Laparoscopic Wedge Resection Research Articles

Gastric duplication cyst: rare cause of upper gastrointestinal bleeding in a young adult, with a review of literature

Duplication cyst along the alimentary canal is a congenital anomaly which is rare and usually incidentally found at endoscopy or radiological imaging. It can develop anywhere along the alimentary canal with only 4% occurrence in the stomach. Only few cases of gastric duplication cysts were reported to be symptomatic along with its complications. Diagnostic modalities include oesophageo-gastroduodenoscopy (OGDS), endoscopic ultrasound (EUS), computerized tomography (CT) scan and magnetic resonance imaging (MRI). However, the best option to confirm the diagnosis is complete resection of the lesion. We are reporting about a teenage girl whereby she presented with sudden episodes of hematemesis, which led to a syncopal attack. She also complained of intermittent central abdominal pain for a month prior to her presentation. Physical examination was unremarkable. However, her blood investigation showed a significant drop in hemoglobin. The patient had an endoscopy during which a submucosal lesion at the greater curvature was identified and the provisional diagnosis we had was a gastrointestinal stromal tumor (GIST). CT scan of the abdomen was also done showing an endoluminal cystic gastric lesion measuring approximately 2×2×2 cm. The lesion was confined to the stomach with no local infiltration of the adjacent structures. Decision was made to proceed with a laparoscopic wedge resection after outweighing the risk and benefits of surgery. Gastric duplication cyst is a rare anomaly. Despite its rarity, it should be included as a differential when we encounter a submucosal lesion due to its tendency for malignant transformation and other complications.

Endocarditis following an unsuccessful attempt to remove a gastric GI stromal tumor by laparoscopic endoscopic cooperative surgery

Gastrointestinal Stromal Tumors (GIST) are the most common subepithelial lesions of the gastrointestinal tract. Treatment of lesions greater than 2 cm in diameter is by laparoscopic wedge resection. We report a 77-year-old man who was diagnosed with a 2.3 cm diameter gastric GIST. He had a thickened mitral valve, severe mitral annular calcification, mild mitral regurgitation and moderate aortic stenosis. One week after undergoing an unsuccessful attempt at Laparoscopic Endoscopic Cooperative Surgery (LECS), he was admitted with a fever of 40.2o C. Blood cultures grew Staphylococcus lugdunensis. Transthoracic and transesophageal echocardiography revealed moderate mitral regurgitation and an 8 X 5 mm vegetation on the mitral valve and posterior annulus. This is the first report of endocarditis following LECS. Physicians need to be aware of this possible complication. Keywords: endocarditis; GI stromal tumor; endocarditis; endoscopic tumor.

An Unusual Cause of Recurrent Subepithelial Mass in the Stomach

Question: A 58-year-old woman presented with a subepithelial tumor, approximately 2 cm in size, incidentally detected in the posterior wall of upper body of the stomach during a screening endoscopy (Figure A). The sample from an endoscopic ultrasound-guided fine-needle biopsy revealed spindle-shaped cells arranged in a fascicular pattern. The spindle cells were immunopositive for c-Kit, cluster of differentiation 34, DOG-1, and smooth muscle actin. The patient was diagnosed with a gastrointestinal stromal tumor (GIST) and underwent laparoscopic wedge resection. The tumor was completely resected with clear margins. The maximal tumor size was 2.3 cm, and the mitotic count was 2 per 50 high-power fields; therefore, it was diagnosed as a GIST with a low risk of malignant potential. Follow-up abdominal computed tomography after 2 years showed a new low-density mass in the previous resection site (Figure B, arrow). Endoscopy showed no definite lesion at the resection site (Figure C), and endoscopic ultrasound revealed a 1.5-cm heterogeneous hypoechoic lesion originating from the muscularis propria (Figure D). Laparoscopic wedge resection was performed again for a definitive diagnosis and treatment. What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Histopathologic examination of the resected specimen revealed sweeping fascicles of bland and uniform spindle cells with collagenous stroma and compressed, thin-walled vessels (Figure E). The spindle cells were immunonegative for c-Kit (Figure F), cluster of differentiation 34 (Figure G), DOG-1 (Figure H), and S-100 protein, and were immunopositive for smooth muscle actin (Figure I), which suggested the exclusion of GIST. Therefore, additional immunohistochemistry was performed for the differential diagnosis. The tumor cells were negative for anaplastic lymphoma kinase but positive for nuclear β-catenin (Figure J). Based on morphologic and immunohistochemical findings, a diagnosis of a desmoid tumor occurring at the previous resection site of the gastric GIST was made. No further treatment was provided because the tumor was completely resected. No signs of recurrence or metastasis were found during 12 months of follow-up. Desmoid tumors are rare mesenchymal tumors occurring in patients with risk factors, such as a previous history of abdominal surgery, familial adenomatous polyposis, or pregnancy, and they can be easily mistaken for GIST because both tumors show similar clinical presentation and morphology.1Murshid A.A. Al-Maghraby H.Q. Subsequent development of desmoid tumor after a resected gastrointestinal stromal tumor.Case Rep Pathol. 2018; 2018: 1082956Google Scholar The desmoid tumor and GIST are both microscopically characterized by spindle-cell proliferation, and the differential diagnosis of these two tumors is performed mainly by immunohistochemistry. Because desmoid tumors usually have activating mutations in β-catenin, abnormal nuclear positivity of β-catenin is seen in most desmoid tumors.2Lu Q. Wang K. Liu D. et al.Stomach desmoid tumor: a case report and review of the literature.Int J Clin Exp Pathol. 2017; 10: 10531-10538Google Scholar Surgical resection with a negative margin is currently the treatment of choice. When local recurrence occurs or complete surgical resection is not feasible, radiotherapy, chemotherapy, and other comprehensive therapies, such as estrogen receptor antagonists and nonsteroidal anti-inflammatory drugs, should be provided.2Lu Q. Wang K. Liu D. et al.Stomach desmoid tumor: a case report and review of the literature.Int J Clin Exp Pathol. 2017; 10: 10531-10538Google Scholar Owing to the rarity of gastric desmoid tumors, information about their prognosis is very limited. According to a review of the literature on gastric desmoid tumors, no recurrence was reported during follow-up assessments,2Lu Q. Wang K. Liu D. et al.Stomach desmoid tumor: a case report and review of the literature.Int J Clin Exp Pathol. 2017; 10: 10531-10538Google Scholar indicating a good prognosis. However, considering the local recurrence rate of 13% for intra-abdominal sporadic desmoid tumors,3Wilkinson M.J. Fitzgerald J.E. Thomas J.M. et al.Surgical resection for nonfamilial adenomatous polyposis-related intraabdominal fibromatosis.Br J Surg. 2012; 99: 706-713Google Scholar regular follow-up is mandatory.

Laparoscopic wedge resection as an alternative to laparoscopic oncological colon resection for benign endoscopically unresectable colon polyps.

AimThe aim of this study was to investigate, by comparing clinical and histological outcomes, whether laparoscopic (hybrid) wedge resection (LWR) could be a less invasive and safe alternative to laparoscopic oncological colon resection (OCR) for patients with an endoscopically unresectable, suspected benign, colon polyp.MethodAll patients with an endoscopically unresectable colon polyp who were referred for surgery between 2009 and 2018 and without biopsy‐proven colon cancer were identified from a prospectively maintained database. Patients with macroscopic features of malignancy during endoscopy were excluded. Clinical and histological results for patients who underwent OCR or LWR were reviewed.ResultsOne hundred‐and‐twenty‐two patients were included. Ninety‐seven patients underwent OCR and 25 LWR. Major complications occurred in 16.7% (n = 16) of the OCR group compared with 4.0% (n = 1) of the LWR group (p = 0.06). In the OCR group the anastomotic leakage rate was 6.3% (n = 6) and the mortality rate 3.1% (n = 3). No anastomotic leakage or deaths occurred in the LWR group. The median length of hospital stay after OCR was 5 days [interquartile range (IQR) 5–9 days)] compared with 2 days (IQR 2–4 days) after LWR (p < 0.0001). Definite pathology showed a malignancy rate of 4.2% (n = 4) in the OCR group and 4.0% (n = 1) (without high‐risk features) in the LWR group.ConclusionThis study shows that LWR was associated with significantly lower complication rates and acceptable oncological risks compared with OCR. Therefore we suggest that LWR is a safe alternative treatment, next to other endoscopic options. The treatment that is most suitable for an individual patient should be discussed in a multidisciplinary meeting.

Single-Incision Laparoscopic Intragastric Surgery for Gastric Submucosal Tumors Located Near the Esophagogastric Junction.

Background: Laparoscopic local resection of the stomach for gastric submucosal tumors (SMTs) is widely accepted by surgeons. For SMTs located near the esophagogastric junction (EGJ), simple laparoscopic wedge resection is rarely performed owing to concerns of causing cardia deformities or stenosis. Single-incision laparoscopic intragastric surgery (sLIGS) has been used to treat SMTs located near the EGJ in carefully selected cases. Methods: We modified sLIGS using a subxiphoid incision. Thirteen consecutive patients with intraluminal or intramural growth type gastric SMTs located near the EGJ underwent sLIGS at our institution from July 2018 to April 2020. Results: Thirteen operations were successfully performed using sLIGS, including eight full-thickness resections and five submucosal resections. There were no conversions to an open procedure and all tumors were confirmed to have negative margins on pathology. The mean operation time was 100 ± 10 minutes (range, 85-160 minutes). The mean blood loss was 50 ± 10 mL (range, 50-100 mL). The mean length of postoperative hospital stay was 7 ± 1.5 days (6-10 days). One patient was found to have oozing of blood confirmed by gastroscopy postoperatively and recovered after stopping antiplatelet therapy. Ten cases were gastrointestinal stromal tumor (GIST), two cases were leiomyoma, and one case was neuroendocrine neoplasm. Of the 10 GISTs, 9 were classified as low risk; 1 showed medium risk and the patient received adjuvant imatinib therapy. There were no tumor recurrences during a mean follow-up of 14 ± 4 months (range, 5-25 months). Conclusions: This modified sLIGS for the treatment of the gastric SMTs located near the EGJ is simple and safe. This can be used as an alternative treatment for gastric SMTs near the EGJ.

Gastric GIST with progressive mitotic index

Gastrointestinal stromal tumors (GISTs) account for less than 1% of gastrointestinal tumors;they are the most common mesenchymal neoplasms of the gastrointestinal(GI) tract. GISTs are usually located in the stomach,but can occur anywhere along the gastrointestinal tract.GIST ranks third as histology after adenocarcinomas and lymphomas among the gastrointestinal tract.Case presentation.The patient, aged 58 years, is transferred from the Gastroenterology Clinic with symptoms of stenosis and hemorrhage from a endophytic submucosal tumor located on the posterior gastric wall, under the eso-gastric junction, objectified endoscopically and CT scan. Laparoscopic wedge resection was performed with three linear Endo-GIA staplers. The evolution was favorable. After 7 months (without chemotherapy because pTNM was T1NoMo), the patient is sent back by the gastroenterologist for „CT scan:perigastric lymphadenopathies”. The patient was operated laparoscopically converted.We found 10 tumors with typical malignant GISTs 3-10 cm diameter,on the peritoneal serosa:in the right subhepatic space, perigastric, left interhepato-phrenic, hepato-gastric;these were excised R0; with simple evolution. The immuno-histo-chemical examination specifies the diagnosis of GIST at the first and the second operation (DOG1,CD117,CD34-positively in tumor).Ki 67 was 15% in the tumor and the mitotic index &lt;5/5 square mm at the moment of the first operation but in the metastatic tumor at the reintervention Ki 67 was 80% and mitotic index &gt;5/5 square mm.Discutions.GIST tumours can be classified into low-risk and high-risk categories of recurrence depending on size, location, capsule rupture and mitotic activity. Disseminated metastases in the abdominal cavity are the most common clinical manifestations of malignancy. Complete surgical resection is recommended if bleeding or other symptoms are present. Tumour perforation, spontaneous or produced at the time of surgical resection, should be recorded because it has a high negative prognostic value due to peritoneal contamination. The average survival rate in localized disease is 5 years but in metastatic or recurrent disease is about 10-20 months. Conclusion. Complete excision of residual metastatic lesions has been shown to be associated with a favourable prognosis, provided that the patient responds to imatinib treatment; resection of tumour recurrence is accompanied by an average survival of 15 months. Gastric GIST recurrence risk depends of localisation, tumor size, mitotic index and capsular rupture.

Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study.

To compare the effect of pituitrin local injection (PIT) and uterine artery embolization (UAE) as pretreatment before surgery during the management of cesarean scar pregnancy (CSP). Forty-nine CSP patients diagnosed in our department of Suzhou Ninth People's Hospital from October 2017 to October 2019. All patients underwent hysteroscopy and negative pressure aspiration (for type I CSP) or laparoscopic wedge-resection (for type II and III CSP) following one of the preoperative treatments: PIT group (n = 26) and UAE group (n = 23). The baseline clinical data, intraoperative blood loss, blood transfusion rate, postoperative hospital stay, hospitalization expenses, postoperative pain, postoperative fever, postoperative serum β-human chorionic gonadotropin (β-hCG) level, and pregnancy outcome were reviewed and analyzed. There was no significant difference (p ≥ 0.05) between two groups in baseline characteristics including age, gravidity, previous cesarean section times, interval since last cesarean delivery, menolipsis time, maximum diameter of gestational sac or mass under ultrasound, fetal cardiac activity and preoperative β-hCG level. There was no significant difference in blood loss, transfusion rate, and postoperative β-hCG reduction percentage (p ≥ 0.05) either. The postoperative hospital stay, hospitalization expenses, postoperative pain, and postoperative fever rate in PIT group were significantly lower than those in UAE group (p < 0.05). Moreover, β-hCG level of all patients turned negative 1 month after surgery successfully. PIT pretreatment seems to be a same effective, more economical, and with fewer side effects pretreatment method compared to traditional UAE pretreatment in the management of CSP.

Laparoscopic ultrasound guided wedge resection of the stomach: a novel procedure for gastric submucosal tumor.

It is essential for the surgery of gastric submucosal tumors to resect the tumor with a negative margin and minimize the incision of the normal stomach wall. We developed a novel procedure for patients with gastric submucosal tumors using a laparoscopic ultrasound probe as a guide to determine the resection line. Since 2014, we have performed the laparoscopic ultrasound-guided wedge resection of the stomach in seven patients. The tumor was localized, and the property of the tumor was clearly identified using a laparoscopic ultrasound probe. As a result, the ideal incision line was determined without intraoperative endoscopy. The stomach wall was perforated along the marking on the planned incision line and the whole layer is subsequently incised along with the tumor. The surgical margins were negative, and there were no obvious injuries of the pseudocapsule, microscopically, in any case. It is possible that the laparoscopic ultrasound-guided wedge resection of the stomach contributes to a simplification of the surgery of gastric submucosal tumors resulting in reduced medical cost while maintaining curability and functional preservation.

Clinical outcomes and functional analysis of third space robotic and endoscopic cooperative surgery versus laparoscopic wedge resection for gastric submucosal tumours: a propensity score-matched study

Third space robotic and endoscopic cooperative surgery (TS-RECS) is a novel minimally invasive surgery for resecting gastric submucosal tumours (GSMTs), which could accomplish the completely oncological curability and maximal functional preservation. This study investigated the clinical outcomes and gastrointestinal function after TS-RECS versus laparoscopic wedge resection (LWR) for GSMTs. This was a single-centre retrospective study that included 130 patients with GSMTs who underwent LWR or TS-RECS from 2013 to 2019. To overcome selection biases, we performed propensity score matching (1:1) using seven covariates that could impact the group assignment and outcomes. Then, the clinical outcomes and gastrointestinal function in the LWR and TS-RECS groups were compared in a matched cohort. Among the 130 enrolled patients, 96 patients underwent LWR, and 34 underwent TS-RECS and were matched into 30 patients for each group. There was no significant difference in the operation time between the two groups (P = 0.543). However, the TS-RECS group had significantly less blood loss (20,5–100 vs 95,10–310 ml, P < 0.0001) and better postoperative recovery in terms of time to oral intake (2,2–4 vs 3,2–6 days, P < 0.0001) and postoperative hospital stay (5,4–10 vs 8.5,5–16 days, P < 0.0001) than the LWR group. The severity and frequency scores of postoperative gastrointestinal symptoms in the TS-RECS group were significantly lower than those in the LWR group. The median follow-up period was 24 months (10–60 months) in the LWR group and 18 months (10–27 months) in the TS-RECS group, and there was in total a single recurrence in the LWR group. TS-RECS appears to be a technically safe and effective surgery with preservation of gastrointestinal function for resection of GSMT resection.

A137 LAPAROSCOPIC ENDOSCOPIC COOPERATIVE SURGERY FOR GASTROINTESTINAL STROMAL TUMOURS: EARLY EXPERIENCE IN A CANADIAN ACADEMIC CENTRE

Abstract Background Surgical resection with laparoscopic gastric wedge resection is commonly conducted for local management of gastrointestinal stromal tumours (GIST). However, resection margins are often difficult to appreciate for lesions with larger endophytic components. As a result, tumour margins may be compromised or excess tissue resected. Laparoscopic endoscopic cooperative surgery (LECS) was developed in Japan to overcome these technical challenges in the resection of subepithelial lesions, including GISTs. Here, we present a case report of an early Canadian experience utilizing LECS in the management of gastric GIST. Aims To describe a case report of an early Canadian experience of LECS for the resection of a gastric GIST. Methods We performed a review of the literature and describe a case of LECS. Results We present a 70-year-old female referred to our centre for endoscopic resection of a 2.5x2.5cm histologically confirmed gastric GIST (low mitotic index and no known metastases). Repeat endoscopic evaluation at our centre confirmed a 25-30mm subepithelial lesion with both exophytic (small) and endophytic (large) components. After tumour board review, we opted for a LECS approach. In the OR, the lesion was identified endoscopically and marked with a Dual J-Knife (Olympus). The margins were injected with a combination of Voluven, methylene blue, and dilute epinephrine. A circumferential incision was then completed using standard ESD technique. The lesion was subsequently identified laparoscopically, with endoscopic guidance, along the lesser curvature. The lesser omentum was mobilized for clear visualization of the serosa around the lesion. A full thickness incision was made endoscopically along the distal aspect of lesion. Full thickness resection was continued endoscopically for one third of the circumference of the lesion until gastric insufflation became compromised. Full thickness resection was completed laparoscopically under endoscopic guidance with grossly negative margins. The defect was closed with running laparoscopic sutures. Endoscopic leak test was performed which was negative. The specimen was retrieved and follow up pathology demonstrated a GIST with low mitotic index and negative margins without tumour rupture. Conclusions In a review of the literature, LECS appears to minimize tissue resection while maintaining R0 resection rates. This technique is especially useful for subepithelial lesions with larger endophytic and transmural components. It has an excellent safety profile with a less than 5% anastomotic leak rate. As such, the literature supports LECS as a suitable procedure for gastric subepithelial lesions &amp;lt;50 mm. However, further studies are needed to compare it systematically to conventional laparoscopic wedge resection in addition to other innovative endoscopic techniques such as STER and EFTR. Funding Agencies None

A126 GIST – GLUE IN STROMAL TUMOR

Abstract Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and typically located in the stomach. Gastrointestinal bleeding is a frequent complication of GISTs with surgery being the treatment of choice. Managing GIST bleeding endoscopically can be challenging by an underlying friable neovascularization. The use of cyanoacrylate basis glue has well-established utility in the endoscopic management of variceal bleeding. However, the role of cyanoacrylate basis glue in the management of GIST bleeding is exceptionally rare. Aims We present a case of a bleeding GIST that was successfully managed through the utilization of cyanoacrylate basis glue allowing for elective surgical resection. Methods A chart review was undertaken. Also, a literature review of the topic was also conducted using the terms “GIST, Cyanoacrylate Glue, Bleeding” Results A 75-year-old male presented with a four week history of exertional chest pain. He had noticed persistent black stools for the previous two weeks. His past medical history was relevant for coronary artery disease; two years earlier he had drug eluting stents placed. His medications included ASA 81mg PO OD and Pantoprazole 40mg OD. Physical examination revealed stable vital signs, a soft abdomen and melena on rectal examination. Laboratory investigations showed a hemoglobin of 75 g/L, and 2 weeks prior his hemoglobin had been 120 g/L. Platelets were 149. His liver enzymes and liver function tests were unremarkable. His BUN was 9.9 mmol/L and creatinine of 96.0 umol/L. An esophagogastroduodenoscopy (EGD) revealed a 5cm smooth mass with a central deep depression, in the antrum, that was actively bleeding. Attempts to clip were unsuccessful due to the width of the central depression which was the source of bleeding. (See image 1). The endoscopist chose to inject 1cc of cyanoacrylate basis glue directly into the bleeding site. A subsequent CT scan revealed a 5.2cm polypoid mass in the gastric antrum, favored to be a GIST with no evidence of metastatic disease. Surgery and Cardiology were involved in the care of this patient, and emergency surgery was delayed due to the patient having an intercurrent acute coronary syndrome. Post EGD, the patient underwent an angiogram and the culprit coronary artery was stented and patient was started on dual antiplatelet therapy. Patient then successfully underwent a laparoscopic gastric wedge resection for his GIST, this was completed 1 week after EGD. The pathology of the resected area was in keeping with a GIST. Of note, the patient’s hemoglobin had been stable from the time of EGD until surgical intervention. Conclusions Managing GIST bleeding endoscopically can be challenging, and surgical resection is the recommended treatment modality. In situations where surgical intervention is contraindicated, endoscopic therapy with cyanoacrylate basis glue can be considered to achieve hemostasis in GIST bleeding. Funding Agencies None

Postoperative reproductive outcomes in women with ovarian pregnancy: A retrospective analysis

ObjectiveThe reproductive outcomes of ovarian pregnancy are currently unknown. Therefore, the objective of our study was to report the pregnancy outcomes of women with laparoscopically treated ovarian pregnancy. Materials and methodsIn this retrospective case analysis, unpublished cases of ovarian pregnancy between 2009 and 2016 were reviewed. Women were followed up for 3 years to obtain subsequent pregnancy data. ResultsA total of 21 women who intended to become pregnant were included in this study. Predisposing risk factors for ovarian pregnancy including previous pelvic surgery (23.81%), presentation of pelvic endometriosis (23.81%), and prior intrauterine device insertion (9.52%) were identified. The major symptom at presentation was abdominal pain (85.71%), and no preoperative sonographic diagnosis of ovarian pregnancy was identified. Laparoscopic wedge resection was performed in most women (90.48%). During the 3-year follow-up period, spontaneous intrauterine pregnancy was observed in 13 women (61.90%), 2 women (9.52%) became pregnant through artificial insemination treatment, and 6 women are not able to get pregnant (28.57%). None of the women experienced recurrent ectopic pregnancy. ConclusionThe postoperative pregnancy outcomes of women with ovarian pregnancy were encouraging. In this study, the spontaneous intrauterine pregnancy rate was favorable, and no cases of recurrent ectopic pregnancy were reported.

Hybrid approach with laparoscopic wall‐inversion surgery and single‐incision intragastric surgery for intraluminal gastrointestinal stromal tumor: A case report

Laparoscopic wedge resection (LWR) for intraluminal gastrointestinal stromal tumor (GIST) leads to excessive resection of normal gastric wall. We report a case of GIST around the cardia successfully treated with full-thickness partial resection using a hybrid approach of laparoscopic surgery and single-incision intragastric surgery (SIIGS). A 69-year-old woman had a 5cm intraluminal GIST at the posterior wall around the cardia. Submucosal injection of glycerin and indigo carmine was performed with transoral endoscopy. Circumferential seromuscular incision followed by placement of seromuscular sutures to invert the lesion into the stomach was performed under laparoscopy. By SIIGS, resection of the inverted mucosa and retrieval of the tumor were completed. A hybrid approach consisting of laparoscopic wall-inversion surgery and SIIGS was useful for intraluminal GIST and may expand the indications for laparoscopic wall-inversion surgery by removing size limitations.

Gastric Mucosa-associated Lymphoid Tissue Lymphoma: An Important Differential Diagnosis for a Rapidly Growing Gastric Subepithelial Tumor - A Case Report and Literature Review

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is a low-grade lymphoma with a long median survival time because of its low proliferation rate. A 75-year-old man was referred to the hospital for hematemesis. Upper endoscopy revealed a 30-mm subepithelial tumor (SET). Abdominal CT and EUS revealed a homogeneously hypoechoic lesion arising from the second layer of the stomach, without distant metastasis. Laparoscopic wedge resection was performed. On microscopic examination, the tumor showed diffuse aggregation of small lymphoid cells with abnormal architecture. Neoplastic cells showed positive reactivity for CD20 and prominent lymphoepithelial lesions were observed. The urease breath test was also conducted, with a negative result. Our final diagnosis was &lt;i&gt;Helicobacter pylori&lt;/i&gt;-negative MALT lymphoma (Ann Arbor classification I&lt;sub&gt;E2&lt;/sub&gt;), which is a rapidly growing SET pattern. This case highlights the importance of including gastric MALT lymphoma as a differential diagnosis for rapidly growing gastric SETs.

Cirugía endoscópica y laparoscópica combinada para el tratamiento de pólipos de colon benignos complejos (CELS): estudio observacional

PurposeCombined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment. MethodObservational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated. ResultsSeventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 – 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study. ConclusionCELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Malignant Transformation of Heterotopic Pancreatic Tissue in a Patient with BRCA2 Mutation

Background: Malignant transformation of heterotopic pancreatic tissue is a rare entity with only several case reports published in the scientific literature. Adjuvant chemotherapy following oncological resection for lesions with nodal metastasis has not been well described and there are no guidelines available to guide the management of these patients. Case Presentation: We present a case of gastric heterotopic pancreatic carcinoma with nodal metastasis in a young patient with breast cancer gene (BRCA) 2 mutation. He had undergone a laparoscopic wedge resection for a gastric lesion initially thought to be a gastrointestinal stroma tumor. Given the involvement of the wedge resection margins, the patient underwent a distal gastrectomy with oncological lymph nodal clearance. One out of the 33 harvested lymph nodes harboured micrometastasis while the main gastrectomy specimen did not have any residual malignancy. Following the histological diagnosis, he received an adjuvant chemotherapy regime akin to that prescribed for locally advanced pancreatic adenocarcinoma with good response. This is, to our knowledge, also the first such case report in a patient with BRCA2 mutation. Conclusions: Pre-operative diagnostic confirmation is challenging and endoscopic procedures pose significant false negatives. Reports of nodal metastasis following oncological resection are limited and there are no guidelines regarding adjuvant therapies. We would recommend a chemotherapy regimen similar to that for primary locally advanced pancreatic carcinoma in patients found to have nodal metastasis.

A Case of Laparoscopic Wedge Resection of a Schwannoma of the Ascending Colon Diagnosed by Intraoperative Pathological Examination

A Case of Laparoscopic Wedge Resection of a Schwannoma of the Ascending Colon Diagnosed by Intraoperative Pathological Examination

EUS-guided gastroenterostomy assisted by extrinsic abdominal compression to treat gastric obstruction after surgical resection of a GI stromal tumor.

EUS-guided gastroenterostomy is increasingly used to treat gastric outlet obstruction after surgery such as a Whipple procedure.1 Postoperative stenosis of the gastric lumen is a described adverse event after laparoscopic wedge resection of submucosal tumors located on the lesser curvature.2,3 We describe a case of EUS-guided gastroenterostomy facilitated by extrinsic abdominal compression to treat gastric obstruction resulting from a laparoscopic wedge resection of a gastrointestinal stromal tumor.

Laparoscopic Liver Resection: A 7-Year Experience of 123 Resections in a Single Institution.

There has been a significant increase in the use of laparoscopic liver resection (LLR) over the past 2 decades. This study aimed to analyze the outcomes associated with LLR at a single tertiary care hospital. Patients with benign or malignant tumors who underwent LLR by a single surgeon from January 2012 to November 2019 were identified. There were 123 patients who underwent LLR in the study period; 52% were men, and the median age was 61 (24-90) years. Five patients (4.1%) had unplanned conversion to open resection. Ninety-five patients (77.2%) had a wedge resection or single segmentectomy, and 28 (22.8%) underwent resection of 2+ liver segments. Seventy-one cases (57.7%) were for hepatocellular carcinoma (HCC), 24 (19.5%) for colorectal metastasis, and 28 (22.8%) were for other benign and malignant tumors. Median operative time was 239 (range 89-526) minutes. Mean estimated blood loss was 192 (range 0-1800) mL. The median length of stay (LOS) overall was 2 (range 0-9) days. From 2017 to 2019, the mean LOS was 1.2days, compared to a mean LOS of 3.3days from 2012 to 2016. More cases were performed as same-day surgery from 2017 onward; 19 patients (33.9%) had same-day surgery from 2017 to 2019, in comparison to only 1 patient (1.5%) in the period of 2012-2016 (P < .0001). Overall, 28 patients (22.8%) experienced postoperative morbidity; major postoperative morbidity occurred in 4 patients (3.3%). The 90-day mortality was .8%, and the 30-day readmission rate was 5.7%. In conclusion, LLR can be performed safely to treat liver tumors, and LOS decreased over time. Although overall morbidity is moderate, serious morbidity is low, as was the readmission rate. Laparoscopic wedge resection may be a feasible option as an outpatient procedure in select patients.

Laparoscopic wedge resection of the proximal sleeve and handsewn esophago-sleeve anastomosis for repair of complicated staple line leak.

Laparoscopic wedge resection of the proximal sleeve and handsewn esophago-sleeve anastomosis for repair of complicated staple line leak.