Minimally invasive resection of gastric GIST tumor by trans-gastric approach: A case report of a novel technique.

It is a case of 66-year-old female with a past medical history of idiopathic pericarditis and a past surgical history of oophorectomy for endometriosis. The patient has no allergy and is not a smoker nor alcoholic. In addition, she has a paternal history of gastric adenocarcinoma. The patient was complaining of symptoms of pyrosis with dysphonia, which alarmed her gastroenterologist to undergo a gastroscopy. In fact, they discovered a tumor at the lesser curvature of the stomach about 4 cm in size ( Fig. 1 ). Fig. 1 A photo during gastroscopy showing the tumor arising from the lesser curvature of gastric wall, projecting into the gastric lumen. Fig. 1 A photo during gastroscopy showing the tumor arising from the lesser curvature of gastric wall, projecting into the gastric lumen. An attempt to excise the tumor endoscopically had failed. However, during echo endoscopy ( Fig. 2 ) the tumor was well identified and a biopsy was taken to confirm the presence of GIST. The workup was completed by a TAP (Thoracic-abdomen-pelvis) scanner, which showed the tumor ( Fig. 3 ) and a lesion situated on segment 7 of the liver. A MRI (Magnetic Resonance Imaging) was done to rule out metastasis, and indeed it was compatible with hemangioma. We discussed the case with other colleagues from gastroenterology, radiology and oncology departments during our regular staff meeting and we ruled in the indication of surgical resection. Taking into account the location of the tumor, we were hesitant to do a classic atypical resection of the stomach with a healthy margin knowing that this may leave the patient with a high risk of stenosis. On the other hand, a total gastrectomy seemed to be aggressive for such a benign disease. So, we decided to raise the standard and try a new technically- challenging procedure using robot and laparoscopy in order to resect the tumor from within the stomach. Indication to resection was the tumor size being >2 cm. The tumor was resected according to the technique described in the next section and the pathology report showed negative margins of a 4.5 cm GIST. In addition, the mitotic index was <5 and it was classified as low grade pT2N0M0. The hospital stay was without any complications; the naso-gastric tube was removed the next day as well as the foley catheter. Furthermore, water then food were allowed progressively and at day 3 she was able to eat normally. Biologically, no inflammatory signs were detected and we did not find any indication that would trigger radiological control. Fig. 2 Echo-endoscopy image showing the tumor (blue-pointed line). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Fig. 2 Fig. 3 Scanner showing the gGIST tumor via the sagittal, coronal and the axial cut retrospectively. The tumor being pointed by the red arrow. gGIST: gastric Gastro Intestinal Stromal Tumor. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Fig. 3 Echo-endoscopy image showing the tumor (blue-pointed line). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Scanner showing the gGIST tumor via the sagittal, coronal and the axial cut retrospectively. The tumor being pointed by the red arrow. gGIST: gastric Gastro Intestinal Stromal Tumor. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

More studies are needed, especially, prospective ones in order to have this technique as a gold standard at least for tumors close to cardia or pylorus or on lesser curvature of the stomach.

Writing the paper: KANSOUN ALAA. Data collection: OMOURI ADEL, KANSOUN ALAA. Interpretation: KANSOUN ALAA. Supervision: HAMED SAMI.

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

The study type is exempt from ethical approval except for approval from the patient according to the protocol of the Saint Joseph Hospital-Marseille.

None.

N/A.

Alaa Kansoun.

Under general anesthesia, the patient was in dorsal decubitus French position. Pneumoperitoneum was accomplished via Veress needle at the Palmer point. A total of 4 trocars were inserted; 3 trocars were inserted in a lateral semicircular position in the supra umbilical and the left upper quadrant position of the abdomen, in addition to 1 trocar in the right upper quadrant region. Precisely, we inserted one 5-mm trocar, two 10-mm trocars and one 12-mm trocar for the endo GIA (Gastro Intestinal Anastomosis) stapler. Exploration of the abdominal cavity was evident of bulging – representing our tumor- at the lesser curvature of the stomach close to the cardia. However, no carcinosis, hepatic metastasis or other findings were marked. Decision was taken to apply three incisions on the anterior wall of the stomach to have access into the gastric lumen. By laparoscopy, we advanced the 12 mm, 10 mm and 5 mm balloon- trocars into the stomach as shown in ( Fig. 4 ). Fig. 4 An illustration showing the trocars introduced into the stomach, the liver being pushed by the liver retractor, the spleen in proximity with the stomach and the tumor at the lesser curvature in proximity to the cardia. Fig. 4 An illustration showing the trocars introduced into the stomach, the liver being pushed by the liver retractor, the spleen in proximity with the stomach and the tumor at the lesser curvature in proximity to the cardia. Insufflation of the stomach was restricted to 8 mmHg. Notably; we did not find it necessary to clamp the duodenum; however, we inserted a calibration tube into the esophagus to prevent stenosis. The tumor was identified to be approximately 4 cm in size and 2 cm away from the cardia ( Fig. 5 ). It was narrower on the base resembling to a stalk hence allowing it to be stapled. No other lesions were identified inside the stomach. Three violet Endo GIA cartridges of 4.5 cm were used to accomplish the resection of the tumor ( Fig. 5 ). Notably, using the left trocar we double-checked before stapling that no other organ was injured before firing. Fig. 5 Intra gastric laparoscopic view showing, successively, the tumor, the stapling and the final result. Fig. 5 Intra gastric laparoscopic view showing, successively, the tumor, the stapling and the final result. The lesion was put into an EndoCatch bag and sent to analysis. Notably, the specimen was intact without fragmentation. Interestingly, we were able to identify bleeding at the level of staple line and it was managed by a suture. Moreover, the stomach wall was examined laparoscopically, hence, we double-checked and ruled out stenosis and/or hemorrhage. The balloon- trocars were removed and, with the assistance of the robot da Vinci X, we closed the stomach incisions by V-lock 3/0.Peritoneal toilette was done and the aponeurosis was closed by Vicryl 0 and skin by Caprosyn 3/0.

Various operative techniques have been described to manage gGIST tumors. Our technique, although difficult, challenges surgeons to prevent stenosis, hemorrhage and to preserve gastric tissue. This report aims to highlight the effectiveness of laparoscopic trans-gastric resection in the era where minimally invasive approach is becoming more and more demanded.

Laparoscopic resection is not contra-indicated for large tumors [ 10 ] as long as the principles of safe margins are preserved. For instance, various techniques were described to accomplish minimally invasive approach insuring free margin resection. One of them is enucleation; however, it is not recommended at least according to the TNCD (Thesaurus National de Cancerologie Digestive), the French cancerology guidelines [ 1 ], and to other previous reports due to the high risk of recurrence [ 11 ]. On the other hand, and thanks to the presence of stapling devices, wedge resection is becoming the most widely used method to resect gastric tumors including gGIST. Unfortunately, adopting this technique can't be universal for all tumors especially for intraluminal ones or tumors on posterior gastric wall, close to pylorus or juxta cardia tumors [ 12 ]. Moreover, wedge resection can be associated with stomach deformity, stenosis and gastric reflux [ 12 ]. Actually, previous reports [ 11 , 12 ] showed that wedge resection depends on the redundancy and mobility in parts of the stomach as in fundus and the greater curvature. However, this elasticity is lacking in locations as the lesser curvature, which renders wedge resection limited as a choice [ 13 ]. Interestingly, a method called ‘lift and cut’ described by Okumura et al. in 2016 showed that, due to the extensibility of mucosa and submucosa, the tumor can be everted into the abdominal cavity and thus stapled with safe oncological margins [ 14 ]. Another method described in 2011 by Jung Ho Shim is similar to our technique as in introducing balloon-trocars into the stomach in order to access the tumor. This latter report showed that the approach is safe and feasible [ 15 ]. Actually, Ohashi already described the technique we described back in 1995 [ 16 ] where he named it ‘laparoscopic intragastric surgery’ whereby he operated on 8 patients following this technique and monitoring its effectiveness. Benefits of minimally invasive resection of gGIST seems to be of significant importance; as in to avoid total gastrectomy for tumor locations near the cardia or on the lesser curvature. Furthermore, it prevents the risk of stenosis, especially if the tumor is located near the cardia. On the other hand, using our technique, instant hemostatic control can be secured due to direct inspection of the intra gastric lumen. For such a disease that rarely necessitates lymph node dissection, a minimally invasive technique of resection, as the one described by us, seems to be worth of attention and to be applied in practice.

Not commissioned, externally peer-reviewed.

Gastro Intestinal Stromal Tumor (GIST) are mesenchymal tumors that develop most commonly in the stomach followed by the small intestine and rarely in rectum, colon, or esophagus [ 1 ]. The term GIST was found by Mazur and Clark since 1983 [ 2 ]. The incidence is about 15 cases/million per year according to French and global epidemiology statistics [ 1 , 3 ]. Notably, equal ratios between males and females are reported [ 1 ]. Furthermore, the only potentially curative treatment is surgical resection, precisely R0 resection [ 4 , 5 ]. To date, laparoscopic is preferable to open resection of gastric GIST (gGIST) in terms of morbidity and hospital stay [ 6 ]. Moreover, laparoscopic resection is gold standard for small tumors [ 1 ] and recent reports have shown that laparoscopy is feasible and safe even for tumors larger than 2 cm [ 7 ]. Regarding the location of GIST and narrowing it to gastric, since it is the one that concerns us, the stomach poses technical challenges for resection. For instance, in the case of tumors on the lesser curvature of the stomach or ones close to cardia or pylorus, wedge resection or even typical gastrectomy may be necessary to resect gGIST [ 1 ]. Interestingly, previous reports have shown that laparoscopic transgastric resection can be safe and effective in terms of hospital stay, morbidity and on oncological level [ 8 ]. Thus, we are eager to present a case of gGIST tumor managed by minimally invasive technique so called ‘laparoscopic transgastric’ approach. This case was reported in accordance with the SCARE criteria 2023 [ 9 ].

GIST gastro intestinal stromal tumor gGIST gastric gastro intestinal stromal tumor TAP thoracic-abdomen-pelvis MRI magnetic resonance imaging TNCD Thesaurus National de Cancerologie Digestive gastro intestinal stromal tumor gastric gastro intestinal stromal tumor thoracic-abdomen-pelvis magnetic resonance imaging Thesaurus National de Cancerologie Digestive

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