Endoscopic Assisted Laparoscopic Transgastric Resection of GE Junction Gastrointestinal Stromal Tumor (GIST)

The management of gastric submucosal tumors of mesenchymal origin, regardless of size, requires resection with negative pathologic margins. Laparoscopic and endoscopic cooperative surgery (LECS) provides a minimally invasive approach that allows for resection of intra-luminal GIST tumors with minimum surgical margins while avoiding excessive gastric wall distortion. This technique is especially effective for tumors located near the gastroesophageal junction or pylorus and obviates the need for major gastric resection and intestinal reconstruction, while still allowing for negative margins to be obtained.

The patient is placed supine on the operating table with both arms out secured to an arm board on either side. After induction of general anesthesia, a GIF-HQ190 upper endoscope is inserted and diagnostic endoscopy confirms a medium sized, sub-mucosal, non-circumferential mass on the posterior wall of the stomach 0.5cm distal to the GEJ. Methylene blue (5mL) is injected into the area at the base of the mass using an endoscopic injection device. The stomach is then desufflated to allow the surgeon to proceed with exploratory laparoscopy.

A 5mm peri-umbilical port is placed under direct vision and pneumoperitoneum established. Three additional blunt-type 5mm ports are placed in the right hemi-abdomen and one 12mm port in the left hemi-abdomen (See video for port site placement). A liver retractor is placed under direct vision through the right sided port closest to upper midline. The lesser curve of the stomach is exposed and the medial side of the esophagus mobilized in an attempt to visualize the tumor. Methylene blue dye is encountered and confirms the posterior location of the tumor at the GE junction within the stomach. The decision is made to proceed with intra-gastric stapling of the mass. A 1cm gastrotomy is created on the distal greater curvature using a harmonic energy device. Next, a balloon tip 12mm port is placed on the left side through the previously placed trocar site and then placed directly into the stomach via the gastrostomy. The balloon is inflated within the stomach and then affixed to that anterior abdominal wall. At this point, the gastroenterologist re-establishes gastric insufflation and a Rasper grasper is used to provide endoscopic traction and facilitate transgastric stapling of the mass.

The surgeon places an Endo-GIA linear stapler (Purple load; 45mm length) is placed through the intra-gastric trocar. With the tumor retracted, the surgeon proceeds with resection of the mass under direct visualization, to ensure no esophageal tissue is incorporated into the staple line. In total, 4 staple loads are used to safely remove the entire mass without compromising the esophagus. The specimen is endoscopically retrieved by placing it into a retrieval bag, extracted via the mouth, and sent to pathology for permanent section.

The esophageal mucosa is examined for integrity and hemostasis confirmed endoscopically. The gastrotomy is closed with a single fire of the Endo-GIA Purple loaded stapler. With endoscopic gastric insufflation, a leak test is performed and laparoscopy shows no evidence of gasric leakage either anteriorly or posteriorly. The endoscope is then removed, the upper abdomen is irrigated and laparoscopic ports sites removed under direct visualization without any bleeding. Port site skin closure done with 4-0 biosyn and dermabond.

The patient was extubated in the operating room without incident and sent to recovery in stable condition. Operative time: Approximately 80 minutes. Blood loss: 25 ml. Admitted for overnight observation. Diet was advanced as tolerated the next morning and the patient was discharged home on POD#1 tolerating a regular diet without dietary restrictions.

Final Pathology: 3.9cm x 2.6 x 1.6cm gastric gastrointestinal stromal tumor: spindle cell subtype, high grade (G2), mitotic rate 20/50, no necrosis, and negative margins.

1.Intra-gastric Gastrointestinal Stromal Tumors (GIST) 2-5cm in diameter (<8cm2 cross-sectional area) located on the posterior wall of upper stomach or close to the GE junction, amenable to removal via oral endoscopy 1 2.Experienced surgeon with advanced laparoscopic and interventional gastrointestinal endoscopist

1.Patients with cardiopulmonary disease unable to tolerate pneumoperitoneum;
2.Presence of gastric or esophageal varices;
3.Neoplasms involving the distal esophagus
4.GIST tumors >5cm diameter or >8cm2 cross-sectional area; tumor ulceration, or direct tumor exposure that carry risk of dissemination2
5.Inexperienced surgeon/endoscopist
6.Hostile abdomen with extensive adhesions

Flexible Upper Endoscope: Olympus GIF-HQ190 Scope E
Oral Overtube

Endoscopic Equipment:
1.Flexible Upper Endoscope: Olympus GIF-HQ190 Scope E
2.Oral Overtube: Apollo Overtube���® (Apollo Endosurgery)
3.Endoscopic tissue grasper: Rasper grasper
4.Endoscopic tissue injector
5.Methylene blue dye

Laparoscopic Equipment:
1.Laparoscopic ports ���¢ 12mm balloon tip port x1; 5mm port x4
2.30o angled Laparoscope - Karl Storz
3.Atraumatic laparoscopic tissue grasper
4.Laparoscopic coagulating shears - Harmonic���® ultrasonic energy device
5.Endoscopic linear stapler ���¢ Endo-GIA Purple load, 45mm stapler - Covidien

Setup - specific tips for setup for the procedure and instruments
1.Patient supine on operating table with both arms out at the side. Operating surgeon stands on the patients right and assistant on the left. (Surgeon preference for general hiatal dissection - may place patient supine in split leg or lithotomy position, in order to stand between the legs). Instruments at the foot of the bed and scrub nurse standing on same side of the surgeon. Laparoscopic monitors on either side at head of table.

2.Gastroenterologist stands above patient���¢s head with anesthesia. Endoscopic tower placed on left side head of table. Endoscopic monitor at head of bed right to allow visualization by both the operating surgeon and endoscopist.

1.Presenting with dysphagia - a water-soluble contrast UGI study can demonstrate intrinsic lesions at the GEJ that may be causing luminal obstruction. If found, further work-up should be undertaken as described below
2.Suspected GIST ���¢ Computed Tomography (CT) - typically used as initial diagnostic study. It provides detailed information about the location of the tumor and can detect the presence of metastatic disease
3.All patients - diagnostic upper endoscopy to rule out other pathology and biopsies of suspicious lesions if found.
4.All patients - endoscopic ultrasound and fine-needle aspiration biopsy of the gastric mass should be obtained to confirm the pathologic diagnosis. Immunohistochemical analysis of tissue samples for the presence of c-KIT or CD34 is vital to confirm the diagnosis of GIST. EUS also allows for evaluation of lymphadenopathy and further FNA biopsies can be obtained during this time.

Typical appearance of GIST tumors:
UGI contrast study: intrinsic mass with smooth borders that may cause a filling defect or show luminal compression. If central ulceration of the mass is present, contrast may fill the area and can look like a ���¢bull���¢s eye���¢ lesion.
Upper Endoscopy: smooth, solid, subepithelial mass with regular borders typically seen in the upper and middle portions of or stomach. Central ulceration with or without bleeding can be seen.
Endoscopic ultrasound: will show a subepithelial, hypoechoic, solid mass continuous with the muscularis layer

1.Size and location may require additional intra-gastric ports to be placed.
2.Lesions that are not able to be removed via oral endoscope may require transgastric removal via the abdominal wall, necessitating enlargement of the one of the laparoscopic port sites to accoodate the specimen ensuring the specimen is removed intact.
3.Need for conversion to open for difficult anatomy

Intra-operative:
Aspiration ���¢ assoc. with upper endoscopy. May be minimized by use of overtube
Esophageal mucosal injury or perforation - May be minimized by use of overtube
Narrowing of GEJ ���¢ adequate endoscopic visualization is imperative to ensure distal esophagus free from intended staple line
Possible need for conversion to laparotomy

Post-op Early:
Staple line bleeding
Port-site bleeding / infection

Post-op Late:
Gastric leak from compromised staple line
Dysphagia / GEJ stenosis / Decreased PO intake
Recurrence

Intra-operative:
Aspiration ���¢ assoc. with upper endoscopy. May be minimized by use of overtube
Esophageal mucosal injury or perforation - May be minimized by use of overtube
Narrowing of GEJ ���¢ adequate endoscopic visualization is imperative to ensure distal esophagus free from intended staple line
Possible need for conversion to laparotomy

Post-op Early:
Staple line bleeding
Port-site bleeding / infection

Post-op Late:
Gastric leak from compromised staple line
Dysphagia / GEJ stenosis / Decreased PO intake
Recurrence

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