Table of Contents
This case illustrates a laparoscopic resection of a gastrointestinal stromal tumor (GIST)- the most common mesenchymal tumor found in the gastrointestinal tract. GISTs can be found anywhere along the gastrointestinal tract, however, they are most commonly found in the stomach and small intestine. These tumors are often associated with mutations in the KIT (receptor tyrosine kinase) and PDGFRA (platelet-derived growth factor receptor alpha) genes. Because it is difficult to achieve a permanent cure using protein tyrosine kinase inhibitors, such as imatinib, surgical resection is the recommended therapy in most cases. While the surgical approach may vary on tumor characteristics, the laparoscopic approach is associated with low perioperative morbidity and mortality.
Gastrointestinal stromal tumors (GISTs), originating from the interstitial cells of Cajal, can be found anywhere along the gastrointestinal tract.1,2 These subepithelial tumors are most commonly found in the stomach and small intestine, and less commonly in the colon and rectum.1
Here, we present the case of an 80-year-old woman who presented with gastrointestinal bleeding and was found to have a tumor located on the stomach. Its location on the anterior wall of the lesser curvature provides a suitable location for a wedge resection with a laparoscopic linear stapler. Despite this optimal position, care must be taken to avoid iatrogenic injury of the nerves of Latarjet.
Most GIST tumors are discovered incidentally on imaging studies or endoscopy. Patients can also present with abdominal pain and gastrointestinal bleeding.2,3,4,5 These tumors can also present as part of familial syndromes, such as familial GIST syndrome, Neurofibromatosis type 1, and Carney-Stratakis syndrome.1
The majority of GISTs are discovered incidentally, often detected through endoscopic or radiographic studies, or surgery, performed for other reasons. CT with oral and intravenous contrast is the preferred imaging modality for a detailed evaluation of the tumor’s anatomic location as well as to look for metastatic disease. On CT, GISTs typically appear as hyperdense solid masses.5 Positron emission tomography (PET) scan can be used to gain information regarding the metabolic activity of a tumor, metastases, as well as response to chemotherapy, but is not recommended unless neoadjuvant chemotherapy is planned.5
Most GIST tumors are asymptomatic and grow slowly. Although all GISTS have malignant potential, the risk of aggressive behavior is determined by size, location in the GI tract, and mitotic index. GISTs smaller than 2 cm are unlikely to pose much risk of either causing symptoms or metastasizing and therefore can be observed with serial imaging studies or endoscopy. GISTs larger than 2 cm should be removed.
Surgical excision is the standard therapy for a GIST.2 Targeted therapy with Imatinib is used in the neoadjuvant setting when GIST tumors are locally advanced with the aim of converting the tumor to a status where an R0 resection would be possible. Resection of the tumor with a 1 cm margin is sufficient and more radical resections add morbidity without benefit. Since spread occurs hematogenously or via peritoneal seeding, there is no role for lymphadenectomy.
The operative approach to GISTs is dependent on tumor size and location. Most can be removed with laparoscopic wedge resection. Very small tumors can be approached with endoscopic submucosal tunneling and resection, or endoscopic full-thickness resection, although one must question whether or not tumors of this size need to be resected at all. Intraoperative endoscopy is often performed to aid in localizing the lesion, determining the resection approach, and ensuring proper closure of the defect.5 Not all lesions can be excised using only a stapler so it is important that the surgeon have the facility to perform intracorporeal suture repair of the stomach- particularly for lesions close to the gastroesophageal junction or pylorus. Postoperatively most patients undergoing laparoscopic resection are discharged on post-op day 1 and do not require imaging studies.4
The prognosis following resection of GIS tumors with clean margins depends on three factors: location in the GI tract( proximal is better than distal), tumor size, and mitotic index.6 Both the risk of recurrence and the intensity of follow up are determined using Fletcher’s risk classification.2 This classification system risk-stratifies tumors by size, mitotic index, and the site of the primary tumor. A very low to intermediate risk is defined by a tumor size < 5 cm and/or < 5 mitoses per 50 HPF. High risk is defined by tumor rupture or tumor size >10 cm and/or >10 mitoses per 50 HPF. Using this classification system, those tumors ranging from very low to moderate risk are followed every six to twelve months by CT scan, while those in the high-risk group are reassessed every four to six months.2 Adjuvant therapy with Imatinib is recommended for those patients with a greater than 50% chance of recurrence as predicted by Fletcher’s risk index.7
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.
- Morgan, J et al. Epidemiology, classification, clinical presentation, prognostic features, and diagnostic work-up of gastrointestinal stromal tumors (GIST). In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA: UpToDate Inc.
- Akahoshi K, Oya M, Koga T, Shiratsuchi Y. Current clinical management of gastrointestinal stromal tumor. World J Gastroenterol. 2018;24(26):2806-2817. doi:10.3748/wjg.v24.i26.2806.
- Søreide K, Sandvik OM, Søreide JA, Giljaca V, Jureckova A, Bulusu VR. Global epidemiology of gastrointestinal stromal tumours (GIST): A systematic review of population-based cohort studies. Cancer Epidemiol. 2016;40:39-46. doi:10.1016/j.canep.2015.10.03.
- Novitsky YW, Kercher KW, Sing RF, Heniford BT. Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors. Ann Surg. 2006;243(6):738-747. doi:10.1097/01.sla.0000219739.11758.27.
- Gerrish ST, Smith JW. Gastrointestinal stromal tumors-diagnosis and management: a brief review. Ochsner J. 2008;8(4):197-204. PMID: 21603502.
- Lamb G, Gupta R, Lee B, Ambrale S, Delong L. Current Management and prognostic features for gastrointestinal stromal tumor(GIST) Exp Hematol Oncol. 2012; 1: 14. doi: 10.1186/2162-3619-1-14
- Laurent M, Brahmin M, Dufresne A et al. Translate Gastroenterol Hepatol 2019; 4: 24. doi: 10.21037/thg.2019.03.07 PMID: 31143845.
Table of Contents
- Incision and Placement of Ports
- Liver Retraction
- Identify Tumor Location
- Placement of Additional Ports
- Dissect Around Nerves of Latarjet
- Maneuver Tumor
- Insert Staples
- Insert Endo-Catch Bag
Hi, my name is David Rattner, surgeon at Mass General. We're going to do a laparoscopic resection of a gastric GIST tumor. This case is an 80-year-old woman who had some gastrointestinal bleeding and was found to have a submucosal tumor in the stomach. It's probably a GIST tumor, and we're going to take it out laparoscopically. It seems to be in an appropriate location. What we’ll do is, we’ll explore laparoscopically- sort of determine where it is on the stomach, confirm it with an upper GI endoscopy, and then try to do a wedge excision. If it's on the lesser curvature of the stomach, then we’ll be mindful of the nerves of latarjet- to try to keep them intact. If you injure the nerves of latarjet, then you can get delayed gastric emptying. So if it's not close to the nerves, it's easy. If it's close to the fat in the nerves, then they have to be preserved.
Let's have a knife, please. Just a little in from umbilical, so we have a little extra room today. 12 millimeter trocar, please. I hate to be a pain in the butt, but the screen is way over there. Thank you. Yeah, that’ll be okay, I think. And I’ll take two low stands too- if Amy gets up on them, I want them. Yeah.
Let's go into reverse Trendelenburg. Can I get the liver retractor, please? The post for the liver retractor? That's good. Let’s have a knife and a 5. Okay, can I have a blank grasper, please? Just make sure what we're seeing is real. Your OG tube, I don't think, is in the stomach. It’s all peristalsis, my dear. Let me see the liver retractor, please.
Let’s have a knife and a 5, please, down here. Yeah, we’re going to be right there, okay. Here? Yeah. Can we go green here, please? Alright, take a grasper and let's start feeling around here. It feels like stomach. See - I agree, so I think this is it, right here. That’s it. That’s it, right there. This is it, right here. But that's it- see the extra little vessels on it? And a lot of it is inside now, see that? Yeah, okay. Alright.
How is this going to work here? To get at this, probably something like this'll work, here. We're going to need a stapler and a suture. This will be a little too high. Let’s go right about here. With a 12? 12. Actually, no do a 5 first. Let’s put a 5 there- yeah, put a 5 there, first. Okay, good. Straight up, kiddo. Straight up, nice. It’s all about the angles. Alright, let me have another- do you have another 5, or is it 12? Could you open one more 5 for me, please? We’re going to hold off on that- for the extra 12, for just a minute.
We’ll put this here, and then what we're going to have to do is to take down all the vessels in that area. I had a very interesting complication for one of these in that- and I’ll show you as we get to do it. I bagged the nerves of latarjet. Oh really? Which is quite understandable, especially- and then the patient had delayed gastric emptying, and it's just massive stomach pushing her diaphragm up.
It would probably have to be right about here. You know, that's why they do it. I mean- when I went to the Philippines, I did a colectomy in 45 minutes because there was no fat. So easy. Sinful. Right, I want you to take this stomach about here and pull that down there, okay. Okay, look- bring the camera in here and let's look right in through here.
So this right here- pull back on the camera just a touch, is- well, you know... I mean, that’s Crow’s foot right there. See the nerves of latarjet come right down into this Crow’s foot area? Saving them is going to be hard, but we're going to try. Alright, so you see these little white things here? That's- those are called the nerves of latarjet, and the little branches of the vagus. Okay, Amy, grab right- that's- what you just did is awesome. Do it again. If we can improve the focus a little bit. Yes, staple. I may put a few stitches in, yes. I’m going to do this a little bit closer. See, one of the tricks here is you really, really have to clean this off, and you also use up much more length in space than you think. So I’ve never felt that I cleared- I don't remember a case where I felt like I cleared off more than I needed. It always seems like you get ready to put a stitch in and then you realize: oops, I need to clear up a little bit more.
Okay, there’s the other nerve of latarjet. You see it? That's the posterior bundle. The anterior is there. This is the posterior one, right there. Where’s the tumor, again? Just remind me- the tumor is in there. Okay, okay. Why don’t you grab that. Yep.
Okay, I just don’t see- quick, come a little bit closer. So, the muscle really ends here- I think it’s right there. You want me to grab where your spreading? Just get the specimen first, here. There we go, that’s in the lesser sac. So this is lesser Sac, underneath here. So that means this has to go. Yeah, keep the traction on. You were doing great. It’s me that's fumbling. Here we go, good. Well, that's good there. Alright, where is this lesion again? It's up in here. It’s right there. Maybe at the point- let’s see. Going to make sure that it's actually on the anterior wall, too. That's the other thing you could get faked out; it could be posterior. It’s actually right there. So it’s pedunculated, here. Could we get a 5 millimeter scope, please?
Okay, so I'm going to have you take this scope out- I’m going to have you put the scope here, and I'm going to suture through there for a minute. First have just a blank grasper for a minute, and then I’ll take a stitch.
Now it might be time for scope. Actually, just need to make sure this is not on the posterior wall. I don't think it is- I think it's got to be on the anterior wall. We also still have not decompressed the stomach. Did you get anything out of your OG tube? Because I don't think you're in the stomach. See, that would seem to be it right there, right? Yeah. No, it just slid away from you there. Now I've got it up there. Yeah, it’s got to be on the anterior wall. I think so, too. If I pull on it- what happens if you replace that with this? Take that out. What I want you to do is get under it the way I did and sort of milk it up, so you squeeze it up like that, okay. Like that, I like that. Keep going, oh, do that again. Right, yeah. Keep- nice. Okay, stay right there. I'm going to want purple loads. Stitch, please. 60 purple reticulating. Stitch.
We’re losing it. We’re losing the mass here. Okay, squeeze it up again. There we go. This would make Mullen crazy. This is actually the way to do it. Alright. Let’s see the dolphin, please. Now I’m going to- what we’re going to do next, Amy, I think is to have you scope and confirm that when I pull on this stitch that I've got the mass, okay? So we don't have any swing and missed stuff going on here, today. And then we're going to get off this stapler. Fire it, and then we are going to Harvard Gardens.
So you use the stitches as a traction... You got it. So this way we don't lose it. You can hold off on the OG tube for a minute because we're going to do an endoscopy now, okay? Very awkward suturing angle, but we’ll get this done. Okay, can I have scissors now, please? How am I lined up? Not bad, really. I'll just whack this thing off just like this. I think. That’s halfway across right there without entering... See, we can just snip this off right here, and that should work.
See, we’ve of got all this stomach over here, so I don't think we’re really going to narrow it. And you could put another stitch in there if you wanted us to suspend it two ways, but, see, now we've got control of it. It’s just sort of, you know, bobbing around, beforehand.
Good. Okay, good. Alright, fine. That's good. And we just want to park this here? We're going to leave it in the esophagus. Okay, can we tape this to the bed, here? Hold that straight up in the air. Okay, let me have a blank grasper now, please? Get the purple load there. Okay, first thing I want to do is take one more trial run at this with the intestinal grasper. Just try to get a good angle. Let's see the intestinal grasper, first. That's better like that, and now we can come across the stomach transversely, too. I don't like that double fold. That's the only thing about it- I'm not crazy about. Let’s see, if I go that way, is it better? That looks better. I think so, too. Okay, I like that better. One, two. Yeah, exactly. Got it. Just hold it right there up by the liver- just the we have it. Okay, stapler. We're going to need one more purple.
Okay, pull that towards you, so let's look on the other side of the stapler. So this needs to be pulled towards, you this way. That's good. Okay, I think that way we've got margin. I think that should be fine, and then the next one we can start to go up a little bit. Yep. Okay. Don't pull too hard, okay, because we don’t want to distort the orientation here. Okay, let’s have another cartridge. Just take a quick look- see what do we got to do. Okay, that's perfect. Okay, it’s going to be awesome.
Okay, that’s good. And I want you to hold that up in the air- straight up in the air like… You did, yeah- but we just want to, in terms of the actual surgery here. Let's get this back to this position here, okay. Let’s get that on some stretch like that. Good, so I can see the crotch. I want- what I want to do is make sure my staple line hits the crotch of the other staple line. Can you provide a little bit of traction on this? Up, one more time. Looks pretty good there.
Let's try something different here. Let go of the mass for just a minute, okay. Instead can you grab the fundus, over there on this side. Just lay it out? Yeah. I’m happier with that. Yeah, it looks better, much better.
Now, let’s take a close look here, and just take a close look at our staples. That looks really good. This corner right here- I got staples all the way to the bitter end. It should be fine. Yeah, I think so. Okay, let's have the endocatch bag now, please. We're done except for an endoscopy. Alright, you want to see whether you can get around the corner this time? Yeah. Okay, put a little snap or Kelly on that please.
You just about almost slid in right there. Push there it is. It’s right there. Push. You're not, you’re still not quite in, and get the lumen in the center. Yes! Okay, now blow it- blow in the air. Just let the stomach get real distended. Alright, Nicolette, run some saline over that, so watch the screen up there, okay. And, Sarah push the scope in closer. Run some more saline over it. Good. Now the stomach is very well distended. Good, alright.
And one of the reasons you’re maximally flexed is because the stomach is distended. The more it’s distended, the more in the shape of a J it is, and the harder you make things for yourself. So, I’m a- just a little bit concerned about having this fresh staple line in, sort of torquing too much. Well, here is it, right here. Nothing's bleeding. And look up there, we have the stomach’s pretty well decompressed. Now I’m going to grab it here- from here because I'm going to come at it, this way. See what kind of an angle- see what kind I got to get. I think we have to change the angle of it. Let go, just- now, that's awesome. That's A+, prime. Okay, does that make everybody happier? Yeah me, too. Okay, good. Alright, room lights on, please.
Alright, skin knife, please. That’s fine, just go right up to the belly button, there. Yeah, here’s the edge of it, right there. Bovie, please. Awesome, okay. Let’s see whether this will come out or not, here. That’s saline. There you go, feel that.
We can close with zero vicryl. It’s fine. Great. Debrief. Laparoscopic resection of gastric mass and upper GI endoscopy. Any concerns for recovery. Not really on my part, I'm okay. Pager. Yep, yep. Okay, so all set? Thank you.
That case was a good illustration of how to do a wedge resection of a gastric tumor with a favorable location on the anterior wall in the lesser curvature. We were able to see the nerve of latarjet nicely as the patient was not obese, and preserve them and then confirm that our staple line was airtight with a post-resection endoscopy.