Surgery remains the primary treatment modality for both localized and locally advanced Gastrointestinal Stromal Tumors (GISTs). Complete resection with negative margins, even of locally advanced tumors, is associated with improved survival. The purpose

1
Laparoscopic Resection of Gastrointestinal
Stromal Tumor
Bren Heaton, MD, Lucas Henn, MD, Peter DeVito,
MD, FACS Western Reserve Care System, Youngstown,
Ohio

Discussion Gastrointestinal stromal tumors (GIST)
are the most common mesenchymal tumors of the
gastrointestinal tract. GISTs are thought to
arise from a pacemaker cell within the
gastrointestinal tract known as the interstitial
cell of Cajal. They express the hematopoietic
progenitor cell marker CD34 and the growth factor
receptor c-Kit (CD117). c-Kit is a transmembrane
glycoprotein receptor with an internal tyrosine
kinase component which when activated triggers a
cascade of intracellular signals regulating cell
growth and survival. These tumors most commonly
arise in the stomach (60 to 70), small intestine
(20 to 30), colon and rectum (5), and esophagus
(lt5), although they can arise anywhere in the GI
tract or omentum/peritoneum. Incidence of GIST
is equal in men and women it generally peaks
between the fourth and sixth decades of life.
Presenting symptoms often represent the site of
tumor origin, but they may be vague, including
abdominal pain, anorexia, weight loss, and
dyspepsia. The imaging technique used most often
for diagnosis is CT. Positron emission tomography
(PET) may be a useful imaging modality in GISTs
patients being treated with imatinib mesylate
(Gleevec). Responses of the tumor are seen with
PET scanning earlier than with conventional CT.
Traditional chemotherapy or radiotherapy has
historically not been effective in the treatment
of GIST. The standard treatment for localized,
primary GISTs continues to be complete surgical
resection with negative margins. If surgery is
not an option or margins are not clean, Gleevec
is used to treat the tumor. Gleevec selectively
inhibits ABL, BCR-ABL, ARG, KIT, and PDGFR
tyrosine kinase and therefore inhibits growth of
tumor cells that express high levels of these
kinases. Major goals of follow-up surveillance
and management should be early identification of
potentially curable recurrences for patients who
have undergone treatment with curative intent and
are free of any gross evidence of disease.
Follow-up should include a history and physical,
cross-sectional imaging to encompass the tumor
bed to evaluate for local recurrence, and routine
chest x-rays for surveillance of metastatic
disease. Conclusion GISTs are common tumors of
the GI tract. In patients who present with
abdominal pain that are found to have an intra
abdominal mass, GIST needs to be considered as a
possible diagnosis. Furthermore, the patient
should be evaluated as a possible candidate for
laparoscopic resection..
Introduction Surgery remains the primary
treatment modality for both localized and locally
advanced Gastrointestinal Stromal Tumors (GISTs).
Complete resection with negative margins, even of
locally advanced tumors, is associated with
improved survival. The purpose of this case
report is to describe a laparoscopic resection of
In abdominal mass that proved to be a benign
GIST. Case Report This is a 47-year-old male who
presented to the Emergency Room with vague
abdominal pain. During the patients workup a CT
scan of the abdomen and pelvis was obtained which
showed a possible mass between the spleen and the
stomach (see figure 1). The patient was then
scheduled for esophagogastroduodenoscopy and
colonoscopy by Gastroenterology which revealed no
abnormalities. A small bowel follow through was
then completed and proved to be normal. The
patient then underwent capsule endoscopy, which
also revealed no abnormalities. Another review by
a Staff Radiologist indicated a possible
accessory spleen. To confirm, the patient was
ordered a tagged white blood cell scan (SPECT
scan). This was also negative (see figure 2).
The patient was then referred to Interventional
Radiology for a CT guided percutaneous biopsy of
the lesion. The results returned indeterminate.
After exhausting all non-invasive testing
modalities the patient was scheduled for
diagnostic laparoscopy with possible resection of
this mass. Informed consent was obtained for
diagnostic laparoscopy, possible exploratory
laparotomy, possible bowel resection. After the
patient was placed in a semi-right lateral
decubital position, three 5mm ports were placed
supraumbilical, left upper quadrant, and
subxiphoid. One 12mm port was placed in between
our subxiphoid and left upper quadrant port. A
thorough diagnostic laparoscopy was performed. We
identified the spleen as well as the stomach. No
mass was visualized immediately. The lesser sac
was entered using the Ligasure (Valleylab-
Boulder, Colorado) and the tumor was found to be
arising from the posterior wall of the stomach.
The mass was completely dissected free from the
omental attachments without difficulty using the
Ligasure. The mass was noted to be attached by a
1 centimeter stalk to the posterior wall of the
stomach (see figure 3) and approximately 5cm in
circumference. An Endo GIA 35 millimeter was used
to transect the attachment (see figure 4). The
mass was then removed via the 12mm port site via
an endo bag (see figure 5). Intra operative
pathologic examination revealed a GIST that
appeared to be benign. The specimen was found to
positive for vimentin, CD177, and CD 34. The
patient was able to be discharged home just three
hours following surgery on a liquid diet for
twenty-four hours. Follow-up arrangements were
also made.
Figures
Figure 1. CT abdomen posterior gastric mass
Figure 2. SPECT scan showing no accessory spleen
Figure 3 Mass Attached to posterior stomach
Figure 4. After resection with Endo GIA
Figure 5. Mass removed from posterior wall of
stomach.