Laparoscopic total gastrectomy for juvenile polyposis.

Yulia Zak, MD1, Ozanan R Meireles, MD2, David W Rattner, MD, FACS2. 1Mount Sinai Beth Israel, 2Massachusetts General Hospital

OBJECTIVES:  Juvenile polyposis syndrome is a rare condition, in which hamartomatous polyps with malignant potential can affect the entire gastrointestinal tract.  Juvenile polyps are most frequently found in the colon, but individuals with the SMAD4 mutation in the MADH4 gene exhibit a prevalence of gastric polyposis instead.   This is a case of a 62-year-old man who presented with chronic iron-deficiency anemia due to bleeding from massive gastric polyps.  Although traditionally total gastrectomy has been performed using an open surgical approach, advances in technology now allow the consideration of laparoscopic methods of resection.

METHODS:  Upper endoscopy revealed normal esophagus and duodenum, with numerous polyps throughout the stomach.  Laparoscopic exploration revealed no signs of malignant spread.  A 45cm Roux limb and a 30cm biliopancreatic limb were created, and a stapled side-to-side jejuno-jejunostomy was constructed.  The gastrohepatic and phrenoesophageal ligaments were opened, and the distal esophagus was mobilized circumferentially.  The short gastric, left gastric, accessory left hepatic, and gastroepiploic vessels were ligated, and the stomach was mobilized from the retroperitoneum.  The duodenum was transected just distally to the pylorus, and the esophagus was stapled off at the gastroesophageal junction.  With the aid of traction sutures, an OrVil device was used to pass a 25mm EEA anvil trans-orally through an esophagotomy.  An end-to-side esophagojejunostomy was created with the EEA stapler inserted through an enterotomy in the antecolic Roux limb.  The air leak test was negative and there was no tension at the completion of the procedure.

RESULTS:  The patient recovered well without complications.  Surgical pathology confirmed the presence of juvenile polyposis without any evidence of dysplasia.

CONCLUSIONS:  Laparoscopic total gastrectomy is an effective treatment for benign and premalignant conditions of the stomach.

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