Hariruk Yodying, MD. Department of surgery, HRH Princess Maha Chakri Sirindhorn Medical Center (MSMC) Hospital, Srinakharinwirot University
BACKGROUND: Laparoscopic resection has become an accepted treatment for small Gastrointestinal stromal tumors (GISTs) of the stomach, but its application for large GISTs exceeding 5 cm. remains controversial. Because of the advancements in laparoscopic surgical techniques, the combination of different surgical procedures in a single operation has been widely reported. We present our experience of simultaneous laparoscopic resection for large gastric GIST with left adrenal incidentaloma in an obese patient.
CASE PRESENTATION: A 75-year-old female patient with BMI of 31 kg/m2 presented with dyspepsia for 3 months. The abdominal ultrasounds showed a heterogeneous mass at epigastrium and nodule at left adrenal gland. Contrast-enhanced CT scan of the abdomen revealed lobulated enhancing mass size 13cm × 11cm × 8cm arising from greater curvature of the stomach. There was heterogeneous enhancing nodule size 3cm at left adrenal gland. It measured 23.8 HU in non-contrast, 95.0 HU in enhanced and 56.5 HU in the delayed phase. The absolute enhancement washout was 53% and relative washout was 40%. The laboratory evaluation for the functional adrenal tumor was negative. Upper GI Endoscopy was normal.
OPERATION AND OUTCOME: The patient underwent laparoscopic subtotal gastrectomy with left adrenalectomy. The patient was placed in supine split leg position. The trocar positions are shown in the following picture. During laparoscopic exploration, a large extramural pedunculated mass was located in the gastric body. Subtotal gastrectomy was performed. Then Left adrenalectomy was performed by the transperitoneal approach. The tumor specimen was extracted through an extended umbilical incision. A Roux-en-Y gastrojejunostomy was constructed. ICG-enhanced fluorescence was used during left adrenalectomy and verified the adequate perfusion of the gastrojejunostomy anastomosis. There was no tumor rupture during surgery. The operation time was 270 mins. The postoperative course was uneventful and the patient was discharged postoperative day 5.
Pathological examination of extramural gastric mass was confirmed as GIST with a high level of mitotic activity. The left adrenal gland was atypical diffuse cortical hyperplasia.
CONCLUSION: Laparoscopic resection of a large gastric GIST is feasible in selected case. The minimally invasive treatment of coexisting abdominal pathologies such as gastric GIST and adrenal incidentalomas seem to be suitable and safe. The near-infrared (NIR) camera system in conjunction with ICG-enhanced fluorescence provides several benefits in terms of identifying vascular structures, enhance the borders of the tumor during adrenalectomy and help estimate the blood supply of visceral anastomosis, especially for an obese patient.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94080
Program Number: V124
Presentation Session: Endocrine Videos
Presentation Type: Video