Gastric Wedge Resection Research Articles

Non-healing Gastric Ulcer: Rare Presentation of Metastatic Seminoma

Purpose: Introduction: Metastatic seminoma presenting as gastric ulcer and hemorrhage is rare. Liver, lung, and bones are the most common locations of metastasis. Case Description: 39-year-old Hispanic male with history of end stage renal disease (ESRD) requiring hemodialysis and hypertension that presented to the hospital with hematemesis. Esophagogastroduodenoscopy (EGD) showed 2 large cratered antral ulcers ranging from 12 mm to 15mm. The ulcers were actively oozing and were treated with epinephrine and bipolar electrocoagulation (BICAP). A second look EGD to re-evaluate the ulcer was performed. Multiple biopsies were taken at this time to rule out a malignant ulcer. The pathology returned negative for malignancy, but presence of some atypical cells on the cautery end. The patient re-presented to the emergency room 6 months and 8 months later with continued episodes of hematemesis. Repeat endoscopy were performed and showed chronic large gastric ulcer with raised irregular borders with visible vessel. The ulcers were again treated with epinephrine, endoclips, and BICAP. Computed tomography (CT) scan of the abdomen and pelvis were performed. Findings showed an enlarged pelvic mass, retroperitoneal lymph node, and large bilateral inguinal hernias. He underwent laprascopic pyloromyotomy and gastric wedge resection for non-healing gastric ulcer as well as pelvic mass resection. Pathology returned metastatic poorly differentiated seminoma. He was found to have metastasis to stomach and retroperitoneal perigastric lymph nodes. It is suspected that the seminoma originated from the pelvic mass, which may actually be an undescended testis. It is suspected that due to his inguinal hernias, he actually had large bowel in his scrotum. Alpha-fetoprotein and lactated dehydrogenase were normal, but had a mildly elevated beta- human chorionic gonadotropin (HCG). He is scheduled to undergo chemotherapy. Discussion: Upper gastrointestinal bleeding as a presentation of metastatic seminoma is quite rare. Only 2.5% of seminomas are metastatic on initial presentation. Liver, lung and bones are the most common locations of metastasis. The reported incidence of metastases to the stomach has ranged from 0.2% to 0.7%. There have been reports of a “burned-out” phenomenon where a metastatic germ cell tumor is present with a regressed testicular primary. This may be a variant of that situation as the pelvic mass is suspected to be an undescended testis, but was not confirmed by pathology.

Loop-and-let-go technique for a bleeding, large sessile gastric gastrointestinal stromal tumor (GIST)

A 77-year-old woman was admitted for syncope followed by melena. She was under oral anticoagulant therapy for atrial fibrillation. An urgent upper endoscopy revealed active oozing of blood from an ulcer crater on the surface of a 3.5-cm, sessile submucosal tumor at the gastric fundus. Endoscopic hemostasis was achieved by epinephrine injection and application of hemoclips ([Fig. 1]). Although surgical gastric wedge resection is considered the gold standard treatment for such lesions ≥ 2 cm in size, since the patient presented a high risk for general anaesthesia and recurrent bleeding as well as the need of further anticoagulant therapy, we were forced to consider endoscopic treatment. Endoscopic snare resection and submucosal dissection are associated with a significant risk of perforation [1]. Endoscopic band ligation technique has been described as effective for smaller lesions [2]. Another alternative, the endoloop technique, has also been recently reported as potentially effective, provided the loop is tightened around the base of the lesion, which results in tissue strangulation and slow mechanical transection of a gastrointestinal stromal tumor (GIST), that is, ischemic necrosis followed by spontaneous sloughing [3].

Laparoscopic Gastric Wedge Resection and Prophylactic Antireflux Surgery for a Submucosal Tumor of Gastroesophageal Junction

A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

Surgical management of gastric gastrointestinal stromal tumor: A single center experience

Background/Aim:Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Our objective is to evaluate the outcome of surgical treatment of primary gastric GIST.Materials and Methods:Between January 1997 and April 2008, thirty seven consecutive patients underwent resection for GISTs (35 patients with primary gastric GISTs and two patients with intestinal GISTs who were excluded from the study). These patients underwent upper endoscopy ± biopsy, barium meal and abdominal CT scan. Patients’ demographics and clinical presentations were analyzed. Perioperative parameters measured included operative times, estimated blood loss, intraoperative finding, surgical techniques, morbidity and length of hospitalization. Recurrence and survival were also analyzed.Results:Of the 35 patients with gastric GISTs included in the study, 63% were female. The median age was 59 ± 14 years (range, 23 to 75 years). The primary presenting symptoms were bleeding and dyspepsia; 43% of these tumors were located mainly in the body of the stomach. Tumor size was < 10 cm in 80% of the patients. The average tumor size was 6.3 ±3.2 cm (range from 3 to 13 cm). Regarding the surgical management, 20 patients (57%) underwent gastric wedge resection, eight patients (23%) underwent partial gastrectomy and the remaining seven patients (20%) underwent total gastrectomy. Radical resections were found in 32 patients (91.5%) while palliative resections were found in three patients (8.5%). The resected lymph nodes were negative in 32 patients (91.5%). Recurrence was noted in three patients, with a median time to recurrence of 14.3 months (range, 7 to 28 months). The three- and five-years survival in patients who underwent wedge resection was 92% and 81%, respectively, where it was 95% and 87%, respectively, in patients who underwent gastrectomy (either partial or total). There were no major intraoperative complications or mortalities.Conclusion:Complete surgical resection either through wedge resection or gastrectomy with negative margins remains the gold standard treatment in the management of patients with primary resectable gastric GISTs.

Recurring gastrointestinal stromal tumor with splenic metastasis

Malignant gastrointestinal stromal tumors (GISTs) are rare non-epithelial, mesenchymal neoplasms of the gastrointestinal tract that metastasize or recur in 30% of patients who undergo surgical resection with curative intent. A 59-year-old man visited our hospital for an examination of a palpable mass in the left abdomen. Fourteen months prior to his visit, the patient underwent gastric wedge resection to remove a GIST of the gastric cardia. At the time of surgery, no evidence of metastatic disease was observed and the pathological interpretation was a high-risk GIST. A follow-up computed tomography scan of the abdomen revealed a partially necrotic solid mass (9.8 × 7.6 cm) and enhancing mass in the spleen (2.3 cm). On exploration, multiple masses were found in the liver, greater omentum, and mesentery. Here, we report a case of recurring GIST of the stomach that metastasized to the spleen. To the best of our knowledge, few reports of metastasis to the spleen exist.

Single-incision laparoscopic gastric resection for submucosal tumors: Report of three cases

Between March and April 2009, three consecutive patients underwent single-incision laparoscopic gastric wedge resection for a submucosal tumor located in the anterior wall or greater curvature of the stomach. First, we placed two or three trocars through the same infra-umbilical skin incision. Then, we either elevated the tumor with a mini-loop retractor or retracted the gastric wall near the tumor with a laparoscopic grasper. Finally, we resected the tumor using an endoscopic linear stapler. Single-incision laparoscopic gastric resection was successfully completed in all three patients without the need for any extraumbilical skin incisions or conversion to conventional laparoscopic procedures. There was no morbidity. The mean operating time and blood loss were 86 min and 4 ml, respectively, and the mean tumor size and surgical margin were 34 mm and 8 mm, respectively. Histopathologically, two tumors were diagnosed as gastrointestinal stromal tumors and one as a carcinoid tumor. Thus, single-incision laparoscopic gastric resection for submucosal tumors is safe and feasible when performed by experienced laparoscopic surgeons using conventional laparoscopic instruments.

Laparoscopic wedge resection will be the optimal treatment for nonepithelial, submucosal gastric tumors

We thank Professor Zoras and Dr. Spiliotis for their interest in our article. I also believe that extraluminal laparoscopic gastric wedge resection (ELWR) will be the optimal treatment for nonepithelial, submucosal gastric tumors. First, gastrointestinal stromal tumor (GIST) cells tend to metastasize through hematogenous or transabdominal implantation and rarely through lymphatic vessels, so routine lymph node dissection is not recommended [1, 2]. Such characteristics of GIST determine that open surgery can be replaced by laparoscopy in the treatment of most gastric stromal tumors, in contrast to the management of epithelial gastric tumors. Second, I absolutely agree that the surgeon plays a central role in operative and oncologic safety during laparoscopic gastric surgery. Not only D2 lymph node dissection for gastric cancer but also ELWR for submucosal tumors in the upper part of the stomach during laparoscopic surgery is a demanding procedure and should currently always be performed appropriately only in specialized institutions. In our hospital, laparoscopic surgery was introduced in 1992, and I with my colleagues have been performing laparoscopic gastric surgery since 1993 [3], so we have more opportunities (including cases and skill promoting) than others. In our early experience (1997–1999), we had about a 10.5% (2/19) rate for postoperative complications such as esophagostenosis and gastric incision leakage, which urged us to explore a novel strategy for treating submucosal tumors. Since 2000, we have used ELWR to treat GISTs in the upper part of the gastric body and in the gastric fundus [4]. Finally, but importantly, in our study, the largest tumor had a diameter of 6.5 cm. We believe that patients with tumors smaller than 5 cm in diameter will have a better prognosis. To perform the ELWR procedure better, we also complied with the principle of no touch and less squeeze during the procedure, fully exposed the surgical area, and sufficiently resected the tumors. As long as these precautions are taken, I believe ELWR for submucosal tumors in the upper part of the stomach is safe, effective, and oncologically sound.

Feasibility of Laparoscopic partial gastrectomy with sentinel node basin dissection in a porcine model

This study aimed to evaluate the technical feasibility and safety of laparoscopic partial full-thickness gastrectomy with extensive sentinel node basin (SB) dissection in a porcine model before its application to gastric cancer without lymph node metastasis. A series of 10 pigs (30-37 kg) were used for a survival study approved by an animal use committee. The imaginary lesions were located in the greater curvature (n = 2), lesser curvature (n = 2), anterior wall (n = 2), posterior wall (n = 2), cardia (n = 1), and angle of the stomach (n = 1). The SBs were assumed to be located around each lesion in question. Laparoscopic partial gastrectomy and SB dissection were performed. Upper gastrointestinal series (UGIS) studies were performed with gastrograffin 5 days after the operation to detect possible stricture, leakage, and passage problems. The pigs were kept alive for 3 weeks, then killed. The procedure was completed for all the pigs. Nine gastric wedge resections and one segmental resection of the stomach with several SB dissections were performed. The mean operation time was 102 min (70-150 min). The postoperative mean weight gain was 3.19 kg. There was no perioperative morbidity or mortality. The UGIS studies failed to detect leakage and stricture, but all the pigs exhibited delayed gastric emptying. Necropsies did not detect procedure-related complications. As shown by a pig model, laparoscopic limited gastrectomy with SB dissection appears to be safe and technically feasible.

Laparoendoscopic Single-Site Gastrectomy for a Gastric GIST Using Double-Bended Instruments

Laproscopic single-site surgery is the natural evolution of minimally invasive surgery. A 70-year-old male was planned for a resection of a gastric GIST (gastrointestinal stromal tumor). A Triport trocar (Olympus, Aartselaar, Belgium) was placed through a 2-cm periumbilical incision. Besides the placement of a Nathanson liver retractor in the subxiphoidal position, no additional trocars had to be added. The partial gastrectomy was carried out by using clinical prototypes of double-bended intruments and of a "goose neck" videolaparoscope, all specially designed for single-port surgery. Total operative time was 140 minutes, and estimated blood loss was 10 mL. No intra- or postoperative complications occurred. Hospital stay was 4 days. Final pathology revealed the complete resection of a GIST tumor of gastric origin. We have demonstrated the technical feasibility and described the detailed surgical technique of laparoendoscopic single-site surgery gastric wedge resection.

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases

Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. All of the procedures were performed successfully, with mean operation time of 62.6 +/- 8.9 min and mean intraoperative blood loss of 86.2 +/- 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7-2.5 cm, with a mean distance of 1.4 +/- 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 +/- 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection.

Single Port Endolaparoscopic Surgery (SPES) in Double Abdominal Procedures

Background: Single port endolaparoscopic Surgery (SPES) has gained enthusiasm in the surgical community because of the perceived better postoperative outcome, namely a single incision. We write this prospective observational study to ascertain the feasibility and safety of this technique in patients needing two operations. Methodology: Three patients who underwent double procedures each. Case 1: Transabdominal preperitoneal hernia repair with gastric wedge resection. Case 2: Cholecystectomy with diaphragmatic hernia repair. Case 3: Oophorectomy with incisional hernia repair. Patient demographics, type of port used, operating time, complications and scar length were collected. Results: Operating time for the first case was 250, 210 and 105 minutes respectively. Incision length varied from 2 to 3 cm. Addition of a 5 mm port and an intraoperative complication of a laceration of the liver after suturing of the gallbladder fundus was noted in the second case. Conclusion: SPES is a feasible and safe technique for approaching double procedures. It drastically reduces the number of scars that a double procedure creates and if difficulty arises another port can always be added to ease the operation.

Safety of Gastric Resections During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

Cytoreductive surgery (CRS) including gastric resection combined with hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancies. Perioperative morbidity of this aggressive treatment strategy is high; however, overall mortality can be low in specialized centers. The aim of this study was to assess the safety of gastric resections with anastomosis during CRS and HIPEC. Between 2005 and 2008, 204 patients underwent CRS and HIPEC at our tertiary referral centre. Of these, 37 procedures (male/female 24/13, median age 55 years) included gastric resections. The clinical data of all patients were introduced into a database and analyzed with respect to the morbidity associated with the gastric resections. Of all patients included, 16 had pseudomyxoma peritonei, 11 gastric carcinoma, 4 ovarian carcinoma, 3 malignant peritoneal mesothelioma, and 3 colon carcinoma. Twenty-seven patients had previous surgery (n = 22) and/or systemic chemotherapy (n = 18). Fifteen total gastrectomies, 3 subtotal gastrectomies, 12 distal gastrectomies, and 7 gastric wedge resections were performed during CRS. The overall postoperative morbidity was 45%; main surgical complications were pancreatitis (n = 6), abdominal abscess (n = 4), bile leakage (n = 2), and digestive fistula (leakage of ileorectostomy and small bowel perforation) (n = 2). However, no complications occurred at the site of the esophageal anastomosis (n = 15), gastric anastomosis (n = 15) or gastric suture (n = 7). No patient died postoperatively during the hospitalization period. CRS in combination with HIPEC is associated with high postoperative morbidity; however, anastomosis following total or subtotal gastrectomy is safe in experienced centers. No leakages related to gastric resections occurred in this high-risk patient group.

Ancillary N.O.T.E.S. procedures for early stage gastric cancer

The potential for performing truly scarless, safe surgery that at the same time may be less morbid is tempting both patients and physicians alike to seriously consider Natural Orifice Transluminal Endoscopy Surgery (NOTES) for a range of clinical applications. Given the move towards gastric-preservation by minimally invasive techniques for definitive management of early gastric cancer, this radical approach may find a niche within future clinical care paradigms for early stage malignant lesions of the stomach. Indeed already selected T1,N0 adenocarcinoma is being treated and even cured by advanced endoscopic techniques such as Endoscopic Submucosal Dissection. NOTES may initially therefore find a role in furthering the application of such endeavour by ensuring oncological providence in the treatment of those T1 lesions with higher risk of lymphatic metastases that currently are advised to lie outwith the scope of pure endoscopic resection (for reasons of oncological propriety rather than technical capacity). One such means NOTES could supplement ESD is by providing for direct sampling of sentinel nodes from the perigastric lymph basins. Subsequently perhaps a NOTES technique may develop capable of performing localized, full-thickness gastric wedge or sleeve resection for T2,N0 adenocarcinoma (and indeed perhaps other pathologies such as small gastrointestinal stromal tumors). This review examines how advancing technology along with progressive surgical thinking and innovation could lead to NOTES becoming absorbed into clinical care pathways for early gastric malignancy.

Tumeur endocrine développée sur pancréas ectopique gastrique

We report the case of a 49-year-old caucasian woman, in whom an endocrine tumor arising in gastric heterotopic pancreas was diagnosed. The patient was treated surgically with a gastric wedge resection. Heterotopic pancreas is a benign anatomic condition, probably widely underdiagnosed because usually asymptomatic. The malignant transformation of aberrant pancreas is very rare and almost always in adenocarcinoma. The endocrine tumors developed in heterotopic pancreas are exceedingly rare. Of our knowledge, only four cases have been published and only one case in the gastric location similar to this reported case.

Exophytic inflammatory myofibroblastic tumor of the stomach in an adult woman: A rare cause of hemoperitoneum

Inflammatory myofibroblastic tumor (IMT) of the stomach in adults is extremely rare, with unpredictable prognosis. We present a 55-year-old woman with a gastric IMT. She experienced sudden abdominal pain 4 d previously. Physical examination showed mild abdominal tenderness in the hypogastrium, but no palpable abnormal abdominal mass. Abdominal CT showed a mass of approximately 8 cm in the gastrocolic ligament. On laparoscopic exploration, unexpected hemoperitoneum of approximately 1.5 L of blood was found, and an exophytic gastric mass of approximately 10 cm, appeared from the anterior wall of the gastric body along the greater curvature. Laparoscopy further showed that non-clotting blood in the abdominal cavity seemed to be from the gastric tumor. After conversion to open surgery for more precise evaluation of the cause of hemoperitoneum and the large friable tumor, gastric wedge resection, including the tumor, was conducted. The final diagnosis was consistent with IMT that originated from the gastric wall.

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size. Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device. In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases. The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.

Low Incidence of Adhesion-Related Bowel Obstruction After Laparoscopic Colorectal Surgery

Postoperative adhesions are a major cause of morbidity, accounting for approximately 5% of the readmissions of surgical patients. Bowel obstruction is attributed to adhesions in more than half of the cases, many of which are following colon and rectal surgery. Laparoscopic surgery has the potential advantage of reduced adhesion formation owing to attenuated surgical trauma, less tissue handling, and smaller scars. However, the translation of these advantages to a reduced rate of bowel obstruction has not been sufficiently demonstrated. The aim of this study was to assess the rate of adhesion-related bowel obstruction after laparoscopic colon and rectal surgery. Data regarding all cases of laparoscopic colon and rectal surgery were prospectively collected. Information relative to demographics, surgical procedures, and follow-up was analyzed, and patients who were readmitted for bowel obstruction were identified. Over a period of 8 years, 306 patients, at a mean age of 63 years, had a laparoscopic colon and rectal operation in our department-122 for benign conditions and 184 for malignant disease. The mean length of follow-up was 38 months. Six cases (2%) of bowel obstruction, which were unrelated to hernia or advanced cancer, were identified. Two patients had a history of open surgery, in addition to the laparoscopic procedure, so adhesions could be attributed solely to the laparoscopic procedure in 4 patients, which consisted of 1.3% of the total study group. Obstruction occurred within 2 weeks of surgery in 2 patients, and one early reoperation was required. The incidence of adhesion ileus after laparoscopic colon and rectal surgery appears to be very low. This long-term benefit of laparoscopic surgery should be considered when comparing this technique to its open counterpart.

Laparoscopic surgery for gastric and small intestinal stromal tumors

To evaluate laparoscopic surgery for gastric and small intestinal stromal tumors. The clinical data of patients with laparoscopic resection of gastric and small intestinal tumors, admitted to our center from Dec. 2003 to Jul. 2006, were retrospectively analyzed. The data included the surgical procedure, operative time, blood loss, length of incision, time for passage of flatus, postoperative length of stay, operative complications, pathology and the results of follow-up. All the 33 patients with gastric and small intestinal stromal tumors were treated by laparoscopic procedures successfully, including 8 laparoscopic gastric wedge resections, 8 laparoscopic transgastric tumor-everting resections, and 17 laparoscopic segmental resections of small intestine. The mean operative time was (73.1+/-27.0) min, the mean blood loss was (19.8+/-14.0) ml, the mean length of incision was (3.3+/-1.1) cm, the mean time for passage of flatus was (2.2+/-1.0) d and the postoperative length of stay was (8.1+/-2.0) d. The bleeding of intestinal anastomosis and gastric mucosa occurred on 3 patients (9.1%), who were healed with conservative therapy. No recurrence was found during 2-33 months follow-up. Laparoscopic surgery is an effective, safe, less invasive procedure for treatment of gastric and small intestinal stromal tumors.

The Endoscopic Ultrasound Survey of Upper Gastrointestinal Stromal Tumor/Leiomyoma

Background and Aims: EUS was used for differential diagnosis between benign and malignant GIST/leiomyoma, most common mesenchymal tumors of the gastrointestinal tract. However, the natural course of benign-appearing submucosal tumor is not clearly elucidated. The aim of this study was to evaluate the natural course of benign GISTs/leiomyomas by EUS in upper gastrointestinal tract. Methods: We regarded submucosal tumors as benign GISTs/leiomyomas which were compatible with the following criteria of EUS: 1) originated from muscularis mucosa or muscularis propria 2) well demarcated 3) regular surfaced 4) homogenous 5) hypoechoic mass. We evaluated retrospectively the changes of size, internal eco pattern and marginal regularity in 26 patients who were followed up for more than 2 years. We regarded an increase or a decrease of over 25% in maximal diameter as significant size change. Results: Submucosal tumors from the following areas were included: esophagus 16, stomach 9, and duodenum 1. Of 26 submucosal tumors, 7 were originated from muscularis mucosa and 19 from muscularis propria. The average size of tumors measured by EUS was 11.5 mm. Three lesions showed homogenous hypoechogenecity with internal calcification. The mean follow-up period were 47.4 months (range 24-84 months). Followed-up EUS finding revealed no change in echo patterns in 25 of 26 patients. In only one patients, tumor increased from 26 to 34 mm without the change of internal echo or marginal regularity at surveillance of 24 months and underwent laparoscopic gastric wedge resection. Surgical pathology showed leiomyoma. Conclusion: Most small submucosal tumors compatible with EUS criteria of benign GIST/leiomyoma do not change during a period of 24 months and EUS criteria are effective to conclude to a benign GISTs/leiomyomas. Benign GIST/leiomyoma at EUS might be followed at interval of 2 years by EUS.

Experience with laparoscopic gastric resection: results and outcomes for 37 cases

This study aimed to review the authors' technique, results, and outcomes for laparoscopic gastric wedge and segmental resections in patients with benign gastric diseases. A retrospective clinical chart review was performed for all the patients who underwent laparoscopic gastric resection at the Washington University Medical Center from 1997 through March 2004. The surgical approach, operative results, complications, and subsequent clinical course were analyzed. Data are expressed as mean +/- standard deviation. Laparoscopic gastric resection was attempted in 37 cases involving 21 women and 16 men with a mean age of 61 +/- 13 years. The indications for surgery included suspected gastric stromal tumor (GIST) or carcinoid (n = 22), other benign gastric lesions (n = 6), benign gastric outlet obstruction (n = 4), and nonhealing peptic ulcer (n = 5). Segmental resection using gastroenteric anastomosis, with or without vagotomy, was performed in 14 patients, wedge resection in 22 patients, and laparoscopic enucleation in 1 patient. Resection was totally laparoscopic in 25 cases and laparoscopically assisted (with an accessory incision) in 12 cases. The mean operative time was 165 +/- 58 min, and the blood loss was 84 +/- 77 ml. Two patients (5.4%) underwent conversion to open resection. Intraoperative gastroscopy was performed in 16 cases (44%) as an aid to the resection. Regular diet was resumed at a mean of 3.0 +/- 1.7 days, and the mean length of hospital stay was 3.9 +/- 2.1 days. Four patients (10.8%) experienced major complications including subphrenic abscess (n = 1), pneumonia with respiratory failure (n = 1), splenic vein injury requiring splenectomy (n = 1), and gastric outlet obstruction (n = 1) that required reoperation 1 year later. Minor complications included intraabdominal fluid collection (n = 1), postoperative gastroparesis (n = 1), urinary retention (n = 1), and incisional hernia (n = 1). Laparoscopic gastric resections can be performed safely in patients with a variety of benign gastric disorders. The use of an accessory incision for reanastomosis and specimen extraction facilitates the procedure in difficult cases.