Endoluminal Stomach-sparing Resection of Gastric Gists

Stephanie Downs-canner, MD, Kenneth Fasanella, MD, Kevin Mcgrath, MD, Kenneth K Lee, MD. University of Pittsburgh School of Medicine

 

Gastrointestinal stromal tumors, or GISTs, are common mesenchymal tumors of the gastrointestinal tract. Malignant behavior among these tumors may occur, and therefore complete surgical resection is the primary treatment for GISTs. Wide margins are not needed and lymphadenectomy usually is not required as lymph node metastases are rare. 70% of GISTs arise in the stomach, and for these, laparoscopic resection is an attractive alternative to conventional open resection. For exophytic gastric GISTs, laparoscopic or open resection can often be easily accomplished by means of a wedge resection of the stomach using surgical staplers. GISTs that predominantly protrude into the lumen of the stomach, however, may be technically challenging as wedge resections performed in the same manner are apt to require more extensive resections of the stomach and result in greater alteration in the configuration of the stomach. Such intraluminal GISTs occurring near the gastroesophageal junction or pyloric channel are particularly problematic as conventional wedge resections in these locations may result in significant narrowing and distortion of the gastroesophageal junction or gastric outlet. In this video we demonstrate minimally invasive stomach-sparing endoluminal resection of a proximal gastric GIST using a combined laparoscopic and endoscopic single intragastric port technique.

Following establishment of pneumoperitoneum and per oral endoscopic localization of the intraluminal GIST, stay sutures were placed into the body of the stomach and a 12mm port was passed through the abdominal wall and into the stomach. The GIST was identified on the proximal lesser curvature of the stomach using both the endoscope passed orally and a laparoscope passed through the 12 mm port. Under endoscopic visualization, a linear stapler was inserted through the 12 mm port and used to resect the GIST. To facilitate positioning of the stapler beneath the mass, an endoscopic snare was secured around the mass and used to place traction upon the mass. The resected mass was then placed into a laparoscopic specimen bag and removed from the stomach and abdomen. After confirming that hemostasis was satisfactory along the gastric resection staple line, the port was removed from the stomach and the port site was closed using a linear staple. A minimal amount of stomach was removed and resulted in negligible changes in the capacity of the stomach. There were no significant anatomic alterations in the region of the gastroesophageal junction. Final pathologic evaluation confirmed the diagnosis of a GIST with margins of resection uninvolved by the tumor.

Three additional intraluminal gastric GISTs located 1.5, 2.0, and 8.0 cm from the gastroesophageal junction have been removed in this manner. In all cases the margins of resection have been uninvolved by the tumors, and with follow-up ranging from 5 to 12 months there have been no signs of recurrence.

These cases demonstrate a novel laparoendoscopic technique of endoluminal stomach-sparing resection of gastric GISTs. This technique minimizes distortion of the stomach and changes in its capacity and may be particularly useful for the treatment of very proximal, very distal, or very large intraluminal gastric GISTs.

 


Session Number: SS25 – Videos: NOTES / Flexible Endoscopy
Program Number: V064

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