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Laparo-endoscopic transgastric resection of gastric gastrointestinal stromal tumor located near the gastro-oesophageal junction with hiatus hernia repair
Richa Mishra, Suryanarayan Gautam, Saurabh Misra
Department of Gastrointestinal and Bariatric Surgery, Apollo Hospitals, Bengaluru, Karnataka, India
|Date of Submission||19-Jun-2021|
|Date of Acceptance||30-Aug-2021|
|Date of Web Publication||19-Oct-2021|
Department of Gastrointestinal and Bariatric Surgery, Apollo Hospitals, No. 154/11, Bilekahalli, Bannerghatta Road, Bengaluru - 560 076, Karnataka
Source of Support: None, Conflict of Interest: None
A 63-year-old male presented to us with upper abdominal pain and odynophagia for 3 months. Contrast-enhanced computed tomography of the abdomen revealed hiatus hernia with ulceroproliferative growth involving the gastro-oesophageal (GE) junction and cardia of the stomach with no obvious transserosal extension. Upper gastrointestinal (GI) endoscopy was suggestive of a tumour of size 3 cm × 3 cm near the GE junction and sliding hiatus hernia. Although there are various ways described in the literature for managing GI stromal tumour (GIST), we opted for laparo-endoscopic transgastric resection with hiatus hernia repair due to obvious advantages in terms of safety and efficacy. Just a handful of cases have been described in the literature being treated in this fashion. The procedure was successfully performed as evidenced by an uneventful recovery of the patient. His histopathology report was suggestive of GIST of size 3.5 cm × 3.0 cm × 2.0 cm. The resected margins were free of the tumour.
Keywords: Gastro-oesophageal junction, gastrointestinal stromal tumours, hiatus hernia, laparo-endoscopy, transgastric
|How to cite this URL:|
Mishra R, Gautam S, Misra S. Laparo-endoscopic transgastric resection of gastric gastrointestinal stromal tumor located near the gastro-oesophageal junction with hiatus hernia repair. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=328697
| ¤ Introduction|| |
Gastrointestinal stromal tumours (GISTs) are the most frequent tumours of the gastric submucosa. These tumours are derived from the interstitial cells of Cajal. The safety and oncologic outcome of laparoscopic gastric GIST resection is well established. The management of tumours located near or at the gastro-oesophageal (GE) junction poses a particular challenge. While the oesophagus and vagus nerves are at risk for injury and the GE junction is at risk for narrowing or dysfunction.
We describe the management of a GIST tumour located near the GE junction with hiatus hernia (HH). The location of the tumour presented a unique problem in which the mass was pulled further into the thoracic cavity due to the HH and a traditional wedge resection of stomach would potentially have led to injury to the GE junction. A decision to excise the tumour was taken under vision using laparo-endoscopic transgastric technique. This was the preferred technique as it would enable us to visualise the Z-line at the GE junction while adequately excising the tumour followed by a hiatal repair.
| ¤ Case Report|| |
A 63-year-old male presented with upper abdominal pain and difficulty in swallowing for 3 months. He had no co-morbidities except hypertension for which he was on medications. A contrast-enhanced computed tomography scan of the abdomen was done which revealed incidental HH type 3 with ulcero-proliferative growth of the size (3.3 cm × 3.2 cm) involving the GE junction and cardia of stomach without a trans-serosal extension [Figure 1]. He was initially evaluated in the emergency department for pain and vomiting and later referred to us for further evaluation.
|Figure 1: Contrast-enhanced computed tomography – abdomen image showing the location of the lesion|
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There was a mild tenderness in the epigastric region but no palpable mass on physical examination. He did not have any constitutional symptoms. Upper gastrointestinal (GI) endoscopy revealed a benign appearing polyp, very near to the GE junction with intact mucosa, along the greater curvature of the stomach and a HH. However, no biopsies could be taken due to risk of bleeding.
After thorough evaluation, the patient was taken up for combined laparo-endoscopic transgastric fundal GIST resection with HH repair. The patient was kept in the supine position with legs split. With the operating table in a reverse Trendelenburg position, the surgery was conducted with the operating surgeon between the legs and the laparoscopic monitor above the left shoulder of the patient. The endoscopic tower was placed above the right shoulder of the patient with the gastroenterologist on the left side of the abdomen. 10-mm optical trocar was introduced, 5 cm above the umbilicus, 1 cm towards the left of the midline and pneumoperitoneum created. A Nathanson retractor was introduced through the subxiphoid 5 mm incision and liver retracted. Two other trocars, one 5 mm (right) and the other, 12 mm (left) trocars were placed on either side of the midline, one and two finger breadths respectively, below the costal margin in the mid-clavicular lines, midway between the xiphoid process and the 1st trocar. These trocars were special balloon tipped with air seals (applied medical, Kii abdominal access system with advanced fixation sleeve). Another 5 mm trocar was introduced in the left anterior axillary line for retraction [Figure 2].
The hiatal dissection was done and oesophagus dissected to get adequate (5 cm) intra-abdominal length. The same 12 mm and 5 mm trocars which were used for fundal dissection were advanced into the stomach under endoscopic guidance after distending it with air. The stomach wall was hitched up using the balloon and seal of the trocars. Three Endo GIA™ (BLUE Coloured) Tri-Staple™ (COVIDIEN) reloads were fired in sequence to resect the tumour under endoscopic guidance, which was retrieved in an endobag through gastrotomy port. This was followed by closure of gastrotomy ports with absorbable 2-0 V-LOC™ sutures (Medtronic). Diaphragmatic crural repair was done with 2-0 Ethibond Excel sutures. Complete resection of the tumour could be achieved [Figure 3], and the stapler line was inspected for potential bleeding at the end of the procedure [Figure 4]. The patient was started orally on the first post-operative day. He was discharged on the post-operative day 3. Follow-up period was uneventful.
Histopathology report was suggestive of (GIST, spindle type) of size 3.5 cm × 3.0 cm × 2.0 cm. The mass was seen extending up to the muscularis propria and measured 0.3 cm from the resected margin.
| ¤ Discussion|| |
GIST tumours located at the esophagogastric junction are infrequent and represent <5% of all GISTs. Surgical resection is the mainstay of treatment. There are several endoscopic, laparoscopic and open surgical procedures available for the management of GIST tumours near the GE junction. Over the last decade, multiple reports have described both the feasibility and safety of laparoscopy in treating these tumours.
In our case, the GIST was located very close to the GE junction, in the fundus of the stomach. The traditional wedge resection of the stomach could not be offered in this case as it poses increased threat to injury to the GE junction and vagus nerves. Hence, it was decided to excise the tumour (with the help of medical gastroenterologist) using combined laparo-endoscopic transgastric technique. Such a technique has been described in a very few cases in the literature and deemed safe and effective.
Intragastric resection was first introduced by Ohashi 1995. This procedure is evolved further into a more mature and safe technique and makes local resection of gastric GISTs possible without disturbing or impairing the function of esophagogastric junction.
The combined laparo-endoscopic approach offers visualisation of the Z-line at the GE junction while adequately excising the tumour. There are minimal chances of injury to the GE junction, continuity of the staple line can be confirmed, minimises the potential blood loss, does not require suturing of the resected stomach wall. All these are some of the advantages of the technique which we have described in this literature.
A similar laparoscopic and endoscopic technique for submucosal tumours located near the Z-line has been described by Shim et al. in a study of six patients and found to be a safe and feasible approach for gastric GIST.
| ¤ Conclusion|| |
Laparo-endoscopic transgastric resection of gastric GIST is a safe, effective and feasible minimally invasive approach for resecting tumours close to GE junction. The combined approach allows precise tumor localisation, adequate resection margins, least risk of damage to anatomical structures, reduced hospital stay, early return to routine physical activities and good patient outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
- Dr. Mohammad Farook. M, PGDFM, Associate Consultant, Department of Medical Gastroenterology
- Dr. ST Gopal, MRCP, FRCP, Senior Consultant – Department of Medical Gastroenterology.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]