CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 3 (2012) 82–85
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Acute pancreatitis secondary to a prolapsed gastric fundal GIST Owain Jones ∗ , David Monk, Trevor Balling, Ann Wright Countess of Chester NHS Foundation Trust, United Kingdom
a r t i c l e
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Article history: Received 20 October 2011 Accepted 24 October 2011 Available online 15 November 2011 Keywords: GIST Acute pancreatitis Stomach Gastric outlet obstruction Wedge resection
a b s t r a c t INTRODUCTION: Gastrointestinal stromal tumours (GISTs) account for less than 3% of all gastrointestinal tract tumours and 5.7% of all sarcomas, and the majority of these tumours are gastric in origin. Patients commonly present with gastrointestinal bleeding or abdominal pain with 10–30% of patients presenting with symptoms of gastrointestinal obstruction. PRESENTATION OF A CASE: We present a case of a 65-year-old gentleman who presented with symptomatic iron deficiency anaemia. Gastroscopy revealed a large submucosal lesion originating from the gastric fundus, consistent with a GIST. The patient developed acute epigastric pain, vomiting with raised inflammatory markers. A CT of the abdomen revealed the GIST to be causing gastric outlet obstruction as result of a prolapse of the tumour through the pylorus into the duodenum. This also resulted in compression of the distal common bile duct and was associated with the radiological appearance of acute pancreatitis. This responded to conservative management. The GIST was resected subsequently using a laparoscopic technique. DISCUSSION: Only one similar case has previously been reported in the literature. Several surgical approached have been described in the management of gastric GISTs including open, laparoscopic, hand assisted, ultrasound assisted and a combined endoscopic and laparoscopic approach. A laparosopic ‘eversion’ techinque was preferred in our case due to the close proximity of the tumour to the gastrooesophageal junction. CONCLUSION: Pancreatitis secondary to a prolapsed gastric GIST is a rare entity. Laparoscopic wedge resection of these tumours can be safely performed with a satisfactory oncological outcome. © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
1. Introduction Gastrointestinal stromal tumours (GISTs) account for only 0.1–3% of all gastrointestinal tract tumours and 5.7% of all sarcomas.1 The majority of GISTs originate in the stomach (60%), followed by the small intestine (25%), rectum (5%) and oesophagus (2%). Other less common sites make up the remainder.2 GISTs were previously classified as being either benign or malignant, but this has since been replaced by a low, moderate and high risk classification. This classification describes the likelihood of malignant behaviour, as determined by the tumour size and mitotic count.3 Nevertheless, GIST can be unpredictable with several reports of recurrent disease in small low risk tumours. On the other hand, there is also a report of a patient living with liver metastases for three decades.4 Overall, gastric GISTs carry a more favourable prognosis, with small bowel the least.5 Patients commonly present with gastrointestinal bleeding, abdominal pain or can be found incidentally during imaging for
∗ Corresponding author at: Department of Upper Gastrointestinal Surgery, Countess of Chester NHS Foundation Trust, Countess of Chester Health Park, Chester, Cheshire, CH2 1UL, United Kingdom. Tel.: +012 44 365 000; mobile: +07590988774. E-mail address:
[email protected] (O. Jones).
other reasons. Only 10–30% of patients present with symptoms of gastrointestinal obstruction.6 2. Case presentation A previously healthy 65-year-old gentleman presented to his general practitioner complaining of general lethargy, vomiting and weight loss. He was discovered to be anaemic with a Hb of 6.7 g/dL and was referred for investigation. A gastroscopy revealed a large submucosal lesion originating in the fundus of the stomach, closely associated to the gastro-oesophageal junction (Image 1). A staging CT scan confirmed a 7.5 cm well-defined lobular intragastric mass arising from the posterosuperior aspect of the fundus (Image 2). There was no evidence of extramural invasion or metastatic disease. Incidental findings included a single large gallstone in the gallbladder, along with large liver cysts. Biopsies taken during endoscopy supported a radiological diagnosis of a gastric GIST. A period of nutritional support was planned for optimisation prior to his planned surgery. During this period he developed worsening vomiting, upper abdominal pain with rising inflammatory markers (CRP of 345 mg/L and a white cell count of 18 × 109 /L). Previously normal liver function test showed an acute deterioration with a bilirubin of 43 U/L, ALT 183 U/L, ALP 91 U/L, GGT 157 U/L. A repeat abdominal CT revealed the GIST had prolapsed into the second part of the duodenum causing gastric outlet obstruction.
2210-2612 © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. Open access under CC BY-NC-ND license. doi:10.1016/j.ijscr.2011.10.018
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Image 1. Gastroscopy image revealing a large submusosal lesion in close proximity to the gastro-oesophageal junction.
The tumour was also compressing the distal common bile duct with proximal ductal dilatation. There was extensive oedema of the mesenteric fat surrounding the pancreas consistent with acute pancreatitis (Image 3). The large solitary gallstone was once again noted in the gallbladder. Serum amylase was 151 U/L but was taken approximately 48 h following the onset of abdominal pain. A further gastroscopy was performed where the CT findings were confirmed. Multiple attempts at reducing the tumour back into the stomach were unsuccessful and the patient was commenced on total parenteral nutrition. The attack of pancreatitis was treated conservatively and the patients liver function normalised. Following an improvement in the patients nutritional status, he progressed to surgery. Under a general anaesthetic, five standard hiatal ports were inserted, with an additional 5 mm port in the right upper quadrant for a cholecystectomy. Initial laparoscopy revealed that the GIST
Image 3. GIST prolapsed into the duodenum with associated peripancreatic inflammation consistent with pancreatitis. The inferior portion of the single large gallstone can be seen in Hartmann’s Pouch. A nasogastric tube is seen in the stomach.
remained prolapsed in the duodenum. The proximal stomach was mobilized by division of the gastrosplenic ligaments, yet traction on the gastric fundus failed to reduce the prolapsed tumour. A longitudinal gastrostomy was made anteriorly and 20 mg of intravenous hyoscine butylbromide administered. The tumour was successfully reduced with minimal pressure and extracted through the gastrostomy by everting the gastric fundus. This allowed a wedge resection of the gastric fundus to be undertaken under direct intraluminal vision. This was done with three firings of the Ethicon EchelonTM 45 mm Endocutter. A gastroscope was then passed to ensure that the gastro-oesophageal junction had not been compromised. The gastrostomy was closed with two layers of Vicryl, and the specimen removed in a bag (Covidien EndoCatchTM ) through an extended port site incision. A routine cholecystectomy and cholangiogram was also performed (Image 4). Macroscopic examination revealed an ulcerated polypoid mass measuring 82 mm in its maximum diameter (Image 5). Histologically this was a completely excised spindle cell type GIST, with eleven mitoses per fifty high power fields (high risk group). Postoperatively, his recovery was slightly delayed by a parapneumonic effusion requiring a chest drain. Biochemical examination of the fluid excluded the presence of amylase. He was well at six months follow up. 3. Discussion
Image 2. Contrast enhanced CT slice showing a 7.5 cm intragastric lesion arising from the posterior aspect of the fundus.
During our literature search, we only identified one previous case of a gastric GIST causing pancreatitis.7 That particular GIST originated in the gastric antrum and had also prolapsed into the second part of the duodenum. However, there are several reports of prolapsing gastric polyps causing acute pancreatitis,8,9 and gastric outlet obstruction,10 with the majority arising from the distal stomach. Several surgical approaches have been described in the management of gastric GISTs including open, laparoscopic, hand assisted, ultrasound assisted 11 and combined endoscopic with laparoscopy.12 As lymphadenectomy is not required, laparoscopic wedge resection has been regarded as the treatment of choice for gastric GISTs
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Image 4. Intraoperative images (Left Upper) The prolapsed gastric fundus which was irreducible with traction. (Right Upper) Anterior gastrostomy revealing the reduced GIST which has now been reduced following intravenous Buscopan. (Left Lower) Eversion of the GIST through the gastrostomy preparing for a wedge resection. (Right Lower) Anterior gastrostomy closed with a single layer of Vicryl.
in recent years. One series 13 of 51 cases describes no recurrences with a median follow up of over five years, however the majority of patients had either low, or very low risk disease. Laparoscopic wedge resection is a particularly favourable approach for extraluminal tumours and those located on the posterior gastric wall, with access via the lesser sac. Anterior gastrostomy with tumour eversion was initially described for benign pathology,14 and this has since progressed to the resection of large tumours of the anterior gastric wall.15 This approach seems to be favoured over a simple wedge resection for any tumour close to the gastro-oesophageal junction due to the risk of postoperative stenosis.16
4. Conclusion Acute pancreatitis secondary to a gastric GIST is a rare entity. Depending on the tumours anatomical location, size and surgeon experience, laparoscopic wedge resection can be safely performed with a satisfactory oncological outcome. An anterior gastrostomy approach should be utilized in the resection of lesions near the gastro-oesophageal junction. Conflict of interest None. Funding We have received no funding for this case report. Ethical approval Written consent has been obtained from the patient. All images have been anonymised. Author contribution OJ wrote the case report with assistance from TB. OJ and DM undertook the literature review and conclusion. AW interpreted all radiology and undertook the final review in association with DM. References
Image 5. The excised specimen.
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