Endoscopic and Laparoscopic Full-Thickness Resection of Endophytic Gastric Submucosal Tumors Very Close to the Esophagogastric Junction

PURPOSE: Gastric submucosal tumors (SMTs) located very close to the esophagogastric junction (EGJ) are a challenge for gastric surgeons. Therefore, this study reports on the experience of using endoscopic and laparoscopic full-thickness resection (ELFR) with laparoscopic two-layer suturing in such tumors. MATERIALS AND METHODS: Six patients with gastric SMTs very close to the EGJ underwent ELFR with laparoscopic two-layer suturing at Kyungpook National University Medical Center. With the patient under general anesthesia, the lesser curvature and posterior aspect adjacent to the EGJ were meticulously dissected and visualized using a laparoscopic approach. A partially circumferential full-thickness incision at the distal margin of the tumor was then made using an endoscopic approach under laparoscopic guidance. The SMT was resected using laparoscopic ultrasonic shears, and the gastric wall was closed using two-layer suturing. Thereafter, the patency and any leakage were checked through endoscopy. RESULTS: All the ELFR procedures with laparoscopic two-layer suturing were performed successfully without an open conversion. The mean operation time was 139.2+/-30.9 minutes and the blood loss was too minimal to be measured. The tumors from four patients were leiomyomas, while the tumors from the other two patients were gastrointestinal stromal tumors with clear resection margins. All the patients started oral intake on the third postoperative day. There was no morbidity or mortality. The mean hospital stay was 7.7+/-0.8 days. CONCLUSIONS: ELFR with laparoscopic two-layer suturing is a safe treatment option for patients with an SMT close to the EGJ, as major resection of the stomach is avoided.

Subepithelial Lesion of the Gastric Fundus Caused by an Accessory Spleen / 대한내과학회지

When a submucosal lesion is discovered at the gastric fundus by gastroscopy, it may be difficult to distinguish a gastric external compression from a true submucosal tumor (SMT). The stomach is a hollow organ centrally placed in the upper abdomen, and it is possible to have a protruding external compression at the fundus, particularly from an enlarged spleen or splenic artery. An accessory spleen or splenosis is not a very unusual finding but may rarely produce such external compression at the gastric fundus. We experienced a case of an accessory spleen mimicking a gastric SMT diagnosed through a gastroscopy after a splenectomy.

Subepithelial Lesion of the Gastric Fundus Caused by an Accessory Spleen / 대한내과학회지

When a submucosal lesion is discovered at the gastric fundus by gastroscopy, it may be difficult to distinguish a gastric external compression from a true submucosal tumor (SMT). The stomach is a hollow organ centrally placed in the upper abdomen, and it is possible to have a protruding external compression at the fundus, particularly from an enlarged spleen or splenic artery. An accessory spleen or splenosis is not a very unusual finding but may rarely produce such external compression at the gastric fundus. We experienced a case of an accessory spleen mimicking a gastric SMT diagnosed through a gastroscopy after a splenectomy.

Malignant Solitary Fibrous Tumor of Retroperitoneum Mimicking Gastric Submucosal Tumor / 대한소화기학회지

Solitary fibrous tumors (SFTs) are an uncommon neoplasm characterized by the proliferation of spindle cells. The diagnostic criteria of malignant solitary fibrous tumors (MSFTs) include high cellularity, high mitotic activity (4>10 HPF), pleomorphism, hemorrhage and necrosis. This tumor frequently involves the pleura and MSFTs of retroperitoneum mimicking gastric submucosal tumor are very rare. We report a rare case of MSFT that presented as a gastric submucosal tumor. A gastroscopic examination showed a large bulging mucosa in the gastric body. Abdominal computed tomography revealed a well-defined heterogeneous enhancing mass between the left hepatic lobe and gastric body. Surgical resection was performed and histologic features were consistent with a MSFT.

Single Port Laparoscopic Gastric Wedge Resection: Case Reports / 대한내시경복강경외과학회지

Laparoscopic wedge resection for treating a gastric submucosal tumor is a widely accepted and feasible procedure. As the skills for performing laparoscopic surgery have been developed, a great deal of effort has also been given to minimize the size of the abdominal wound and its scar. Some studies have introduced single port laparoscopic surgery for these purposes, but most of these single port laparoscopic surgeries were carried out to perform appendectomy and cholecystectomy. There have been fewer reports on this for gastric surgeries. We report here on 2 cases of single port laparoscopic gastric wedge resection for treating gastric submucosal tumor.

Image-based Approach for Surgical Resection of Gastric Submucosal Tumors

PURPOSE: This study was done to evaluate the usefulness of preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound to facilitate treatment of gastric submucosal tumors. MATERIALS AND METHODS: The feasibility of laparoscopic wedge resection as determined by CT findings of tumor size, location, and growth pattern was correlated with surgical findings in 89 consecutive operations. The role of laparoscopic ultrasound for tumor localization was analyzed. RESULTS: Twenty-three patients were considered unsuitable for laparoscopic wedge resection because of large tumor size (N=13) or involvement of the gastroesophageal junction (N=9) or pyloric channel (N=1). Laparoscopic wedge resection was not attempted in 11 of these patients because of large tumor size. Laparoscopic wedge resection was successfully performed in 65 of 66 (98.5%) patients considered suitable for this procedure. Incorrect interpretation of preoperative CT resulted in a change of surgery type in seven patients (7.9%): incorrect CT diagnosis on gastroesophageal junction involvement (N=6) and on growth pattern (N=1). In 18 patients without an exophytic growth pattern, laparoscopic ultrasound was necessary and successfully localized all lesions. CONCLUSIONS: Preoperative CT and laparoscopic ultrasound are useful for surgical planning and tumor localization in laparoscopic wedge resection.

Image-based Approach for Surgical Resection of Gastric Submucosal Tumors

PURPOSE: This study was done to evaluate the usefulness of preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound to facilitate treatment of gastric submucosal tumors. MATERIALS AND METHODS: The feasibility of laparoscopic wedge resection as determined by CT findings of tumor size, location, and growth pattern was correlated with surgical findings in 89 consecutive operations. The role of laparoscopic ultrasound for tumor localization was analyzed. RESULTS: Twenty-three patients were considered unsuitable for laparoscopic wedge resection because of large tumor size (N=13) or involvement of the gastroesophageal junction (N=9) or pyloric channel (N=1). Laparoscopic wedge resection was not attempted in 11 of these patients because of large tumor size. Laparoscopic wedge resection was successfully performed in 65 of 66 (98.5%) patients considered suitable for this procedure. Incorrect interpretation of preoperative CT resulted in a change of surgery type in seven patients (7.9%): incorrect CT diagnosis on gastroesophageal junction involvement (N=6) and on growth pattern (N=1). In 18 patients without an exophytic growth pattern, laparoscopic ultrasound was necessary and successfully localized all lesions. CONCLUSIONS: Preoperative CT and laparoscopic ultrasound are useful for surgical planning and tumor localization in laparoscopic wedge resection.

Inflammatory Pseudotumor of Splenic Hilar Node Mimicking Gastric Submucosal Tumor

Inflammatory pseudotumor (IPT) is an uncommon clinical condition characterized by proliferation of spindle cells, inflammatory cells, and small vessels. IPT has been reported in various anatomical sites, including the orbit, lung, liver, spleen, and so on. IPT of the lymph node is very rare. We recently experienced a 65-year-old woman diagnosed with IPT of the lymph node in the splenic hilar, or distal supra-pancreatic area, mimicking gastric submucosal tumor. The tumor was removed without event using the laparoscopic method. This lesion in the splenic hilum is extremely rare and has not been cited in the current literature. We describe such a rare case of IPT with a review of the literature.

The Surgical Outcome for Gastric Submucosal Tumors: Laparoscopy vs. Open Surgery

PURPOSE: Laparoscopic gastric resection (LGR) is increasingly being used instead of open gastric resection (OGR) as the standard surgical treatment for gastric submucosal tumors. Yet there are few reports on which technique shows better postoperative outcomes. This study was performed to compare these two treatment modalities for gastric submucosal tumors by evaluating the postoperative outcomes. We also provide an analysis of the learning curve for LGR. MATERIALS AND METHODS: Between 2003.4 and 2008.8, 103 patients with a gastric submucosal tumor underwent either LGR (N=78) or OGR (n=25). A retrospective review was performed on a prospectively obtained database of 103 patients. We reviewed the data with regard to the operative time, the blood loss during the operation, the time to the first soft diet, the postoperative hospital stay, the tumor size and the tumor location. RESULTS: The clinicopatholgic and tumor characteristics of the patients were similar for both groups. There was no open conversion in the LGR group. The mean operation time and the bleeding loss were not different between the LGR group and the OWR group. The time to first soft diet (3.27 vs. 6.16 days, P<0.001) and the length of the postoperative hospital stay (7.37 vs. 8.88 days, P=0.002) were shorter in the LGR group compared to the OGR group. The tumor size was bigger in the OGR group than that in the LGR group (6.44 vs. 3.65 cm, P<0.001). When performing laparoscopic gastric resection of gastric SMT, the surgeon was able to decrease the operation time and bleeding loss with gaining more experience. We separated the total cases into 3 periods to compare the operation time, the bleeding losses and the complications. The third period showed the shortest operation time, the least bleeding loss and the fewest complications. CONCLUSION: LGR for treating a gastric submucosal tumor was superior to OGR in terms of the postoperative outcomes. An operator needs some experience to perform a complete laparoscopic gastric resection. Laparoscopic resection could be considered the first-line treatment for gastric submucosal tumors.

A Case of Chronic Gastric Eosinophilic Abscess Treated by Endoscopic Submucosal Dissection / 대한소화기내시경학회지

Anisakiasis is a parasitic disease caused by ingestion of raw fish infected with anisakis larvae. The endoscopic features of the gastic mucosa are edema, ulceration and hemorrhage. Chronic gastric anisakiasis forming a submucosal tumor is rare. A 53-year old female was diagnosed with having a 1 cm sized gastric submucosal mass-like lesion by gastroscopy. Endoscopic ultrasonography showed an inhomogenous low echoic tumor with an irregular margin in the submucosal layer. The patient underwent an endoscopic submucosal dissection and band ligation. A serological assay with an enzyme-linked immunosorbent assay for an anisakiasis specific IgG antibody were positive. The pathological finding of the resected mass was centrally denatured larvae with eosinophilic abscess in the submucosal layer. We report a case of chronic gastric anisakiasis that presented as a gastric submucosal tumor that was removed by the endoscopic submucosal dissection method, with a review of the relevant literature.

Wedge Resection of the Stomach for Gastric Submucosal Tumors: Laparoscopic vs. Open

PURPOSE: Laparoscopic wedge resection (LWR) is replacing open wedge resection (OWR) as the standard surgical treatment for gastric submucosal tumors. However, few scientific comparisons exist as to whether LWR or OWR is better in terms of postoperative outcomes. This study was performed to compare these two treatment modalities for the treatment of gastric submucosal tumors by evaluating the postoperative outcomes. METHODS: Between 1993 and 2004, 112 patients with a gastric submucosal tumor had undergone either LWR (n=42) or OWR (n=70). Their medical records were retrospectively reviewed with regard to tumor size, operative time, time to first flatus, postoperative hospital stay and analgesics use. RESULTS: The demographics and tumor characteristics of the patients were similar in both groups. Four (9 %) cases in the LWR group were converted to an open procedure. The mean operation time was longer in the LWR than the OWR group (100.6 vs. 84.3 min)(P = 0.015). The time to first flatus (1.8 +/- 0.1 vs. 3.3 +/- 0.1 days, respectively, P < 0.0001) and soft diet intake (3.5 +/- 0.3 vs. 6.0 +/- 0.2 days, respectively, P < 0.0001) were shorter in the LWR compared to the OWR group. The postoperative hospital stay was significantly shorter in the LWR than in the OWR group (5.3 +/- 0.6 vs. 8.5 +/- 0.2 days) (P < 0.0001). The number of analgesics uses (2.7 +/- 0.4 times) in the LWR was less than that in the OWR group (2.7 +/- 0.4 vs. 4.1 +/- 0.5 times)(P=0.0056). CONCLUSION: Laparoscopic wedge resection of a gastric submucosal tumor was superior to open wedge resection in terms of the postoperative outcomes. Laparoscopic wedge resection could be considered the first-line treatment for gastric submucosal tumors.

A Case of Intraabdominal Sparganosis Presenting as Submucosal Tumor on Gastroscopy / 대한소화기내시경학회지

Sparganosis in humans is caused by migrating larvae of the cestode Spirometra. Humans are considered the second intermediate host that are incidentally infected. Sparganosis usually infestates the subcutaneous tissues and visceral organs have rarely been reported to be involved. A case is herein reported however, a 67-year old female patient with sparganosis in the gastric wall and perigastric region, presented as a submucosal tumor upon gastrofiberscopy. The diagnosis was made after surgery by the pathologic findings determining a characteristic degenerated Sparganum and multiple tunnel-shape cavities surrounded by many inflammatory cells and necrotic materials.

A Case of Metastatic Gastric Cancer Resulting from Small Cell Lung Cancer / 대한소화기내시경학회지

Blood-borne metastatic cancer of the stomach is a rare occurrence according to a number of reports in the literature. Morever, it is extremely rare that gastric metastasis is man- ifested during life and most metastatic gastric tumors have been found at autopsy. The tumors most commonly reported to metastasize to the stomach include melanoma, breast carcinoma, and lung carcinoma. The frequency of metastatic gastric cancer from small cell lung cancer is 0.2-0.5% in the world literature. In Korea, there has been only one case reported on metastatic gastric cancer from small cell lung cancer. A 53-year-old man who had primary small cell lung carcinoma with brain metastasis complained of nausea, vomiting, and poor oral intake, An esophagogastroduodenoscopy revealed two submucosal tumors in the fundus and the mid body of the stomch. Pathologic examination revealed submucosal infiltration of small cell carcinoma. We report a case of metastatic gastric cancer, from small cell lung cancer that could be diaignosed during the subjectis followed by review of the life, literature.