Perforated gastrointestinal stromal tumor in Meckel's diverticulum treated laparoscopically

Gastrointestinal stromal tumor in perforated Meckel's diverticulum: a case report and literature review

Introduction

Gastrointestinal stromal tumor (GIST) is rare neoplasms of the gastrointestinal tract associated with high rates of malignant transformation. GIST has been found largely in the stomach, small bowel, colon and rectum, and esophagus, but about 5% are found in other locations. We herein report a 56-year-old woman with a GIST in perforated Meckel's diverticulum. After encountering this patient, a review of the literature found reports of 18 similar patients.

Case presentation

A 56-year-old woman diagnosed with galactosialidosis (β-galactosidase-neuraminidase deficiency) presented with vomiting. On contrast-enhanced computed tomography, peritonitis due to perforation of the intestine was diagnosed based on the free air and dilated loop of the small bowel. Laparotomy revealed perforation of Meckel’s diverticulitis located 50 cm from the ileocecal valve. Partial resection of the ileum, including the diverticulum, and end-to-end anastomosis of the small intestine were performed. Regarding the pathological findings, the edge of the diverticulum wall consisted of a solid mass measuring 1.0 cm in size, and the tumor cells were spindle-shaped with 1 mitosis present per 50 high-power fields. The diagnosis was established as GIST of the Meckel's diverticulum. The postoperative period was uneventful. Follow-up at two years revealed no evidence of recurrence.

Conclusion

GIST in perforated Meckel's diverticulum is very rare. The potential for the coexistence of GIST or other tumor should be considered in the treatment of perforated Meckel's diverticulum.

Acute Right Lower Abdomen in a Patient with a History of Gastrointestinal Stromal Tumor

Background

Gastrointestinal stromal tumor (GIST) is an uncommon tumor of the GI tract usually seen in elderly patients, often difficult to diagnose because of the unspecific symptoms such as abdominal pain and fullness. Recurrent GIST may have an even more obscure clinical presentation.

Case Report

A 44-year-old female with a history of surgically treated GIST presented to the emergency room complaining of acute onset sharp RLQ pain, nausea, and vomiting. Clinically, she had RLQ tenderness with rebound, her WBC was elevated, and CT scan showed signs of appendicitis and also soft tissue masses suspicious for malignancy. After contemplating treatment options including antibiotics and further workup, it was recommended to proceed with surgery. Laparoscopy showed a thickened appendix with nodular infiltration and multiple mass-like lesions in the RLQ not amendable to minimal invasive resection. From a lower midline incision, an open appendectomy and excision of multiple masses in the terminal ileum and in the abdominal wall were done. Narrow-based Meckel's diverticulum with multiple nodular lesions was also removed. Pathology identified appendicitis and serosal involvement of GIST in all specimens staining positive for CD68, CD117, and vimentin. The patient was started on imatinib and remained recurrence-free after 6 months.

Conclusions

This case illustrates a rare presentation of acute symptomatic recurrent metastatic GIST. Our patient was unusually young, and GIST recurrence presented with acute RLQ pain suggestive for acute appendicitis and also involved Meckel's diverticulum. Surgical debulking followed by imatinib seems to be a reasonable approach in such cases.

A Diagnostic Surprise For A Right Iliac Fossa Mass - A Perforated Ileal Gastrointestinal Stromal Tumour

Gastrointestinal Stromal Tumours (GISTs) are tumours of the gut found mostly in stomach and small intestine. The complications are Gastrointestinal (GI) bleeding, obstruction, pain and rarely perforation. We are reporting an abnormal presentation of GIST masquerading as an acute abdomen with Right Iliac Fossa (RIF) mass in 60-year-old lady. Contrast Enhanced Computed Tomography (CECT) of abdomen revealed a peripherally enhancing encapsulated abscess in RIF in close contact with base of caecum and adjacent peritonitis suggesting caecal perforation. On laparotomy, a gangrenous perforated ileal GIST was identified along the antimesenteric border of ileum. Pathological examination confirmed the tumour to be a GIST of spindle cell type, further reiterated by immunohistochemistry. Our case report emphasizes, GIST as a rare and unusual differential diagnosis of RIF mass, and to have high degree of clinical suspicion when a similar situation is encountered in an emergency scenario, keeping in mind the poor outcome due to delay in appropriate management of the disease.

An Unusual Pelvic Mass in a Pediatric Patient: A Case Report and Review of the Pathology

INTRODUCTION

Neurofibromatosis type 1 (NF1) is the most commonly inherited autosomal dominant disorder in humans. NF1 patients have increased risk for gastrointestinal stromal tumors (GISTs). A Meckel's diverticulum (MD) represents a persistent embryonic omphalomesenteric duct characterized as a true diverticulum located near the ileocecal valve. We report a unique clinical case whereby a patient with NF1 developed a GIST within a MD.

CASE

An adolescent male with NF1 presented with persistent lower abdominal pain. Clinical evaluation demonstrated a large pelvic mass. In the operating room, the mass was noted to emerge from a MD. Final pathology demonstrated a GIST with negative margins and CD117 positivity.

DISCUSSION

Patients with NF1 are at increased risk for mesenchymal tumors including malignant peripheral nerve sheath tumors. GISTs are the most important and frequent non-neurological malignancy in NF1 and develop in ∼7% of NF1 patients. GISTs tend to be multifocal in NF1; however, they rarely occur within a Meckel's diverticula.

CONCLUSIONS

Our case represents a rare case of a patient with NF1 who developed a symptomatic GIST within a MD. We recommend utilizing laparoscopy to determine resectability and clarify the diagnosis in this unique patient population who are at risk for multiple neoplasms.

Serosal and muscular layers incision technique in laparoscopic surgery for gastric gastrointestinal stromal tumors

INTRODUCTION

To minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we developed laparoscopic wedge resection with the serosal and muscular layers incision technique (SAMIT) for gastric gastrointestinal stromal tumors.

MATERIALS AND SURGICAL TECHNIQUE

SAMIT involves resection of the mucosal and submucosal layers and then an incision in serosal and muscular layers around the tumor. SAMIT is simple and does not require special devices. The data of 13 patients who underwent laparoscopic wedge resection with SAMIT for primary gastric gastrointestinal stromal tumors were reviewed. No intraoperative complications were observed, and postoperative stenosis occurred in only one case of a middle stomach lesion. Adequate oncological resection was performed in all cases.

DISCUSSION

Laparoscopic wedge resection with SAMIT is technically and oncologically safe. It is useful for treating gastric gastrointestinal stromal tumors, including those close to the esophagogastric junction or pyloric ring.

Perforated Gastrointestinal Stromal Tumor of the Meckel's Diverticulum: a Case Report and Review of Literature

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the GI tract, they have a wide spectrum of clinical manifestations, and a small proportion of them present as an acute abdomen due to obstruction, perforation, or hemoperitoneum. We present a case of a perforated GIST of the Meckel's diverticulum and review the current literature on perforated GISTs. We ran a search on Pubmed and Google Scholar with the following terms "perforated GIST," "perforated Meckel's diverticulum," "GIST with peritonitis," and "GIST in Meckel's diverticulum." After selecting the relevant articles, we tabulated our results and analyzed the data. Out of the 45 cases, 32 (71.1 %) were male and 13 (28.8 %) were female. Out of the 45 reported cases, 41 (91.1 %) were from the small intestine, 2 (4.44 %) cases from the stomach, and 2 (4.44 %) from the small bowel. In 15 (33.33 %) cases, the site of perforation was the Meckel's diverticulum (MD). Forty-year-old male, presented with features of peritonitis localized to the right iliac fossa, was diagnosed as acute appendicitis and subjected to a diagnostic laparoscopy. Intraoperatively, a perforated Meckel's diverticulum was found, which on histopathological examination contained a low-grade GIST. Our literature search revealed that in reported cases of perforated GISTs, there is a slight male preponderance. Small bowel appears to be the most common site for a perforated GIST, and a significant proportion (30.23 %) arise from the Meckel's diverticulum. And most importantly, the commonest tumor to cause perforation of a Meckel's diverticulum is a GIST.

A gastrointestinal stromal tumor found in perforated Meckel's diverticulum

Background

Meckel’s diverticulum is the most common anomaly of the gastrointestinal tract. It is usually asymptomatic, but approximately 4 % present with complications such as bleeding, intestinal obstruction, and inflammation, while perforation is rare. Carcinoid or gastrointestinal stromal tumors are occasionally found in the resected specimens of Meckel’s diverticulum, particularly in the context of perforation.

Case presentation

A 62-year-old male with a recent history of admission and evaluation for hematochezia presented with abdominal pain. His physical examination was consistent with peritonitis. Results of laboratory testing were significant for white blood cell count of 32,000/μL. CT scan of the abdomen revealed pneumoperitoneum. During the exploratory laparotomy, perforated Meckel’s diverticulum was encountered and segmental bowel resection was performed. Histological examination findings were compatible with gastrointestinal stromal tumor within Meckel’s diverticulum.

Conclusions

While gastrointestinal stromal tumor is a rare finding in Meckel’s diverticula, the potential for the coexistence of this and other tumors suggests that segmental resection of the small bowel should be considered in the treatment of perforated Meckel’s diverticulum.

Spontaneous Rupture of Adenocarcinoma of Meckel's Diverticulum- A Rare Entity

Meckel's diverticulum is a true diverticulum from remnant of vitelline duct. It is most common congenital anomaly of intestine. It is associated with intestinal atresia and anorectal anomalies. It contains heterotrophic epithelium. Most common heterotrophic mucosa is gastric followed by pancreatic tissue. Adenocarcinoma arising from Meckel's diverticulum is very rare. Spontaneous perforation of adenocarcinoma rarely reported. Most of perforation reported in Meckel's diverticulum diagnosed during intraoperative period. This is a case report of spontaneous rupture of adenocarcinoma of Meckel's diverticulum, which was managed with primary resection and ileostomy.

A case of an omphalomesenteric duct remnant in an adult treated with laparoscopic surgery

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An omphalomesenteric duct (OMD) remnant is a rare case in an adult.

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A ductal structure was found between the distal ileum and the umbilicus in this case.

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Laparoscopic surgery was performed by inserting three trocars into the left side of the abdomen.

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A good field of view around the umbilicus and adequate working space were provided.

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Both diagnosis and treatment were accomplished with minimally invasive laparoscopic surgery.

Introduction

The presence of an omphalomesenteric duct (OMD) remnant is a rare condition that typically affects the pediatric population. This report describes an extremely rare case of an OMD remnant that was diagnosed and resected by laparoscopic surgery in an adult.

Presentation of case

A 52-year-old man underwent a medical examination at our hospital for right lower quadrant pain. Laboratory findings showed slight leukocytosis and an elevated C-reactive protein level. A luminal structure connected to the umbilicus was detected in the right pelvic wall by abdominal computed tomography, and an OMD remnant was suspected. Laparoscopic surgery was performed by inserting three trocars into the left side of the abdomen; no trocars were inserted near the umbilicus. This procedure provided both a good field of view around the umbilicus and adequate working space. We definitively diagnosed the structure as an OMD remnant and resected it with minimal invasion. The patient was discharged on postoperative day 7 without complications. Pathologic analysis found the lumen is covered by ileum-like mucosa, and a microabscess is formed in the surrounding fat tissue.

Discussion

OMD remnants are uncommon, and their diagnosis is difficult. Most reports advocate for prompt surgical resection in symptomatic patients.

Conclusion

In the present case, definitive diagnosis and treatment were accomplished with minimally invasive laparoscopic surgery.