Laparoscopic Transgastric Enucleation of a Gastric Leiomyoma near the Esophagogastric Junction and Concomitant Sleeve Gastrectomy: Video Report

Laparoscopic endoscopic cooperative surgery for gastric subepithelial lesion during laparoscopic sleeve gastrectomy for severe obesity

BACKGROUND

The frequency of pathologies detected incidentally before, during, and after a bariatric surgery, such as subepithelial lesion (SEL) of the stomach, is likely to rise as bariatric surgery becomes more common.

CASE PRESENTATION

A 49-year-old female patient presented with severe obesity, for which laparoscopic sleeve gastrectomy (LSG) was planned. During a preoperative examination, endoscopy revealed a 10 mm SEL in the posterior wall of the upper body of the stomach. Excision of the SEL was performed simultaneously with the LSG. Endoscopy demonstrated that the SEL was situated on the remnant side of the stomach. Endoscopic resection using laparoscopic endoscopic cooperative surgery was performed for the SEL, and the thinned gastric wall was closed by hand-sewing. Thereafter, LSG was performed. Pathological analysis of the SEL led to a diagnosis of leiomyoma. The patient was discharged on postoperative day 6.

CONCLUSION

Surgeons should be prepared to manage incidentally detected pathologies before, during, and after bariatric surgery and to choose the surgical method most suitable to the individual patient.

Submucosal Tunnel Endoscopic Resection of Gastric Lesion Before Obesity Surgery: a Case Series

BACKGROUND

Submucosal tumors (SMTs) of the gastrointestinal tract are a rare pathological entity comprising a wide variety of neoplastic and non-neoplastic lesions. Even if most SMTs are benign tumors (e.g., leiomyomas), a smaller portion may have a malignant potential (e.g., gastrointestinal stromal tumor (GIST)). Preoperative diagnosis of SMT in bariatric patients may arise challenging clinical dilemmas. Long-term surveillance may be difficult after bariatric surgery. Moreover, according to SMT location, its presence may interfere with planned surgery. Submucosal tunneling endoscopic resection (STER) has emerged as an effective approach for minimally invasive en bloc excision of SMTs. This is the first case series of STER for SMTs before bariatric surgery.

METHODS

Seven female patients underwent STER for removal of SMTs before bariatric surgery. All lesions were incidentally diagnosed at preoperative endoscopy. STER procedural steps comprised mucosal incision, submucosal tunneling, lesion enucleation, and closure of mucosal defect.

RESULTS

En bloc removal of SMT was achieved in all cases. Mean procedural time was of 45 min (SD 18.6). No adverse event occurred. Mean size of the lesions was 20.6 mm (SD 5.8). Histological diagnoses were 5 leyomiomas, 1 lipoma, and 1 low grade GIST. Bariatric procedure was performed after a mean period of 4.1 months (SD 1.6) from endoscopic resection.

CONCLUSION

STER is a safe and effective treatment for the management of SMT even in bariatric patients awaiting surgery. Preoperative endoscopic resection of SMTs has the advantages of reducing the need for surveillance and removing lesions that could interfere with planned surgery. STER did not altered accomplishment of bariatric procedures.

Value of CT Imaging in the Differentiation of Gastric Leiomyoma From Gastric Stromal Tumor

Purpose:

To discuss significant computed tomography (CT) findings that differentiate gastric leiomyomas (GLs) from small gastric stromal tumors (GSTs).

Methods:

One hundred sixty cases with pathologically proven GLs (n = 50) and GSTs (n = 110) with comprehensive CT images were enrolled in this retrospective study. Computed tomography findings (ie, size, location, contour, growth pattern, enhancement degree, necrosis, ulceration, calcification, and lymph nodes) were analyzed through the χ2 or Fisher exact test, independent T test, and multivariate (logistic regression) analysis. Sensitivity and specificity were also calculated.

Results:

Features of cardia location, endophytic growth, homogeneous gradual enhancement, absent of necrosis, long diameter less than 24 mm, short diameter less than 20 mm, unenhanced CT value larger than 35.2 Hounsfield units (HU), portal venous phase CT value larger than 67.4 HU, and enhancement degree of arterial and venous phase less than 16.2 HU and 32.4 HU were found to be statistically significant between GLs and small GSTs ( P < .05). On multivariate analysis, cardia location, endophytic growth, and homogeneous gradual enhancement were independent predictive factors for GLs and small GSTs.

Conclusion:

These 10 CT criteria are very helpful to differentiate GLs from small GSTs. Especially cardia location, endophytic growth, and homogeneous gradual enhancement are of high value in differential diagnosis.

Laparoscopic Transgastric Resection of a Gastrointestinal Stromal Tumor and Concomitant Sleeve Gastrectomy: a Case Report

BACKGROUND

Incidences of obesity, obesity surgeries, and gastric submucosal tumors (GST) have increased worldwide. This case report aims to demonstrate that concomitant laparoscopic transgastric resection (LTGR) of a gastrointestinal stromal tumor (GIST) near the esophagogastric junction (EGJ) can be performed safely and effectively in a patient with morbid obesity and scheduled sleeve gastrectomy (SG).

METHODS

The patient was planned to undergo SG surgery after the diagnosis of morbid obesity (BMI, 40.4 kg/m²). The routine preoperative endoscopic examination revealed a 4-cm diameter GIST-compatible lesion in the stomach near the EGJ. The LTGR with concomitant SG was scheduled for the patient.

RESULTS

The ports were placed for laparoscopic SG. Greater curvature and gastric fundus were fully mobilized. Along the greater curvature gastrotomy was performed, and thus the tumor was localized. The tumor was resected with a linear stapler by considering surgical margins. The frozen section examination showed no malignancy. The gastrotomy was closed, and the SG was performed via the orogastric tube (39F). In the postoperative passage X-ray, there was no stenosis or leaking, and the patient was externed on the third postoperative day. In the immunohistochemical examination, it was reported that the tumor was a GIST, and the surgical margins were negative.

CONCLUSION

The LTGR may help to protect the stomach or minimize the degree of partial resection in the treatment of especially GSTs near the EGJ.

Laparoscopic Transgastric Resection of a Gastric Submucosal Tumor near Esophagogastric Junction with Concomitant Sleeve Gastrectomy: a Video Case Report

BACKGROUND

Over the past two decades, there has been a significant rise in bariatric surgery. As a consequence, the prevalence of obese patients with a combined gastric pathology such as a submucosal tumor (SMT) requiring excision at the same time as bariatric surgery is higher but the management remains controversial. We report the safety and effectiveness of a simultaneous laparoscopic transgastric resection of a large gastric SMT near the esophagogastric junction (EGJ) with sleeve gastrectomy (SG).

METHODS

We present a video report of a 52-year-old male (BMI = 49 kg/m²) referred for bariatric surgery, who was found to have a large SMT 2 cm from the EGJ on the lesser curvature on previous gastroscopy.

RESULTS

Using five ports placed for laparoscopic SG, the gastric SMT was localized through an anterior gastrotomy and fully excised using a linear stapler and the gastrotomy site was closed. SG was then performed over a 54Fr bougie, including the gastrotomy suture closure.

CONCLUSIONS

Several factors play important roles in deciding the best surgical approach for patients who are candidates for bariatric surgery and have concomitant gastric SMTs. This video report describes a safe and effective technique of simultaneous transgastric resection of a lesser curvature gastric SMT near the EGJ in a patient undergoing SG.