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The stomach is involved in multiple common ailments, including gastroesophageal reflux disease, gastric ulcers, and cancer, the latter of which can take many forms. One type of cancer that presents a management challenge is gastrointestinal stromal tumors or GIST tumors for short. Originally, these are tumors that arise from the connective tissue, or stroma, of the stomach, rather than the lining, from which the more common and more deadly gastric adenocarcinoma finds its origin. However, over time, studies revealed that GIST arises from a very specific cell, called the interstitial cells of Cajal, that are responsible for the timing of contraction in the stomach and small intestine. GIST masses generally behave more indolently than gastric adenocarcinoma, with distant or lymph node metastases a rare feature, although involvement of the liver and peritoneum has been described. Due to this indolent nature, certain masses, once they have been identified as GIST through endoscopic biopsy, are candidates for surveillance. However, larger masses (as identified through evidence of necrosis on imaging) and rapidly growing masses are treated primarily with surgical resection. While in the past surgical resection would have involved a large abdominal incision and a lengthy postoperative recovery, laparoscopic techniques have allowed gastric resection to become a short procedure necessitating only an overnight stay.
Most patients presenting with GIST are symptomatic, with the common complaints being vague abdominal pain and evidence of gastrointestinal bleeding, either through melena, or stool with digested blood, or hematochezia. In situations where metastases exist at the time of presentation, signs of liver failure, although this is rare. GIST can also occur in the setting of endocrine syndromes such as von Hippel-Lindau disease or neurofibromatosis, but the majority are isolated findings. A small, but, due to the overall increase in imaging studies, an increasing number of patients are being diagnosed via abdominal imaging and are thus asymptomatic.
Patients with GIST have little in the way of physical findings, unless the tumor is markedly advanced, at which time a palpable abdominal mass overlying the stomach may be identified. Patients also may have pain to palpation of the abdomen, and, if the liver is involved, findings of jaundice.
The nature of the history of gastric GIST is variable, with some tumors behaving indolently while others exhibit local and distant metastasis, but two variables, in particular, have been identified as predictive of metastasis. The first is the size of the tumor, with greater than 10 centimeters in the greatest dimension being a poor prognostic sign. Greater than 5 mitoses per high power field on histologic analysis of the tumor is also a harbinger of metastasis.
In masses, less than 2 centimeters, that do not demonstrate increased mitotic activity on endoscopic biopsy, the natural history is uniformly benign and nothing further needs to be done. In tumors that are either between 2 and 5 centimeters with no increased mitotic activity, or tumors less than 2 centimeters but with increased mitotic activity, a watchful waiting strategy with surveillance CT may be adopted. However, in larger tumors (>5 centimeters) that are accompanied by increased mitotic activity or signs of necrosis on imaging, resection of the mass is the mainstay of treatment.
In this particular patient, a stomach mass was discovered after an endoscopy was performed secondary to abdominal pain. Due to the small size and lack of mitotic activity on biopsy, surveillance was elected initially. However, the mass grew over the course of a year, and repeat biopsy showed an increase in mitotic activity, as well as positive c-KIT staining. After discussion with the patient, the decision was made to proceed with resection of the mass.
Contraindications to the procedure would be the general ones of systemic illness precluding general anesthesia.
While GIST is the most common sarcomatous tumor of the gastrointestinal tract, it is still rare cancer, comprising only one percent of all GI tumors.1 Due to this, effective screening strategies have proven elusive. Most patients with gastric GIST present with symptoms, most commonly abdominal pain, although an increasing number are discovered incidentally. Almost one-third of GIST masses carry a high risk for malignant potential or are frankly malignant, and the poor state of adjuvant therapy associated with GIST is reflected in the high mortality rates associated with these high-risk and frankly malignant tumors.2
Diagnosis of gastric GIST is based on histologic analysis of tissue obtained at the time of endoscopy. This is due to two specific defects that have been identified as giving rise to GIST. The most common is found in the c-KIT gene of the affected cells. The c-KIT gene encodes for a transmembrane receptor, which is thought to play a crucial role in cellular apoptosis.3 In affected cells, the c-KIT tyrosine kinase is constitutively active, causing deregulation of cellular growth.1 Another, and mutually exclusive, gene defect is the one found in the gene responsible for platelet-derived growth factor-alpha (PDGFR-α).4 Presence of either of these mutations are diagnostic of GIST; however, they do not predict the malignant potential of the mass. Rather, the combination of the number of mitoses, or actively dividing cells, that are seen during histologic analysis, combined with the size of the tumor itself, is highly predictive of metastatic potential.5 In one large pathologic review of patients identified as having GIST, 86% of patients with greater than 5 mitoses per fifty high-powered field on microscopy, combined with a tumor mass of greater than 10 centimeters had eventual metastasis of GIST, while only two to three percent of patients who had neither found.5
If a GIST is detected and found to have concerns for increased malignant potential, removal of the mass via surgical resection is the mainstay of treatment. With the advent of laparoscopy, in otherwise uncomplicated patients, resection of gastric masses has become a much less morbid procedure, with patients returning home within twenty-four hours, as well as returning to regular diets soon postoperatively. This is especially the case for tumors located on the greater curvature of the stomach, where the mass is relatively simple to access and may be removed simply by stapling across the base of the mass with an endoscopic gastrointestinal stapler.
In the setting of metastatic or unresectable disease,6 or patients with high risk for recurrence based on primary tumor characteristics7, adjuvant therapy with imatinab, a tyrosine kinase inhibitor, may be considered. In fact, response to imatinib has been so positive that its continuous use in patients with GIST has been approved by the Federal Food and Drug Administration.8
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Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Judson I, Demetri G. Advances in the treatment of gastrointestinal stromal tumours. Ann Oncol. 2007;18(suppl 10):x20-x24. doi:10.1093/annonc/mdm410.
- Nilsson B, Bümming P, Meis-Kindblom JM, et al. Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era. Cancer. 2005;103(4):821-829. doi:10.1002/cncr.20862.
- D'Amato G, Steinert DM, McAuliffe JC, Trent JC. Update on the biology and therapy of gastrointestinal stromal tumors. Cancer Control. 2005;12(1):44-56. doi:10.1177/107327480501200106.
- Heinrich MC, Corless CL, Demetri GD, et al. Kinase mutations and imatinib response in patients with metastatic gastrointestinal stromal tumor. J Clin Oncol. 2003;21(23):4342-4349. doi:10.1200/JCO.2003.04.190.
- Miettinen M, Sobin LH, Lasota J. Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up. Am J Surg Pathol. 2005;29(1):52-68. doi:10.1097/01.pas.0000146010.92933.de.
- Blanke CD, Rankin C, Demetri GD, et al. Phase III randomized, intergroup trial assessing imatinib mesylate at two dose levels in patients with unresectable or metastatic gastrointestinal stromal tumors expressing the kit receptor tyrosine kinase: S0033. J Clin Oncol. 2008;26(4):626-632. doi:10.1200/JCO.2007.13.4452.
- DeMatteo RP, Ballman KV, Antonescu CR, et al. Adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumour: a randomised, double-blind, placebo-controlled trial. Lancet. 2009;373(9669):1097-1104. doi:10.1016/S0140-6736(09)60500-6.
- Mahvi DM, Krantz SB. Stomach. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 19th ed. Philadelphia, PA: Saunders; 2012:1182-1226.
Table of Contents
- Incise skin and dissect down to fascia.
- Place fascial stay sutures and open fascia and peritoneum.
- Sweep any abdominal structures away from port site with finger sweep.
- Place umbilical port.
- Other two ports placed under direct vision of camera passed through abdominal port.
- Identify any peritoneal adhesions.
- Under direct vision via umbilical port
- Ligasure used to divide short gastric vessels close to edge of greater curvature of the stomach.
- Mass tattooed preoperatively by gastroenterology service.
- Endo-GIA stapler with 45mm load used to staple across base of mass.
- Removal of specimen via endo-catch bag
- Inspection of abdominal contents and gastric staple line
- Fascial closure
- Infiltration of local anesthetic
So she had a previous tram flap. So we’ve got to be careful. Right I guess. Yea, but you’re off the midline. You want to stay off the midline or come. Yeah midline should be okay. I would go like there. You have a hemostat? Two army-navys and two kochers. Umbilical cord is our visual course. It’s what we do if most of these laparoscopic cases...There you go. This is the fascia. Let’s get her stitch in there. One on each side. It’s kind of, right there. There it is. You’re in. So in this situation, you always do direct placement? I always do direct, with all of them. Put the gas on, please. Okay. Okay. So I usually, use a 30 degree scope for these. Forty-five is fine. Do you want, is that okay? Nope, that’s fine.
Yea, so this is... That’s stomach down there… Liver, falciform, gallbladder. Yea it was huge on the CAT scan. Let’s take a quick look around. Yea, looks like a nice adhesion. Hernia in the making or a bowel obstruction in the making, you know? Is that the normal incision? Yea, she had a tram flaps and then with a tummy tuck with it. So this could be if they could into the, you know over here, they probably got in a little bit. You can usually get into the abdomen with the tram flaps? Yea, we’ll be careful to take that down.
So where do you want to put your ports? So you’re going to want, the 12 inch here with a stapler. And then probably 2 here? I would probably do it the way we normally do with the spleens. I would probably put one here and two here. This way it’s more like the triangular area. So flap over here, and then 12 and 5? Yea so we’ll put a 5 here for retraction, a 12 here for the stapler and ligature and then another 5, way lateral over here for the retraction. Because I’ll be able to triangulate up for the thing where the tumor is.
So let’s put these in first. Let’s see where this thing is, down here. Is that it? So this should be good. Over here anyway. Because then you can work downwards. What’s that one? Is that anything we should take down? We could. That’s easy. Can I get the patient in some reverse? That’s good. Thanks. Let’s look at the stomach again. I just want to see where we are at. Yup. Right over here. Might be too low. I think this is better. Do you have the knife? Fifteen blade? I know I made my skin incision big enough, maybe not. Do you have a fifteen blade again? There we go. Can I have the five, please? So now, I would probably go higher. But should we be on, probably want to be over here so we're not going through the falciform. Blade again. See that fifteen two? Think you arein. You just… go past the falciform though. Yeah, I can get under that.
Can I have a grasper, too? Pull the omentum down. Carefully, comb this way, I would rotate it, yeah, that way. Why is this stuck up here? What if I… so this omentum is stuck. Just got to take that down. So that goes up. That’s all lesser omentum. See? I thought that was greater omentum. Can I have another grasper, please? Would you like the endoshears? No, we’re okay. Grab the stomach, pull it towards you. It’s on the posterior greater curve, up high. That’s it probably, right here. Alright, relax a second. Let me just see... I can’t pull any farther than that, that’s as far as it it will go in. Just want to see the, yes, it’s going to be right here. So that’s spleen, there. Think it’s going to be right over here. So I would, let’s just take the shorties down. Okay.
Can these masses ever be benign? Can they be like mild myeloma? Yea, well it’s a GIST tumor, which is what it is, they’ll, they have a high propensity to, depending on the size and how many mitotic figures there are, they can metastasize. The problem is you can't, you don't know if something's malignant or not, until it actually already is has gone somewhere. So you watch to see if they've gotten bigger. So is there a goal for watching certain types of gastric masses? You can if they're small. And her, her’s was small to begin with, like one and a half centimeters.And then it got bigger and this biopsy came back that it was a GIST. Just go right there. Closer and closer to me, a little bit. So you know most patients go on Gleevec afterwards if they're higher risk, just to prevent it from coming back or if it is a malignant form, because it came out.
You just want to make sure we take the short gastrics, not the gastroepiploic here. Well you buzzed down here. Why don’t you see if you can get that spot a little bit. There you go. So we’re just taking the short gastrics down now. Okay. Let me do this a second. Is that it? That’s the NG tube. NG tube. Nice thought, but nope. You can get closer to the stomach if you want. Might actually have to grab the stomach. Let’s grab the stomach itself. There you go, pull it towards us. Good. You can get closer to the stomach again. Yea this is why I want you to pick the other one because this one is going to take forever.
So I think this is tattooed, also. So we should be able to see, some blue, which is good. So starting to see the blue here from where they tattooed the tumor. Oh they tattoo it! Yea. Otherwise it can be difficult to find it. Yea, sometimes it’s easy. Sometimes it’s not. Her’s is around 2.5 cm. About an inch. So that could potentially be a little bit difficult. So how do they, do the GI people tattoo it? Yea. Yeah. If we could stay closer to the edge than we could just take-Avoid all that fat. Get a little closer to the stomach, if you can. You need to have more traction so I would...Careful not to rip it. I know I said more tension, but you know what I mean. So I would be closer to the stomach, right where the clear stuff is. Down there more? Yea. Is she alright? Yea. It’s because her BP cuff is on the same side.
So I would be okay grabbing that, because you’ve already, you already ligatured that stuff, right? Right so if you grab that you can wind up tearing it. Let me regrab it for you. Keep pulling down towards the feet. Let me regrab now. If you do it twice in the same place, it... yea. Alright let’s see, what we got going on here. Of course I don’t feel it. Let’s keep going. You got it? Seemed too low. So we got to be way up by the spleen. Sorry. Back up and you see that little, thing there? Right there? No, this. That’s is right there. Yep. So angle it so you, like your, you with your left hand. You can angle so you can adjust it to where the angle of that is. Pull on that. Okay let’s see what we got here. Still can’t get it too good. Sticky. Alright. Let’s see if you can get that. Alright, good. I’m letting go in a second. So what are we stuck on? Nothing. This little stalk there. On this tumor, do you have to be very careful in terms of tumor spillage and all that? Yea you don’t want to. Because they actually will, seed it.
So we’re just debating what size stapler we want to use. We want the appropriate thickness but not too thick because then it’ll bleed. Now can you just staple across and that’s the end of that? That’s all we’re doing. That’s a wedge resection of the stomach. Yea, I mean we should be able to. I would use a purple. This a reticulate? Yea it does actually. Oh, good. Yep, I see the other side of it. Do you need to have a certain margin on it? You just have to have a margin really. I’d rather you get a little closer. Turn the other way, flip it, turn it towards you little bit. That should be good. Go ahead. Whoops. You’re over there. Sorry I’m not holding it.
Should leave that there. Go for this thing. Two for one. Going to get the adhesion. So you’re working this way. There’s a stitch there. Yea just cut it out a little bit. That might be hard. Let’s see. See how that’s wrapping around there. Yea that’s definitely like, like a...Just be careful. Just be careful don’t push too, don’t push in like that. Just push down. Yea. Give yourself more tension. Get a little closer to the, here let go. Get a bit higher up, can you get higher up and get a good bite. Lower. I think it's lower than that. Right there? Yea I think so. I think because we’ve taken maybe some peritoneum out it’s going to be a little more harder. Get tension. Definitely need more tension on that if you can. Grab it like you mean it. Higher up if you can. If you can’t, you can’t. Get a good bite. Grasp it. Keep pulling down. You want to cut it too. There you go. That’s the spot.
What’s going on there? Yea, stay up high. There you go. Nice. I think you’re safe there. I could be wrong. Famous last words. I don’t think that’s the ureter. You might need to regrab or do something else with your other hands. Help yourself out. Let’s see the back of it, a second. Should be a little just cutting. Stay up high, stay up high and cut. Full thickness. Just do it. Right before you let go, let’s take a peek. Can I have another grasper, please? Grab the distal end or the proximal end, whichever one that is and pull it towards us. Rub on it, so you can see if it’s serosal or muscle or whatever. I think that’s fine actually. We’re okay. I’d leave it alone.
No, the endo-catch bag. The blue, if you can. The staple line. Alright, so let’s look at all the trocars. Remember, you can turn it, so you can… oh geez. Alright let’s just, I want to see the staple line one more time too. I’ll take another grasper, please? There it is. Okay, this looks good. No more bleeding. Let’s take that sucker out. Can you shut everything off please? Scissors please? There it is. Here’s the fascia fat. Here’s the fascia down there. So all that, big bite that way. See there’s that and that back stuff there. That feels pretty good. Okay. Do you have local? Here’s the needle. Thank you.