (SG) with the diagnosis of morbid obesity. In the patient who was scheduled for SG surgery with the diagnosis of morbid obesity (BMI: 40.4 kg/m2), a lesion compatible with GIST of 4 cm in diameter and located in the small curvature of the stomach close to the EGD was detected in the preoperative routine endoscopic evaluation. Simultaneous LTGR and SG were planned for the patient. The ports are placed as in the standard SG. The stomach was released along the greater curvature and a gastrotomy was performed and the tumor was localized. The tumor was resected with a linear stapler, considering the surgical margin. No malignancy was detected in the frozen examination. Later, the gastrotomy was closed and SG was performed over a 39F spark plug. No stenosis or leakage was observed in the postoperative passage graphy. The patient was discharged on the 3rd post-operative day. In the immunohistochemical examination, the tumor was reported as GIST and the surgical margins were negative. LTGR can protect the stomach or minimize the degree of partial resection in the treatment of GSTs, especially near the OGB.

Entrance

Along with the increasing obesity and bariatric surgeries around the world, the frequency of diagnosis of gastric submucosal tumors (GST) has increased (1). The term GST includes submucosal mesenchymal tumors, including ectopic pancreas, schwannomas, leiomyomas, leiomyosarcomas and gastrointestinal stromal tumors (GIST), and all of them are defined by immunohistochemical markers (2). GISTs are the most common mesenchymal tumors in the gastrointestinal (GI) tract, and the stomach is the most common region of all GISTs (50-60%) (3). Although its annual incidence is rare with 10 cases per million, it is believed that asymptomatic GIST cases are much higher (2,4). GIST can be detected at any age, but it is often seen between the ages of 55-65. (5). Tomography should be performed in terms of the tumor’s exophytic extension, its relationship with the stomach wall, and metastasis. Surgical resection is recommended for primary resectable GISTs (6,7).

In this case report, we wanted to emphasize that simultaneous LTGR and SG are a feasible and reliable method for a patient who is scheduled for sleeve gastrectomy due to obesity and GST is detected in pre-op examinations but is not suitable for endoscopic enucleation.

Case Report

39-year-old female patient. He applied to our clinic due to morbid obesity. The patient’s BMI was 40.4kg/m2 (110kg-165cm). The patient underwent routine endoscopic evaluation before surgery. A lesion located on the small curvature of the stomach, close to the esophagogastric junction, ulcerated on the top, with an endophytic growth pattern was observed (Picture-1). The appearance of the lesion was evaluated in favor of GIST. Computed tomography was performed to evaluate the actual size of the tumor and possible metastases. On tomography, a submucosal lesion of approximately 4 cm consistent with GIST was detected on the proximal of the small curvature of the stomach that did not exceed the serosa (Picture-2). Simultaneous SG and LTGR were planned for the patient who was not suitable for endoscopic enucleation. The operation was started between the operator’s legs in the reverse trendelenburg position. Ports were placed as in SG. The stomach was released with ligasure along its greater curvature. With Ligasure, approximately 10 cm of gastrotomy was performed by the greater curvature from the proximal of the stomach antrum to the distal fundus. The lesion was located proximal on the lesser curvature (Picture-3). The tumor was suspended by holding the adjacent mucosa. A full-thickness resection was performed with an endoscopic linear stapler, observing the surgical margins (Picture-4). The play was taken out of the right subcostal port in the specimen bag. No findings in favor of malignancy were found in the frozen examination. No bleeding was observed in the stapler line. In order to prevent contamination, the gastrotomy line was continuously sutured from the fundus to the antrum and the stomach was closed. Then 39F bougie was placed in the stomach. Resection was performed starting from a distance of 3cm from the pylorus, with the gastrotomy line remaining in the resection piece, 5 endoscopic linear staplers were used and the stapler line was supported with metal clips. No stenosis was observed in the postoperative passage graphy (Picture-5). The patient was externated on the 3rd postoperative day. Immunohistopathological examination confirmed the diagnosis of GIST and surgical margins were reported as negative.

Argument

With the increasing number of bariatric surgeries all over the world, the rate of diagnosis of GST has increased. GSTs are often found together with GI bleeding and anemia secondary to the ulceration of the tumor, they can also cause abdominal pain and dyspeptic complaints, but small tumors usually appear asymptomatic (4). In our patient, the tumor was asymptomatic and it was detected in the preoperative routine endoscopic evaluation.

Endoscopic biopsies are recommended for patients with locally advanced disease or those who will receive tyrosine kinase inhibitors, such as metastatic GIST patients. Primer, resected

Excisional biopsy is recommended for detectable GISTs (2,8). In this case, the absence of advanced localized disease or metastases was confirmed by CT and surgery was planned without biopsy.

The surgical treatment principle for primary resectable GISTs is RO resection without causing tumor rupture. Due to the biological behavior of GISTs, extensive resections and lymphadenectomy are not required (6). This situation has made the laparoscopic approach an ideal technique for GISTs. Tumors located in the fundus and greater curvature can be removed with wedge/partial resections. However; For tumors located near the EGJ or pylorus, especially those with intraluminal growth, laparoscopic wedge resection increases the risk of causing gastric inlet deformity or stenosis and may affect the feasibility of the planned surgery in obesity patients. Laparoscopic transgastric techniques have been developed to prevent proximal gastrectomy, stenosis and deformities, and these techniques have been shown to be simple, safe and effective (9,10,11). In this case, the location of the tumor was close to the EGD and on the lesser curvature side. Laparoscopic wedge resection might not have allowed SG or stenosis and deformity might have been observed in the postoperative period. Therefore, simultaneous transgastric resection with SG was planned for the patient.

Endoscopic/transgastric/transluminal enucleation and endoscopic full-thickness resection techniques were also applied for tumors close to the EGJ. In GISTs, there is a risk of perforation, positive surgical margins and perioperative bleeding in endoscopic enucleation/full-thickness resection, since the tumor originates from the muscle layer (12,13). Endoscopic enucleation/full-thickness resection was not preferred in order to prevent possible complications since simultaneous bariatric surgery will be performed and because it is possible to reach the tumor easily intraoperatively.

Frozen examination is recommended during surgery (6,7). In case of possible malignancy, wider resections and lymphadenectomy should be added to the surgery. Sometimes, it may be difficult to distinguish gastric epithelial adenocarcinoma from epithelioid type GIST. Therefore, postoperative immunohistochemistry results should be checked quickly. In this case, no malignancy was observed in the intraoperative frozen examination, and the diagnosis of GIST was confirmed in the immunohistochemical examination.

The simplest LTGR technique is to suspend the tumor by performing a gastrotomy to the stomach and to perform a full-thickness resection with a linear stapler parallel to the gastrotomy line. This procedure allowed preservation of the stomach or minimizing the degree of partial resection. In this technique, stomach contents should be carefully aspirated to prevent intra-abdominal contamination. In order to reduce contamination after resection, the gastrotomy line should be closed and the surgery should be continued and the operating room should be washed. Three cases of GST near the esophagogastric junction performed simultaneously with bariatric surgery have been presented in the literature (14,15,16).

Conclusion

The treatment of obese patients with a combined stomach pathology such as GST, which requires simultaneous excision with bariatric surgery, is controversial. In GSTs with a small curvature located close to the EGJ, LTGR can be performed simultaneously with sleeve gastrectomy without causing narrowing in the stomach volume and unnecessary tissue removal. Large case series are needed to determine the most appropriate approach for bariatric surgeries and simultaneous GST resections.

References

  1. 1Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384:766–81.  
  2. Sicklick JK, Lopez NE. Optimizing surgical and imatinib therapy for the treatment of gastrointestinal stromal tumors. J Gastrointest Surg 2013;17:1997–2006  
  3. Nowain A, Bhakta H, Pais S, et al. Gastrointestinal stromal tumors: clinical profile, pathogenesis, treatment strategies and prognosis. J Gastroenterol Hepatol 2005;20(6):818 – 824.  
  4. Hiki N, Yamamoto Y, Fukunaga T, Yamaguchi T, Nunobe S et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008;22:1729–1735 
  5. DeMatteo RP, Lewis JJ, Leung D, Mudan SS,Woodruff JM, Brennan MF. Two hundred gastrointestinalstromal tumors: recurrence patterns and prognostic factors forsurvival. Ann Surg2000;231:51-58. 
  6. Blay  JY, Bonvalot S,Casali P, Choi H, Debiec-RichterM, Dei Tos AP, et al; GIST Consensus Meeting Panelists. Consensus meeting for the management of gastrointestinal stromaltumors.Reportof the GIST Consensus Conference of 20 – 21 March 2004, under the auspices of ESMO. Ann Oncol 2005;16: 566-578 
  7. ESMO/European Sarcoma NetworkWorking Group. Gastrointestinal stromal tumors: ESMO ClinicalPractice Guidelines fordiagnosis, treatment and follow-up. Ann Oncol2012;23-7:49-55.   
  8. Gold JS, Dematteo RP. Combined surgical and molecular therapy: the gastrointestinal stromal tumor model. Ann Surg 2006;244:176-184. 
  9. Tagaya N, Hikami H, Kogure H, et al. Laparoscopic intragastric staple resection of gastric submucosal tumors located near the esophagogastric junction. Surg Endosc. 2001;16:177–179.  
  10. Walsh RM, Ponsky J, Brody F, et al. Combined endoscopic/ laparoscopic intragastric resection of gastric stromal tumors. J Gastrointest Surg. 2003;7:386–392. 
  11. Xiaowu Xu, Ke Chen, Wei Zhou, Renchao Zhang, Jie Wang, Di Wu,Yiping Mou. Laparoscopic Transgastric Resection of Gastric Submucosal Tumors Located Near the Esophagogastric Junction. J Gastrointest Surg 2013;17(9):1570–1575. 
  12. Gotoda T. A large endoscopic resection by endoscopic submucosal dissection procedure for early gastric cancer. Clin Gastroenterol Hepatol 2005;3:71–73 
  13.  Zhou PH, Yao LQ, Qin XY, et al. Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria. Surg Endosc. 2011; 25(9):2926-2931. 
  14. HashimotoK,SekiY,KasamaK.Laparoscopicintragastricsurgery and laparoscopic roux-y gastric bypass were performed simultaneously on a morbidly obese patient with a gastric submucosal tumor:areportofacase andreview. ObesSurg 2015;25(3):564–567.  
  15. GenserL, TorciviaA, VaillantJC,etal.Laparoscopic transgastric enucleation of a gastric leiomyoma near the esophagogastric junction and concomitant sleevegastrectomy: videoreport. ObesSurg 2016;26(4):913–914 
  16. Saeed Alshlwi, Aly Elbahrawy, Hussam Alamri, Sara Najmeh, Rajesh Aggarwal, Sebastian Demyttenaere, Olivier Court, Amin Andalib. Laparoscopic Transgastric Resection of a Gastric Submucosal Tumor near Esophagogastric Junction with Concomitant Sleeve Gastrectomy: a Video Case Report, Obes Surg 2017;27:552–553