Benign Gastric Tumors Research Articles

A technique for endo-organ resection of gastric wall tumors using one intragastric trocar.

This report describes a new technique for combined laparoscopic and gastroscopic intragastric resection of benign gastric wall tumors. We performed this combined endo-organ procedure in five patients. Endo-organ intragastric resection is only used with posterior gastric wall tumors and tumors located near the cardia and the pylorus. For this approach, only one trocar is placed into the stomach for intragastric introduction of the endostapler. The video gastroscope allows intragastric vision. We recommend our procedure for the extirpation of small, benign, intramural gastric tumors, as a safe and very comfortable method for the patient.

Dedicated multidetector CT of the stomach: spectrum of diseases.

Multidetector computed tomography (CT) offers new opportunities in imaging of the gastrointestinal tract. When thin collimation is used, near-isotropic imaging of the stomach is possible, allowing high-quality multiplanar reformation and three-dimensional reconstruction of gastric images. Proper distention of the stomach and optimally timed administration of intravenous contrast material are required to detect and characterize disease. In contrast to gastroscopy and double-contrast studies of the stomach, CT provides information about both the gastric wall and the extragastric extent of disease. Preoperative staging of gastric carcinoma appears to be the main clinical indication for multidetector CT. In addition, multidetector CT allows detection of other gastric malignancies (lymphoma, carcinoid tumors, metastases, gastrointestinal stromal tumors) and benign gastric tumors (neural tumors, polyps). Gastric inflammation (gastritis, ulcers, Ménétrier disease) and miscellaneous gastric conditions (emphysema, gastric outlet obstruction, varices) can also be visualized with multidetector CT. Multidetector CT is a valuable tool for the evaluation of gastric wall disease and serves as an adjunct to endoscopy.

EUS-guided ethanol injection for treatment of a GI stromal tumor

EUS-guided ethanol injection for treatment of a GI stromal tumor

Gastric stromal tumors: a clinicopathologic study of 77 cases with correlation of features with nonaggressive and aggressive clinical behaviors.

Gastrointestinal stromal tumors are a heterogeneous group of neoplasms that have clinical and histologic features that vary depending on their location within the gastrointestinal tract. Prediction of clinical behavior in this group of tumors is notoriously difficult, and the same criteria for malignancy do not necessarily apply to stromal tumors from different sites within the gastrointestinal tract. Using known clinical behavior with long-term follow-up, we attempted to determine which features, if any, are associated with clinical behavior in stromal tumors arising in the stomach, the most common site for such tumors. Seventy-seven gastric stromal tumors were studied and classified as "adverse outcome (AO) tumors" (malignant) or "nonadverse outcome tumors" (benign) based on their known clinical outcome. AO was defined as metastasis and/or death due to tumor. Patients with a non-AO had at least 5 years of tumor/metastasis-free follow-up. Thirty-seven patients had an AO (follow-up [metastasis at presentation] 0-73 months; median 6 months), and 40 patients had a non-AO (follow-up 60-264 months; median 84 months). All cases were reviewed by two authors (J.R.G., H.D.A.), who were blinded to clinical outcome and gross features, and classified as histologically benign or not benign using preset, defined histologic criteria based upon the authors' prior experience with a large number of these tumors. If the tumor did not fit with either the characteristic cellular spindle cell or benign epithelioid cell patterns, the tumor was classified as not benign. Clinical outcome was then correlated with the histologic designation to determine if these preset criteria were valid. The authors were able to accurately classify the tumors as benign or not benign with a sensitivity of 100% and a specificity of 92%. In addition, for all cases individual morphologic and clinical features were examined. Features associated with an AO included tumor size >/=7 cm, high cellularity, mucosal invasion, high nuclear grade, mitotic counts >/=5/50 high power fields, mixed cell type, and the presence of a myxoid background and/or absence of stromal hyalinization. By recognizing several well-defined patterns of benign gastric stromal tumors and the myriad of individual features shown to correlate with an AO, one can better predict the clinical behavior of gastric stromal tumors.

Combined laparoscopic and endoscopic retrieval of a migrated self-expanding metal stent

Self-expanding metal stents have been used for the palliation of esophageal carcinoma since 1990. They are easier to insert, with a lower perforation risk compared with the older plastic tubes, hence their popularity. 1 Cowling MG Hale H Grundy A Management of malignant oesophageal obstruction with self-expanding metallic stents. Br J Surg. 1998; 85: 264-266 Crossref PubMed Scopus (46) Google Scholar , 2 Neuhaus H The use of stents in the management of malignant oesophageal strictures. Gastrointest Endosc Clin N Am. 1998; 8: 503-519 PubMed Google Scholar , 3 Raijamn I Siddique I Ajani J Lynch P Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients. Gastrointest Endosc. 1998; 48: 172-179 Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar However, once deployed, they are difficult to reposition and are also prone to migration; hence a series of stents has been placed in many patients. 4 Acunas B Rozanes I Akpinar S Tunaci M Acunas G Palliation of malignant oesophageal strictures with self-expanding nitinol stents: drawbacks and complications. Radiology. 1996; 199: 648-652 Crossref PubMed Scopus (117) Google Scholar , 5 Lagattolla NR Rowe PH Anderson H Dunk AA Restenting malignant oesophageal strictures. Br J Surg. 1998; 85: 261-263 Crossref PubMed Scopus (21) Google Scholar There have been sporadic reports of migrated stents being retrieved from the stomach endoscopically. 6 Nayyar S Cho KC Trotman BW Palliation of oesophageal cancer with a self-expanding, silicone covered stent and a technique for stent retrieval. J Assoc Acad Minor Phys. 1996; 7: 78-82 PubMed Google Scholar , 7 Noyer CM Forohar F A simple technique to remove migrated esophageal stents. Am J Gastroenterol. 1998; 93: 1595 Crossref PubMed Scopus (12) Google Scholar We describe a patient who had 2 such metal stents in the stomach that could not be retrieved endoscopically. The transgastric laparoscopic approach has been used for the treatment of trichobezoars, pancreatic pseudocysts and solid tumors of the stomach and duodenum. 8 Basso N Silecchia G Pizzuto G Surgo D Picconi T Materia A Laparoscopic excision of posterior gastric wall leiomyoma. Surg Laparosc Endosc Percutan Tech. 1996; 6: 65-67 Crossref Scopus (27) Google Scholar , 9 Cuesta MA Eijsbouts QA Felt-Bersma RJ van den Berg M Transgastric endoluminal laparoscopic resection of a duodenal polyp. Surg Laparosc Endosc Percutan Tech. 1998; 8: 322-323 Crossref Scopus (8) Google Scholar , 10 Geis WP Baxt R Kim HC Benign gastric tumors: minimally invasive approach. Surg Endosc. 1996; 10: 407-410 Crossref PubMed Scopus (43) Google Scholar , 11 Holeczy P Danis J Laparoscopic transgastric pancreatic pseudocystogastrostomy: first experience with extraluminal approach. Hepatogastroenterology. 1998; 45: 2215-2218 PubMed Google Scholar , 12 Ibrahim IM Silvestri F Zingler B Laparoscopic resection of posterior gastric leiomyoma. Surg Endosc. 1997; 11: 277-279 Crossref PubMed Scopus (48) Google Scholar , 13 Nirasawa Y Mori T Ito Y Tanaka H Seki N Atomi Y Laparoscopic removal of a large gastric trichobezoar. J Pediatr Surg. 1998; 33: 663-665 Abstract Full Text PDF PubMed Scopus (88) Google Scholar Simultaneous endoscopy and laparoscopy have also been used to gain better visualization and control during these procedures. 9 Cuesta MA Eijsbouts QA Felt-Bersma RJ van den Berg M Transgastric endoluminal laparoscopic resection of a duodenal polyp. Surg Laparosc Endosc Percutan Tech. 1998; 8: 322-323 Crossref Scopus (8) Google Scholar , 12 Ibrahim IM Silvestri F Zingler B Laparoscopic resection of posterior gastric leiomyoma. Surg Endosc. 1997; 11: 277-279 Crossref PubMed Scopus (48) Google Scholar We describe here a technique, building on the experience of other laparoendoscopic surgeons, to retrieve these migrated stents from the stomach.

Loss of p16 and p27 is associated with progression of human gastric cancer

We performed the immunohistochemical staining for six G1 check point cell cycle proteins to study their expression patterns and roles in the gastric carcinogenesis. We studied 76 cases of paraffin blocks that included the sections of 18 tubular adenomas (TA), 38 early gastric carcinomas (EGC) (20 cases of mucosal type, nine cases of submucosal type with no nodal metastasis, nine cases of submucosal type with nodal metastasis), 20 advanced gastric carcinomas (AGC) (ten cases with no nodal metastasis, ten cases with nodal metastasis). We found that abnormal expression of p16 and p27 increased with the progression of tubular adenomas to advanced gastric cancers. Inverse relationship between pRb and p16 proteins was found in a small portion of the gastric tumors. Expressions of pRb and cdk4 were consistently high in benign and malignant gastric tumors. Expression of cyclin D1 and cyclin E rather decreased with the tumor progression. In conclusion, losses of p16 and p27 seem to play a significant role during the gastric carcinogenesis, and the G1 checkpoint cell cycle proteins such as pRb, cdk4, cyclin D1, and cyclin E variably participate in the gastric carcinogenesis and metastasis by the mechanisms which are yet unknown; thus, further studies need to be performed to elucidate the mechanisms.

4727 Reassessment of usefulness of eus in differentiation of benign and malignant gastric stromal tumors which were diagnosed according to pathologic guidelines of ackerman's surgical pathology.

Backgrounds: GISTs originate from mesenchymal tissue within the GI tract, and it is difficult to differentiate between benign and malignancy by endoscopy. Although recent development of EUS allows a trial of differentiation from benign and malignant stromal tumors, its diagnostic accuracy is controversial. The aim of this study is to determine whether EUS can differentiate between benign and malignant gastric stromal tumors. Materials and Methods: EUS was performed prior to endoscopic resection or surgical resection of 38 gastric stromal tumors. EUS features such as tumor size(diameter>4 cm), irregular extraluminal border, echogenic foci, and cystic spaces, which were proposed by Chak A et al. as EUS findings of malignant GISTs(Gastrointest Endosc 1997) were evaluated. Pathologic diagnosis was based on guidelines of Ackerman's surgical pathology (Ackerman's surgical pathology 8th ed, 1996). Results: Subjects consisted of 12 males and 26 females. 22 cases has been endoscopically resected, 16 cases surgically removed. The results of immunohistochemical staining showed 12 cases of smooth muscle type, 7 cases of neural type, 1 case of mixed type and 18 cases of uncommitted type. On the basis of above immunohistochemical results and histologic findings, 12 cases were regarded as benign, 17 cases as potentially malignant or malignant, and 9 cases as malignant. Analyses of EUS features according to the criteria of Chak et al. are shown in the following table. Conclusion: When gastric stromal tumors were diagnosed with criteria from Ackerman's surgical pathology, EUS features, which were proposed by Chak et al, were assessed to be less useful in differentiating between benign and malignant stromal tumors. Backgrounds: GISTs originate from mesenchymal tissue within the GI tract, and it is difficult to differentiate between benign and malignancy by endoscopy. Although recent development of EUS allows a trial of differentiation from benign and malignant stromal tumors, its diagnostic accuracy is controversial. The aim of this study is to determine whether EUS can differentiate between benign and malignant gastric stromal tumors. Materials and Methods: EUS was performed prior to endoscopic resection or surgical resection of 38 gastric stromal tumors. EUS features such as tumor size(diameter>4 cm), irregular extraluminal border, echogenic foci, and cystic spaces, which were proposed by Chak A et al. as EUS findings of malignant GISTs(Gastrointest Endosc 1997) were evaluated. Pathologic diagnosis was based on guidelines of Ackerman's surgical pathology (Ackerman's surgical pathology 8th ed, 1996). Results: Subjects consisted of 12 males and 26 females. 22 cases has been endoscopically resected, 16 cases surgically removed. The results of immunohistochemical staining showed 12 cases of smooth muscle type, 7 cases of neural type, 1 case of mixed type and 18 cases of uncommitted type. On the basis of above immunohistochemical results and histologic findings, 12 cases were regarded as benign, 17 cases as potentially malignant or malignant, and 9 cases as malignant. Analyses of EUS features according to the criteria of Chak et al. are shown in the following table. Conclusion: When gastric stromal tumors were diagnosed with criteria from Ackerman's surgical pathology, EUS features, which were proposed by Chak et al, were assessed to be less useful in differentiating between benign and malignant stromal tumors.

Indications for endo-organ gastric excision.

Intragastric surgery for benign and malignant conditions is a new form of minimally invasive surgery, to which the term endo-organ gastric surgery has been applied. This procedure may provide improved results for patients, but reported studies are small, and follow-up evaluation is limited. The indications for endo-organ surgery are evolving as technology and operative expertise begin to meet the need for continued advancements in miniaturized surgery. This new approach is applied primarily to the removal of gastric neoplasms poorly positioned or too large for standard transoral endoscopic excision. Gastric polyps, benign gastric wall tumors such as leiomyomas and carcinoids, and low-grade as well as high-grade malignancies can be removed. The history of endo-organ surgery, the background technology, and surgical experience are reviewed. In addition, current indications for endo-organ surgery and the rationale for algorithms are included. Intraluminal gastric surgery is not widely performed or studied, therefore a further understanding of its role is provided.

Endogastric surgery.

Endogastric surgery is a branch of minimally invasive surgery that combines flexible endoscopy and laparoscopy. By placing trocars directly into the stomach, quite a number of procedures may be performed. Leiomyomas and other benign gastric tumors are readily removed, and in Asia early gastric cancers are removed with these techniques. Large pancreatic pseudocysts abutting the posterior wall of the stomach may be drained through the stomach using an endogastric approach. Lastly, intragastric bleeding in areas not reachable with a conventional endoscope may be approached with an endogastric approach. Although the indications for these procedures are-in general-rare, they are not difficult to perform, and outcomes have been superb.

Mutations in mitochondrial control region DNA in gastric tumours of Japanese Patients

The non-coding control region of mitochondrial DNA (mtDNA), containing the hypervariable regions HV1 and HV2 and the D-loop region, was screened for mutations in 45 gastric tumours (15 tumours each of adenoma, differentiated adenocarcinoma and undifferentiated carcinoma). We found mutations in two of the 45 tumours (4%); a 1bp A deletion at nucleotide position 248 in a differentiated adenocarcinoma and a G to A transition at nucleotide position 16129 in an adenoma. We also observed 10 polymorphisms, four of which were not previously recorded. Both mtDNA mutations were present in replication error negative (RER−) tumours. Short mono- or dinucleotide repeats in the control region, such as (C)7, (A)5 or (CA)5, were not altered regardless of nuclear genetic instability. In summary, mtDNA is mutated in a subset of benign and malignant gastric tumours, but, disruption of the mtDNA repair system appears not to be significantly involved in gastric tumours of Japanese patients.

Minimally invasive management of low-grade and benign gastric tumors.

Benign gastric tumors and tumors of low-grade malignancy can be safely removed laparoscopically. Seven patients were considered candidates for laparoscopic resection of gastric tumors. Inclusion criteria included small tumor size (less than 6 cm), exophytic or endophytic tumor morphology, and benign characteristics. Indications for surgical intervention included bleeding, weight loss, and need for tissue diagnosis. Patients ranged in age from 38 to 70. There were five female and two male patients. All patients underwent preoperative upper GI endoscopy. The procedures were performed using a four- or five-port technique. An Endo-GIA (US Surgical Company, Norwalk, Connecticut) was used to amputate those tumors located on the serosal surface of the stomach. Tumors on the mucosal surface were exposed via a gastrotomy, then likewise amputated using an Endo-GIA. The gastrotomy closure was then either hand sewn or stapled. Operating time ranged from 95 to 225 min. Final pathologic diagnoses included lipoma, lymphoma, leiomyoma, and leiomyosarcoma. There was a 28% conversion rate. There were no complications. Length of postoperative stay ranged from 4 to 7 days. There have been no tumor recurrences in 6-38-month follow-up. Minimally invasive management of benign and low-grade gastric tumors can be performed safely with excellent short- and long-term results.

Laparoscopic Local Resection for Benign Nonepithelial Gastric Tumors

After experience in laparoscopic cholecystectomy and improvement of laparoscopic instruments, we attempted laparoscopic resection of benign nonepithelial gastric tumors using Endo-GIA. We achieved successful results with this procedure in 2 cases. There were no intra- and postoperative complications. For both patients there was no recurrence during the follow-up period (3.3 and 1.5 years). The important points of this approach are confirmation of the location of the tumor by both gastroendoscopy and laparoscopy, proper selection of the trocar site for insertion of the Endo-GIA, and secure grasping and lifting of the gastric wall, including of the tumor. We conclude that this procedure is technically feasible, safe and useful for benign nonepithelial gastric tumors.

Laparoscopic resection of benign tumors of the posterior gastric wall

Laparoscopic wedge excision of benign gastric tumors using stapling instruments alone is not feasible for distal lesions and some tumors arising from the posterior gastric wall. An alternative transgastric approach to distal posterior wall lesions utilizing an anterior gastrotomy for access has been successfully applied in two reported cases.

Benign gastric tumors Minimally invasive approach

Benign gastric tumors Minimally invasive approach

Laparoscopic-assisted resection of a gastric lipoma

Laparoscopic excision of a gastric lipoma is reported here. The diagnosis was done preoperatively be computed tomography, which gave evidence of fat tissue due to its low attenuation. The patient undergoes a complete submucosal excision enjoying the benefit of the laparoscopic approach with rapid postoperative recovery. This procedure offers a good alternative to open laparotomy in the treatment of benign gastric tumours.

MINIMAL ACCESS GASTRODUODENAL SURGERY

Considerable advances are occurring in the application of laparoscopic techniques to gastrointestinal and hepatobiliary disorders. Following studies in experimental animals, surgeons with an interest in gastroduodenal disease have now introduced laparoscopic techniques into current surgical practice. Elective intervention for peptic ulcer disease is currently being established, particularly in patients with proven negative Helicobacter pylori (HP) status, or when eradication has proved unsuccessful with various drug regimens. In addition, emergency laparoscopic intervention for perforation is gaining acceptance, with or without a definitive anti-ulcer procedure. Therapeutic endoscopy for bleeding peptic ulcer may well be followed by anti-ulcer laparoscopic surgery in selected patients. Laparoscopic techniques have been utilized for the treatment of Mallory Weiss tear, congenital hypertrophic pyloric stenosis, Dieulafoy's lesion, gastric trauma or volvulus and benign gastric tumours. More ergonomic instruments are required before laparoscopic gastric resection becomes more widely acceptable. It is essential that objective evaluation of variations on vagotomy themes be undertaken in prospective clinical trials and that the safety and efficacy of gastric resection procedures be substantiated if this renaissance is to revolutionize gastroduodenal surgical practice.

Gastric Adenocarcinoma and Helicobacter pylori Infection

Helicobacter pylori infection, thought to be causally related to chronic gastritis, may also be associated with an increased risk of gastric cancer. To determine whether an association with gastric cancer does exist, we retrospectively evaluated serum samples from 69 patients with histologically confirmed gastric adenocarcinoma (32 with cancer at the cardia and 37 with cancer at other sites) and from 218 patients with one of three categories of nongastric cancers, with other gastric cancers, or with benign gastric neoplasms. These samples were compared with samples from 252 cancer-free control subjects, a group comprising 76 asymptomatic volunteers and 176 persons with nonmalignant disorders. Serum samples collected from cancer patients prior to surgery and from cancer-free controls were tested for antibodies to H. pylori by using a highly sensitive and specific IgG enzyme-linked immunosorbent assay. The risk of H. pylori infection in the case patients relative to the control subjects was estimated with the use of multivariate logistic regression analysis to adjust for potential confounding variables. Antibodies to H. pylori were detected in 65% of the patients with noncardia gastric cancer but in only 38% of the patients with gastric cancer located at the cardia. A significant association was found between H. pylori infection and noncardia gastric cancer (odds ratio = 2.67; 99% confidence interval = 1.01-7.06). Within the subset of patients with noncardia gastric cancer, a statistically nonsignificant tendency existed for those with the intestinal versus the diffuse histologic type of noncardia gastric cancer to have a higher risk of H. pylori infection. Our results support the hypothesis of a relationship between H. pylori infection and the development of noncardia gastric adenocarcinoma.

Nucleolar organizer regions in myogenic stromal tumours of the stomach

Silver staining of nucleolar organizer regions (AgNOR) was studied in 26 primary benign and malignant gastric stromal tumours of myogenic origin. The absolute number of AgNOR per nucleus and the size of AgNOR were compared with histomorphologic features of the tumours. The total number of AgNOR per nucleus in epithelioid and spindle cell leiomyosarcomas significantly (p less than 0.001) exceeded that in leiomyomas, cellular leiomyomas and epithelioid leiomyoblastomas. The mean number or the size of AgNOR did not correlate with the number of mitoses or the tumour size. In addition, large and bizarre AgNOR were seen predominantly in histologically malignant tumours. Only one exceptional epithelioid leiomyoblastoma recurred despite a lack of conventional characteristics of malignancy and a low AgNOR count. Therefore, quantitative determination of the number of AgNOR is a new independent variable in myogenic gastric tumours. It provides additional information for the histopathological evaluation of this heterogenous group of mesenchymal tumours.

Leiomyosarcomas and Benign Smooth Muscle Tumors of the Stomach: Nuclear DNA Patterns Studied by Flow Cytometry

Paraffin-embedded archival tissue samples were used for determination of DNA ploidy by flow cytometry on 117 surgically resected gastric smooth muscle tumors (44 leiomyosarcomas, 53 leiomyomas, and 20 benign leiomyoblastomas). The technique of Hedley was used for preparation of paraffin-embedded tissue into single dissociated nuclei, and the method of Vindeløv was used for staining with propidium iodide. Among the 53 leiomyomas, the DNA ploidy pattern was diploid in most tumors (87%), except for 2 DNA tetraploid/polyploid and 5 DNA aneuploid samples. In comparison, the 20 benign leiomyoblastomas had more frequent abnormal DNA histograms: DNA tetraploidy/polyploidy in 5 (25%) and DNA aneuploidy in 2 (10%). The DNA histograms of the 44 leiomyosarcomas (including 4 epithelioid leiomyosarcomas) were classified as follows: 20 cases (45%) exhibited a DNA diploid pattern, 14 cases (32%) had a DNA tetraploid/polyploid pattern, and 10 cases (23%) had DNA aneuploid peaks. For the patients with leiomyosarcomas, the DNA ploidy pattern was significantly correlated with survival (P less than 0.001), as were tumor grade (P less than 0.001) and tumor size (P less than 0.05). Furthermore, both benign and malignant gastric smooth muscle tumors with DNA tetraploid/polyploid patterns were significantly larger than those with a DNA diploid histogram (P less than 0.05). DNA ploidy pattern cannot be used for diagnosis--that is, to distinguish malignant from benign gastric smooth muscle tumors. For gastric leiomyosarcomas, however, nuclear DNA ploidy pattern is an easily measured objective determination with important prognostic significance.

Staging of Gastric and Esophageal Carcinoma by Means of Endoscopic Ultrasonography

Endoscopic ultrasonography (EUS) enables an exact evaluation of the wall of the upper GI tract. The esophageal and the gastric wall give a typical five-layer image, presumably corresponding to the mucosa, submucosa, tunica muscularis propria, and serosa. Gastric ulcers are often accompanied by a thickening of the gastric wall (10.4 ± 3.7 mm) compared with the normal gastric wall (3.7 2 0.6 mm; p < 0.001). Malignant tumors show an irregular structure with infiltration into the wall and into neighboring tissues with destruction of the GI wall. Para-esophageal and para-gastric lymph node metastases can be visualized. Benign esophageal and gastric tumors are sharply delineated from the surrounding tissue. The results suggest that, by EUS, it is possible to differentiate carcinomas from benign submucosal tumors of the upper GI tract and to judge the extent of the infiltration and the stage of the malignant process.