Laparoscopic resection of large gastric GISTs: feasibility and long-term results.

BACKGROUND: Laparoscopy is the procedure of choice for the resection of gastric Gastrointestinal stromal tumors (GISTs) smaller than 2 cm; there is still debate regarding the most appropriate operative approach for larger GISTs. The aims of this study were to evaluate the safety and long-term efficacy of laparoscopic resection of gastric GISTs larger than 2 cm. METHODS: Between 2007 and 2011, we prospectively enrolled all patients affected by gastric GIST larger than 2 cm. Exclusion criteria for the laparoscopic approach were the presence of metastases and the absence of any involvement of the esophago-gastric junction, the pyloric canal, or any adjacent organ. Final diagnosis of GIST was confirmed by histological and immunohistochemical analysis. Follow-up assessment included abdominal CT scans every 6 months for the first 2 years and yearly thereafter. RESULTS: Twenty-four consecutive patients were enrolled. Twenty-one patients (87.5%) were symptomatic. The most common symptoms were gastrointestinal bleeding and abdominal pain. The mean tumor size was 5.51 cm (range 2.5-12.0 cm). GISTs were located in the lesser curvature in five cases (20.8%), in the greater curvature in seven cases (29.1%), in the posterior wall in one case (4.1%), in the anterior wall in eight cases (33.3%), and in the fundus in 3 cases (12.5%). Laparoscopic resection was possible in all cases and took on average of 55 min (range 30-105 min). Median blood loss was 24 ml. No major intraoperative complications were observed. Mortality rate was 0%. Median postoperative stay was 3 days. No patients were lost to follow-up. No recurrences occurred after a median follow-up period of 75 months. CONCLUSION: Although larger randomized controlled trials comparing different surgical strategies for large gastric GISTs are warranted, our study supports the evidence that laparoscopic resection of gastric GISTs is feasible, safe, and effective on long-term clinical outcome even for lesions up to 12 cm.

Diaphragmatic rupture with right colon and small intestine herniation after blunt trauma: a case report.

INTRODUCTION: Traumatic diaphragmatic hernias are an unusual presentation of trauma, and are observed in about 10% of diaphragmatic injuries. The diagnosis is often missed because of non-specific clinical signs, and the absence of additional intra-abdominal and thoracic injuries. CASE PRESENTATION: We report a case of a 59-year-old Italian man hospitalized for abdominal pain and vomiting. His medical history included a blunt trauma seven years previously. A chest X-ray showed right diaphragm elevation, and computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy, at which time the colon and small intestine were reduced back into the abdomen and the diaphragm was repaired. CONCLUSIONS: This was a unusual case of traumatic right-sided diaphragmatic hernia. Diaphragmatic ruptures may be revealed many years after the initial trauma. The suspicion of diaphragmatic rupture in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only curative treatment for diaphragmatic hernias. Prosthetic patches may be a good solution when the diaphragmatic defect is severe and too large for primary closure, whereas primary repair remains the gold standard for the closure of small to moderate sized diaphragmatic defects.