Tracey C Kim, MD, Jeffrey E Quigley, DO, Manuel Garcia, MD, Stephanie Keeth, DNP, Aarthy Kannappan, MD, Daniel Srikureja, MD, Esther Wu, MD, Keith Scharf, DO, FACS, FASMBS, Carlos Garberoglio, MD, FACS, Marcos Michelotti, MD. Loma Linda University Health
We present a case of a 59-year-old female with a history of thyroid cancer who initially presented to an outside hospital complaining of reflux, abdominal pain, early satiety, and 35-pound unintentional weight loss. Endoscopy demonstrated a 2 cm pre-pyloric mass; with initial biopsies of the mass demonstrating only gastric mucosa. Endoscopic ultrasound and FNA of the lesion also failed to elucidate its pathology. Due to the pyloric location of the mass and inability to rule out invasive malignancy, we recommended a robotic-assisted transgastric submucosal resection with possible distal gastrectomy. Intraoperatively we found a 270-degree circumferential pre-pyloric exophytic sessile tumor. Frozen sections suggested a benign papillary tumor therefore we proceeded with submucosal resection. The resulting mucosal defect and gastrotomy were closed primarily with absorbable suture. Final pathology showed the tumor to be a tubulovillous adenoma with high grade dysplasia arising against a background of intestinal metaplasia. The resection margins were negative for dysplasia. The postoperative course was complicated by a minor leak which did not require operative intervention and subsequent gastric outlet narrowing which required endoscopic dilation and feeding tube placement. However, the patient has recovered well and has advanced to diet as tolerated. Gastric adenoma has a prevalence of 0.5-3.75% in the western hemisphere. The risk of carcinomatous transformation in gastric adenomas is related to size, degree of dysplasia, and villosity. Gastric adenomas are considered precancerous lesions. Pre-operative pathologic diagnosis of dysplasia is often elusive as biopsies will often miss or under-grade the lesion. Guidelines advocate for complete resection with either endoscopic submucosal dissection or surgical resection depending on surgeon preference and local expertise. Endoscopic resection has been shown to be safe and efficacious in the removal of adenomas with good long-term outcomes. In this case the pathology of the lesion was unclear after multiple unsuccessful biopsies and required a surgical diagnosis to rule out invasive malignancy. Management of gastric adenomas, while rare, may require a multidisciplinary approach between surgical endoscopy, minimally invasive surgery, and surgical oncology to achieve local control in an oncologically sound manner. We show that transgastric submucosal resection can be achieved in a minimally invasive fashion using robotic assistance.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88149
Program Number: P419
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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