A case of a gastric gastrointestinal stromal tumor in the esophagogastric junction successfully treated by laparoscopic intragastric resection

Abstract

Introduction and importance

Laparoscopic wedge resection has been widely performed for gastric gastrointestinal stromal tumors (GISTs). However, because GISTs in the esophagogastric junction (EGJ) are prone to deformity and postoperative functional disorders, laparoscopic resection is technically very difficult and rarely reported. Herein, we report a case of a GIST in the EGJ successfully treated by laparoscopic intragastric surgery (IGS).

Case presentation

A 58-year-old man with a GIST, which was intragastric growth type, 2.5 cm in diameter, located in the EGJ, and confirmed by upper gastrointestinal endoscope and endoscopic ultrasound-guided fine needle aspiration biopsy. We successfully performed IGS and the patient was discharged without complications.

Clinical discussion

Using laparoscopic wedge resection by exogastric approach, it is problematic to resect a gastric SMT located at the EGJ because of the difficulty in viewing the surgical field and additional concerns of deformation of the EGJ. We suppose IGS as a suitable method for such tumors.

Conclusion

Laparoscopic IGS for gastric GIST was useful in terms of safety and convenience even though the tumor was in the ECJ.

Highlights

• •GISTs in the esophagogastric junction (EGJ) are prone to deformity and postoperative functional disorders, laparoscopic resection is technically very difficult and rarely reported.
• •Laparoscopic intragastric surgery (IGS) is useful for GIST in the upper stomach or near the EGJ.
• •Even in cases where the tumor is located at the EGJ, which can be more challenging, this IGS is still suitable to perform.

1. Introduction

Recent advances in endoscopic technology have increased the detection of gastric gastrointestinal stromal tumor (GIST) [1] and laparoscopic wedge resection is performed in terms of minimal invasiveness when the tumor size is within 5 cm [2]^, [3]. Moreover, for intragastric growth types of GISTs, laparoscopy and endoscopy cooperative surgery (LECS) is performed to reduce the number of gastrectomies in Japan [4]. On the other hand, intragastric surgery (IGS) reported by Ohashi et al. in 1995 may also be performed on the same type of GISTs [5].

The appropriate surgical method must be carefully chosen as GISTs located in the vicinity of the esophagogastric junction (ECJ) are prone to deformity, even with partial gastrectomy, and to postoperative functional disorders such as esophagogastric reflux and stricture. There are some reports about the usefulness of IGS for GIST in the upper stomach or near the EGJ [6]^, [7]. In our institution, we actively perform IGS in cases of intragastric growth type of GISTs regardless tumor location and have performed 30 cases of such GIST, including 14 cases of GIST located within 2 cm of the EGJ, without intraoperative troubles or major complications.

However, laparoscopic resection of GIST in the EGJ is technically more difficult and rarely reported. Here, we report a case of an intragastric growth type of GIST in the EGJ successfully treated by laparoscopic IGS. The work was written in line with the SCARE criteria [8].

2. Presentation of case

During a routine medical check-up, a 58-year-old Japanese man was diagnosed with a gastric submucosal tumor (SMT) located in the EGJ by upper gastrointestinal endoscopy (UGE). The UGE, upper gastrointestinal series and subsequent CT scan showed that the tumor was an intragastric growth type, 2.5 cm in diameter, and located in the posterior wall of the EGJ (Fig. 1a, b, c). Endoscopic ultrasound showed that the tumor was derived from the muscularis propria (Fig. 1d), and endoscopic ultrasound-guided fine needle aspiration biopsy showed GIST (several spindle-shaped cells were positive for KIT and CD34 via immunohistochemical staining). Thus, the tumor was diagnosed as an intragastric growth type of GIST which informed the decision to perform laparoscopic IGS.

Fig. 1.

a) Preoperative gastrointestinal endoscopic image seen from the stomach side.

b) Preoperative gastrointestinal series.

c) Preoperative image of CT scan.

d) Preoperative EUS image.

2.1. Surgical procedure

• 1.Skin incision: We make a 2 cm-incision for a camera port at the upper midline of the abdomen and pull out a part of the gastric corpus to the outside of the abdominal cavity and put two stitches at the gastric wall for towing. Then, we stab a 12 mm-trocar with balloon into the gastric wall and pinch both the gastric wall and the abdominal wall by inflating balloon. After that, we inflate the stomach and insert two working ports into the gastric lumen.
• 2.Tumor resection: Due to the tumor's location in the EGJ (Fig. 2a, b), we were mindful of the possibility of stenosis or deformation by resection and made a situation where the lumen of the EGJ open by inserting the UGE. Subsequently, we lifted up the tumor by holding the tumor stalk with forceps and confirmed the cutting line before the resection of the tumor (Fig. 2c). Following these procedures, we slid the liner stapler under the forceps so that the tip of the stapler did not face the cardia and resected it using an auto-suturing device (Fig. 2d, e).
• 3.Wound closing: After confirming that there was no stenosis at the EGJ, that hemostasis had been achieved, and that there was no suture leakage of the resected stump (Fig. 2f), we closed the gastric wound by the Albert-Lembert method. Lastly, we ensured that there was no bleeding in the abdominal cavity and closed the abdominal wound. The operative time was 125 min and there was very little intraoperative bleeding. The patient had an uneventful postoperative recovery and was discharged without complications 9 days after surgery. The resected tumor was an elastic soft mass with a capsule, 25 mm in size and resected in all layers of the gastric wall (Fig. 3a). Hematoxylin and eosin staining revealed spindle-shaped cells in the tumor, proving that it was derived from the muscularis propria (Fig. 3b). Immunohistochemical staining showed that KIT and CD34 were both positive (Fig. 3c, d). The MIB-1 index was 9.5 % (Fig. 3e). Therefore, the resected tumor was diagnosed as at a middle risk of gastric GIST using Fletcher's risk classification. No recurrence or complications have occurred in the 11 years since surgery.

Fig. 2.

a) The tumor was located in the EGJ.

b) Intraoperative gastrointestinal endoscope maintains the lumen of the EGJ.

c) The tumor was lifted up as possible.

e) The tumor was resected by automatic liner stapler.

f) It can be confirmed that there is no stenosis or obstruction at the EGJ using gastrointestinal endoscope.

Fig. 3.

a) The serosa was confirmed in the specimen (black arrows).

b) The specimens of resected tumor using Hematoxylin-eosin staining (×400).

c) The specimens of resected tumor using immunohistochemical staining for KIT (×400).

d) The specimens using immunohistochemical staining for CD34 (×400).

e) The specimens using immunohistochemical staining for MIB-1 (×400).

3. Discussion

Here, we report a case of an intraluminal growth type of GIST in the EGJ where laparoscopic IGS could be performed safely. Using laparoscopic wedge resection by exogastric approach, it is problematic to resect an intraluminal-growth type of gastric SMT located at the EGJ because of the difficulty in viewing the surgical field and additional concerns of deformation of the EGJ. Ri et al. described that the conversion rate of LECS at the EGJ was 40 % and this may be a risk factor for conversion operations, and when performing LECS at the EGJ is deemed problematic, conversion to proximal gastrectomy—which can be performed safely—should be considered [9]. Although Aoyama et al. reported the rate of gastroesophageal reflux can be reduced from 37.5 % to 7.7 % by adding fundoplication to LECS, several problems, such as prolonged operation time and unsatisfactory gastroesophageal reflux improvement rate, remain [10].

In contrast, we suppose IGS as a more suitable method for such tumors as presented in this case. IGS for such tumors offers the following advantages: reducing possibility of esophagogastric dysfunction because the excision area is minimum and the His angle is maintained due of no necessary of exfoliating the supporting tissue around the stomach; there is little intraoperative bleeding; IGS provides a good surgical field of view and easy surgical manipulation because of the linear stapler can move bi-directionally. Postoperative UGE and CT scans 1 year after the IGS showed a sharp His angle and no stenosis or gastroesophageal reflex (Fig. 4a, b).

Fig. 4.

a) b) 1-year postoperative gastrointestinal endoscopic image.

Although there was a concern whether IGS can enable full-thickness excision of the gastric wall, our resected specimen provided IGS resected in all gastric wall. It is important to cut the tumor while lifting sufficiently to turn the gastric wall at the tumor site. To do this, we have devised a way to firmly grasp and pull the tumor root while pushing the gastric wall outward around the tumor and the intra-abdominal pressure is reduced to 4–5 mm Hg. Furthermore, intraoperatively, we routinely confirmed that the resected specimen was a full-thickness excision.

Finally, we have experienced GIST near the EGJ in 14 cases including this case and tumors were completely resected in all cases without conversion to laparotomy. In addition, the average operation time was 125 (75–170) min, which is clearly shorter than the 282 (106–515) min for LECS reported by Re et al. [9], therefore, similar to other report [7], we consider IGS for GIST near the EGJ is useful and one of the most suitable procedures.

4. Conclusion

Laparoscopic IGS for gastric GIST was useful in terms of safety and convenience—even though the tumor was in the ECJ.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Ethics committee approval was unnecessary for this report.

Funding

The authors declare that they have no competing interests and did not receive any funding.

Guarantor

TY is the guarantor and head of our surgical unit in Kindai Hospital.

Research registration number

No. N 31-085.

CRediT authorship contribution statement

AY, YK and TY performed the surgery and perioperative management on the patient; AY, YK and TY drafted the manuscript. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest (financial, professional, or personal) to declare and did not receive financial support for this study.