Case Report
A Successful Central gastrectomy and Gastro-gastric Anastomosis for A Large Gastric GIST
https://doi.org/10.21203/rs.3.rs-2573234/v1
This work is licensed under a CC BY 4.0 License
published 27 Nov, 2023
Read the published version in Journal of Gastrointestinal Cancer →
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partial gastrectomy is always the preferred technique for GIST resection. Central gastrectomy is a practical technique that can be employed in many situations during the resection of both subepithelial stromal tumors and gastric tumors. We are presenting a case of a large gastric GIST managed by central gastrectomy and gastro-gastric anastomosis.
GIST
gastro-gastric anastomosis
central gastrectomy
partial gastrectomy
Central gastrectomy is a practical partial gastrectomy technique. Central gastrectomy and gastro-gastric anastomosis have been employed in a variety of surgical scenarios, including gastric cancer and subepithelial stromal tumors. This technique can be performed by an open or laparoscopic approach, with or without lymph node dissection.
A 53-year-old female patient with a 5-year history of non-specific epigastric pain and discomfort has undergone an esophagogastroduodenoscopy (EGD), revealing a large fungating mass at the greater curvature with areas of ulceration and necrosis. Biopsies were taken and their results were inconclusive, immunohistochemistry revealed LCA, pan CK, CD117, and DOG 1 negative. A computed tomography (CT) scan with intravenous contrast administration revealed a heterogeneously enhanced exophytic fungating lesion involving the greater curvature displacing the colon inferiorly, measuring 15*19 cm in max dimensions, extending to the pelvis, and abutting the spleen laterally with no detected locoregional lymph nodes.
Intra-operative laparoscopic examination revealed a large fungating mass obstructing the surgical field hindering surgical dissection. The case was converted to an open technique by a midline surgical incision, and the mass was dissected from the omental covering. Laterally the mass was seen adherent to the splenic hilum, and inadvertent iatrogenic hilar injury lead to a splenectomy. It was not possible to achieve a negative resection margin with lateral or wedge resection, so we decided to perform a central gastrectomy with posterior gastro-gastric anastomosis. On immunohistochemical analysis, the tumor was CD117 positive confirming the diagnosis of GIST. The patient had a good recovery and was discharged postoperative on day 7. The patient’s follow-up for 5 months has gone well with no signs of recurrence.
In daily clinical practice, gastrointestinal stromal tumors (GISTs) are the most prevalent malignant subepithelial lesions of the gastrointestinal system. The interstitial cells of Cajal, which regulate gastrointestinal motility, are believed to be the origin of GISTs (Miettinen & Lasota, 2006; Rubin et al., 2007). Oncogenic mutations in the platelet-derived growth factor receptor (PDGFR) and/or the tyrosine kinase receptor KIT are the primary causes of GISTs (Kindblom et al., 1998). 10–30% of GISTs have a malignant clinical course (Miettinen et al., 2005; Miettinen & Lasota, 2006; Joensuu, 2008). Additionally, it has been shown that small GISTs with a low mitotic index hardly ever demonstrate a malignant clinical course and that large GISTs with a high mitotic index commonly do (Joensuu, 2008). A GIST is therefore regarded as a potentially malignant tumor. The clinical risk of malignancy is employed for categorizing GISTs rather than classifying them as benign or malignant: Extremely low, low, middle, or high (Joensuu, 2008). Regardless of the mitotic count, Miettinen showed that the metastatic risk of GISTs increases with tumor size (Miettinen & Lasota, 2006). Surgical resection is the standard approach to treat localized subepithelial tumors (Nishida et al., 2016).
Surgery aims to achieve R0 resection to the greatest extent possible (Akahoshi et al., 2018). Lymph node dissection is not recommended except when lymph node metastasis is clinically suspected. Most GIST metastasis is liver metastasis or peritoneal seeding, and lymph node metastasis is extremely rare (Fong et al., 1993; Demetri et al., 2010). Therefore, wedge or segmental resection with preservation of organs and organ functions and maintenance of a good quality of life after surgery is recommended (Koga et al., 2015).
A partial gastrectomy is the standard method of surgical resection of stromal tumors (van der Zwan & DeMatteo, 2005; Otani et al., 2006). Many methods have been proposed for segmental gastric resection for subepithelial tumors. Segmental resection of the stomach includes wedge resection, subtotal gastrectomy, distal gastrectomy, and central gastrectomy.
Central gastrectomy is a feasible method of partial gastrectomy. Central gastrectomy and gastro-gastric anastomosis have been variously used in surgical situations varying from gastric adenocarcinoma, and subepithelial stromal tumors. Central gastrectomy can be done both by open and laparoscopic approaches with or without lymph node dissection. 100 case of central gastrectomies was done in Shizuoka hospital, Japan, for gastric cancers with certain indications (Table 1) all of which had excellent prognostic outcomes (Iseki et al., 2003). Central gastrectomy has also been described in the resection of sub-epithelial stromal tumors such as schwannoma and GISTs (Cordera et al., 2019).
| Indications | Exclusion criteria |
|---|---|
| 1. Tumor invasion restricted to T1 or limited to T2 (musclaris propria and macroscopically localized type) 2. Tumor size less than or equal 5cm 3. Tumors in the middle third, distal half of upper third, or proximal half and greater curvature side of lower third of the stomach | 4. Macroscopic Tumors < 2 cm and depth limited to mucosa where endoscopic mucosal resection or wedge gastrectomy is indicated 5. Apparent nodal metastasis noted at the root of the gastric or the gastroepiploic artery where distal gastrectomy (DG) is indicated. |
Central Gastrectomy is an option of surgery for large gastric GISTs when the size or location doesn’t allow a wedge resection.
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GIST
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Gastrointestinal Stromal Tumors
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EGD
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esophagogastroduodenoscopy
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CT
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Computed Tomography
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PDGFR
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platelet-derived growth factor receptor
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Funding
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Ethics approval
The authors state that the study protocol has been approved by the institute’s committee on human research.
Consent for publication
The authors state that informed consent was obtained from the patient.
Acknowledgements
Not applicable
Author’s contribution
M. Zidan wrote the paper and collected the data, Eslam H. edited the manuscript and added valuable points to the discussion, M. Refaie reviewed the manuscript and approved the final version.
Availability of data and material
Not applicable
Competing interests
The authors declare that they have no competing interests.
No competing interests reported.
published 27 Nov, 2023
Read the published version in Journal of Gastrointestinal Cancer →
posted
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