Successful transgastric drainage of a large mucinous adenocarcinoma of the stomach for palliation of malignant gastric luminal obstruction

Abstract

Six months prior to being seen at our institution, a 30year-old man presented with sudden onset of large volume ascites. The fluid cytology revealed malignant cells. An exploratory laparotomy revealed massive peritoneal involvement with metastatic mucinous adenocarcinoma, signet ring type. An ulcerated neoplasm at the gastro-esophageal junction was found on esophagogastroduodenoscopy; it was biopsied and demonstrated moderately differentiated adenocarcinoma. CTscan showed thickening of the gastric wall. He received several rounds of chemotherapy over several months. One month prior to the patient being seen at our institution, a CTscan showed compression of the stomach lumen by a large cystic mass arising from the wall of the stomach (Fig. 1). He presented to Mayo Clinic with anorexia, nausea, and postprandial vomiting of both solids and liquids, and had required 2 hospitalizations for dehydration with weight loss of 50 pounds over 2 months. Gastroenterology was consulted for advice on feeding options. A PEG or percutaneous endoscopic jejunostomy tube was not possible because of the large volume ascites and gastric compression. A nasojejunal tube was declined by the patient. Transmural drainage was offered as a novel approach for palliation. An EUS was done to confirm that the lesion was composed primarily of liquid and amenable to drainage. The EUS showed a large cystic mass abutting the greater curvature of the stomach, consisting mostly of nonviscous fluid with a small solid component (Fig. 2). It was determined, by the endoscopic appearance, that the lesion was fluid, and a primary aspirate was not performed. The presence of viscous contents might have necessitated the use of lavage, though the 10-mm stent would have been adequate to drain viscous fluid, as opposed to 10F plastic stents.