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Gastric GIST, wedge resection after neoadjuvant treatment
Posted in Videos on 8 September 2014
Dulce Momblan, Antonio M. Lacy, Irene Bachero
Hospital Clínic, Barcelona, Spain
104494056

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Case

A 54 years old female patient with history of Addison syndrome and a dermolipectomy was referred to our hospital, she suffered from recurrent abdominal pain and anemia.The first study was an upper GI endoscopy that showed a 8 cm lesion with a central ulcer in the posterior wall of the stomach.

Biopsy and immunohistochemistry were compatible with a  gastrointestinal stromal tumor c-KIT (+). The ultrasound found a tumor with well defined borders that affected until the muscular layer. By CT-Scan seemed like the GIST was at the lesser curvature of the stomach.

Treatment

This patient underwent laparoscopic examination demonstrating a big infiltrating tumor that afected the pancreas and the splenic artery, the surgeons decided to stop and give the patient neoadjuvant treatment. A High definition CT-Scan corroborated the findings of the laparoscopy, so Imatinib 400 mg / day was administered during 6 months until the imaging proved a downsizing and stabilization of the tumor.

In the slides you may appreciate that the GIST invades the pancreas and splenic vessels and experienced a good response to Imatinib (focal contact with the pancreas).

A second look by minimal invasive approach was performed using a total of 5 ports, one of 12mm in supra umbilical position for a 3D camera with flexible tip, two of 11mm (one on each flank) and two of 5mm (one on epigastrium and other in the left flank). The first maneuver is to open the lesser sac, dissect and prove that the pancreas is free, during this part of the surgery is important to maintain the traction of the stomach achieving the exposure of the posterior wall.

The dissection continues through the lesser curvature in order to  identify the right crus. Notice the tumor, depending on the posterior wall at the lesser curvature. The surgeon corroborates that the proximal stomach is completely free from adhesion, this allows a correct manipulation during the section of the gastric wall. A Foucher is introduced to calibrate the wedge resection, in order to preserve the gastric lumen and a margin free from neoplasia. Its important to check the anterior and posterior side before firing mechanical suture.

The surgery took 95 minutes, without any intra/postoperative events.

Outcome

The pathologist described a  2 cm tumor, free margins and only 10% of viable cells. The patient is going to compete imatinib for one year, 8 months after surgery is free from disease.