Intragastric SILS for GIST, a new challenge in oncologic surgery: first experiences.

BACKGROUND: For treatment of Gastrointestinal Stromal Tumour (GIST) located in unreachable areas, such as the esophagogastric junction or pyloric ring, laparoscopic resection cannot be easily applied. We used single-incision laparoscopic surgery (SILS) for intragastric resection of GISTs. PATIENTS AND METHODS: We report on our cases (n=3) of GIST of the stomach treated with the SILS port placed intragastrically through the anterior wall of the stomach. A skin incision of only 2.5 cm was made to perform this intervention. RESULTS: The patients mean age was 68.1 years (range=53-86). The mean operative time was 74.6 (range=67-82) minutes. No intra-operative complications occurred. No conversion was needed. The mean tumor size was 3.8 cm (range=2.7-6.8 cm). All patients healed without any complications. Re-alimentation was started on the third postoperative day. The mean postoperative stay was five days (range: 4-6 days). CONCLUSION: This intragastric SILS procedure for GIST is feasible and safe, and offers a benefiet for further progress in oncologic surgery.

Laparoscopic versus open resection of gastrointestinal stromal tumors of the stomach.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgical treatment is the only chance of cure for patients with a primary localized GIST. A laparoscopic approach has been considered reasonable for these tumors of gastric origin. The current study compares the outcome of laparoscopic versus open resection of gastric GISTs and compares our series with the few published studies comparing the open versus the laparoscopic approach. METHODS: From a prospectively collected database, we found 53 primary gastric GIST resections that were performed in our department. Laparoscopic (LAP) resections were performed in 37 patients and traditional (OPEN) resections in 16 patients. Clinical and pathologic characteristics and surgical outcomes were analyzed according to surgical procedure. RESULTS: Patients who underwent LAP or OPEN resection of gastric GISTs did not differ with respect to age at operation, gender, clinical presentation, and tumor size. Operative time was significantly lower for LAP than for OPEN resection, with a mean duration of 45 and 132.5 min, respectively (p < 0.001). LAP resection yielded a significantly shorter length of stay (median 7 vs. 14 days; p = 0.007) and lower 30-day morbidity rate (2.7 % vs. 18.9 %; p = 0.077). The operative mortality was 12.5 % after OPEN resection and there was no operative mortality after LAP (p = 0.087). The recurrence rate was significantly lower after LAP surgery (0 % vs. 37.5 %; p < 0.001). All patients in the LAP group are alive without recurrence, and 25 % (4/16) of the OPEN group are alive with recurrence but in complete remission under imatinib mesylate treatment. Two patients of the open group died due to progression of GIST (p = 0.087). CONCLUSIONS: Compared to open resection, laparoscopic resection of gastric stromal tumors is associated with a shorter operation time, a shorter hospital stay, and a lower recurrence rate.

Early experience with single-incision laparoscopic surgery for the placement of a gastrostomy in a 10-year-old girl: a case report.

INTRODUCTION: Access procedures for alimentation have been performed both endoscopically and surgically. In patients in whom endoscopic gastrostomy feeding tubes cannot be placed, single-incision laparoscopic surgery gastrostomy is an alternative method. This minimally invasive approach is a new technique performed through a single umbilical incision and without the need for additional laparoscopic ports. CASE PRESENTATION: In this article we present a case of single-incision laparoscopic surgery gastrostomy performed with conventional laparoscopic instruments in a 10-year-old girl of Caucasian ethnicity who was not a candidate for a percutaneous endoscopic gastrostomy tube because of esophageal varices due to her advanced-stage cystic fibrosis with liver cirrhosis and portal hypertension. She also had an umbilical hernia, which was repaired during the same procedure through the same incision. Access and pneumoperitoneum were obtained through the umbilicus with the single-incision laparoscopic surgery port. The selected site for the feeding tube in the stomach was exteriorized through this incision and a feeding tube was placed. The stomach was returned into the abdomen. The fascial defect, and thus also the hernia, was repaired, and the 2cm umbilical incision was closed with endocutaneous sutures. The total operative time was 25 minutes. Our patient's intra-operative and post-operative course was uneventful. We were able to use the feeding tube on the first post-operative day with good intestinal function. Our patient and her parents were pleased with the cosmetic result. CONCLUSIONS: The single-incision laparoscopic surgery procedure seems to be a less invasive alternative to open placement of gastrostomy. This approach has the possible advantages of reduced post-operative pain, faster return to normal function, reduced port site complications, improved cosmesis and better patient satisfaction.

Unusual Appearance of a Pendulated Gastric Tumor: Always Think of GIST.

Objective. To investigate the clinicopathological characteristics of gastrointestinal stromal tumor (GIST) with significant cystic changes and to assess the molecular genetic characteristics. Methods. In a 68-year-old man, a large abdominal tumoral mass was discovered incidentally. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of a large cystic lesion with multiple contrast-enhancing septae and papillary projections. No clear connection with any of the surrounding organs was identified. Malignancy could not be excluded, and surgery was indicated. During surgery, the large mass was found to be attached by a narrow stalk to the large curvature of the stomach. Results. The histological features and immunohistiochemical profile of the tumor cells (positivity for CD117 and CD34) were consistent with a gastrointestinal stromal tumor with a high risk of progressive disease according to the Fletcher classification. Diagnosis was confirmed by mutational analysis; this demonstrated mutation in exon 14 of PDGFRA. During the followup of 97 months, the patient had a cancer-free survival. Conclusions. This case demonstrates that gastrointestinal stromal tumors (GISTs) with extensive cystic degeneration should be considered in the differential diagnosis of a cystic abdominal mass.

Superior mesenteric arterial branch occlusion causing partial jejunal ischemia: a case report.

INTRODUCTION: Ischemic bowel disease comprises both mesenteric ischemia and colonic ischemia. Mesenteric ischemia can be divided into acute and chronic ischemia. These are two separate entities, each with their specific clinical presentation and diagnostic and therapeutic modalities. However, diagnosis may be difficult due to the vague symptomatology and subtle signs. CASE PRESENTATION: We report the case of a 68-year-old Caucasian woman who presented with abdominal discomfort, anorexia, melena and fever. A physical examination revealed left lower quadrant tenderness and an irregular pulse. Computed tomography of her abdomen as well as computed tomography enterography, enteroscopy, angiography and small bowel enteroclysis demonstrated an ischemic jejunal segment caused by occlusion of a branch of the superior mesenteric artery. The ischemic segment was resected and an end-to-end anastomosis was performed. The diagnosis of segmental small bowel ischemia was confirmed by histopathological study. CONCLUSION: Mesenteric ischemia is a pathology well-known by surgeons, gastroenterologists and radiologists. Acute and chronic mesenteric ischemia are two separate entities with their own specific clinical presentation, radiological signs and therapeutic modalities. We present the case of a patient with symptoms and signs of chronic mesenteric ischemia despite an acute etiology. To the best of our knowledge, this is the first report presenting a case of acute mesenteric ischemia with segmental superior mesenteric artery occlusion.

Long-term disease-free survival following dendritic cell therapy and resection of small bowel melanoma metastases - a case report.

BACKGROUND: Although the resection of solitary visceral melanoma metastases is indicated when possible, further progression of metastatic disease is seen in the vast majority of patients. New modalities of immunotherapy can offer durable disease control in a significant proportion of melanoma patients. CASE REPORT: A 28-year-old man was diagnosed with stage III melanoma in 2003 and was treated with autologous dendritic cells in the adjuvant setting. Five years later melanoma metastases causing small bowel obstruction were surgically removed and he was retreated with dendritic cells. Following 5 months without disease manifestations, the patient presented with intermittent abdominal discomfort. Following the visualization of a hot spot at the level of the jejunum on 18F-fluorodeoxyglucose position-emission tomography, the patient underwent a laparotomy, during which a solitary melanoma metastasis of the small bowel causing intussusception was resected. The patient has so far remained disease-free, more than one year after the latest surgical intervention. CONCLUSION: Combined modality treatment with surgery and immunotherapy may result in an improved long-term outcome for patients with metastatic melanoma.

Laparoscopic repair of diaphragmatic Morgagni hernia in children: review of 3 cases.

This article retrospectively reviews the laparoscopic repair of Morgagni hernias in 3 children. The surgical procedure was performed by closing the defect using extracorporeal, interrupted, nonabsorbable sutures. Recovery was uneventful in all 3 patients. There were no recurrences and the chest radiograph stayed normal during the postoperative follow-up.

Outpatient gastroplasty for morbid obesity: our first hundred cases.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity. The aim of the present study was to identify factors actually contributing to the feasibility or to the failure of performing this procedure in an outpatient setting. METHODS: In this prospective study, 100 ambulatory LAGB procedures were compared with 100 procedures performed in patients with an overnight stay. The recorded variables in both groups were first compared by univariate analysis. Logistic regressions were then calculated to analyse which of the variables were independently predictive. RESULTS: The mean time lapse between the end of surgery and discharge from hospital was 8.33 h in the outpatient group and no patient required readmission. Independent risk factors affecting same-day discharge were increasing age of the patient, higher BMI and diabetes. Other variables such as patient's gender, duration of surgery, distance home-hospital, number of previous abdominal procedures and other comorbidities did not demonstrate statistical differences between the two study groups. CONCLUSION: Gastric banding for the treatment of obesity can be safely performed in an outpatient setting. Advanced age, higher BMI and diabetes adversely affect same-day discharge and should be taken into consideration when planning an ambulatory LAGB.

Enterobius vermicularis infection with tuboovarian abscess and peritonitis occurring during pregnancy.

BACKGROUND: Extraintestinal Enterobius vermicularis infections are rare but may occasionally affect the female genital tract. Although mostly asymptomatic or causing minor clinical problems, they may lead to severe infectious complications. METHODS: Case report and review of the pertinent English language literature. RESULTS: A 31-year-old, 30-week-pregnant female was admitted with a clinical suspicion of appendicitis. At surgery, the appendix appeared normal, but generalized peritonitis of unclear origin was present. Eggs of Enterobius vermicularis were found upon microbiological and pathological examination. Because of persisting infectious disease, the patient underwent an elective caesarean section, and at that time the diagnosis of a right tuboovarian abscess was made, and salpingo-oophorectomy was performed. The pathology report confirmed the diagnosis of an E. vermicularis salpingo-oophoritis. CONCLUSION: This case was extraordinary because of a combination of tuboovarian abscess and generalized peritonitis with E. vermicularis infection occurring during late pregnancy. Ectopic enterobiasis should be considered in the differential diagnosis of pelvic infections of gynecological origin.

Laparoscopically assisted ileocolectomy in patients with Crohn's disease: a study of 50 consecutive patients.

BACKGROUND: This study aimed to assess the feasibility, safety, and immediate postoperative outcome of laparoscopically assisted ileocolic resection for Crohn's disease. METHODS: Data were collected retrospectively from a database of 50 consecutive patients with Crohn's disease who underwent ileocolic resection between 1997 and 2007. The mean age of the patients was 40 years (range, 20-74 years), and 21 of the patients were men. Of the 50 patients, 18 had a history of abdominal surgery. The mean time from diagnosis to operation was 6.4 years (range, 1-31 years). The indications for surgery included subobstruction (48%), failure of medical treatment (20%), and internal fistulas (32%). RESULTS: The mean operating time was 150 min (range, 80-360 min), and the blood loss was 130 ml (0-400 ml). Only 1 of the 50 patients underwent conversion to laparotomy. Return of bowel movement occurred at a mean of 3 days (range, 1-7 days). The median hospital stay was 8 days (range, 5-130 days). There was no 30-day mortality. The minor complication rate was 20%. The complications included wound infection, pneumonia, urinary infection, postoperative bleeding, prolonged ileus, and fever of unknown origin. Major complications occurred for four patients, with three patients experiencing an anastomotic leak and one patient a leak after fistulectomy. CONCLUSIONS: The laparoscopically assisted approach to ileocolic Crohn's disease seems to be feasible and safe, with acceptable immediate postoperative outcomes.

Laparoscopic management of insulinoma in a child with multiple endocrine neoplasia type 1.

The diagnosis and surgical management of insulinomas associated with multiple endocrine neoplasia type 1 (MEN1) pose additional problems in children because of the long-term risk of recurrence of other pancreatic and non-pancreatic tumors. We report a diagnostic confirmation by laparoscopic ultrasound of an insulinoma and its successful removal by laparoscopic enucleation in an 8- year-old boy who was admitted to our hospital with a history of recurrent episodes of absences, headache, and visual and auditive disturbances diagnosed as hyperinsulinism-related hypoglycemia. Magnetic resonance imaging of the pancreas showed a small contrast-enhancing lesion in the body of the pancreas, suspected for insulinoma. MEN1 was genetically proven by direct DNA testing. A pancreatic tumor can arise before the age of 10 in patients with MEN1 and can be surgically treated by a laparoscopical approach.

Laparoscopic wedge resection for gastric ectopic pancreas.

Ectopic pancreas is pancreatic tissue found outside the usual anatomic location of the pancreas. It is often an incidental finding in clinical practice and can be found at different sites in the gastrointestinal tract. Although usually a silent anomaly, it may become clinically evident when complicated by pathologic changes such as inflammation, bleeding, obstruction, and malignant transformation. We describe a case of ectopic pancreas located in the stomach, treated with a laparoscopic approach that permitted isolation and complete resection of the lesion. The patient was discharged without complications and without recurrence of symptoms.

Laparoscopic repair of Morgagni diaphragmatic hernia: a new case.

A large diaphragmatic Morgagni-type hernia that was incidentally discovered in an 8-month-old girl is described. The diaphragmatic defect was closed through laparoscopy. The latter approach is felt to be superior over conventional surgery and is therefore recommended in similar cases.