103: Endoscopic-assisted Laparoscopic Transgastric Partial Gastrectomy for Gastroesophageal Junction Gastrointestinal Stromal Tumor

Introduction: Minimally invasive approaches to gastric tumors have been increasingly utilized due to decreased complications and improved functional outcomes. Gastrointestinal stromal tumors (GIST) have a low risk of malignant potential, and non-anatomic and organ-preserving approach to resection is preferred. Proximity to the gastroesophageal junction (GEJ) or pylorus can be challenging and a transgastric approach for tumors near the GEJ can facilitate organ preservation. This video demonstrates our technique for laparoscopic transgastric partial gastrectomy for a GIST near the GEJ.


Methods:
The patient is a 47-year-old male presenting with hematemesis and melena. He was found to have a 3 cm low-grade GIST 1 cm from the GEJ. Neoadjuvant imatinib was considered but given the patient’s acute symptoms and relatively small size of tumor, we proceeded with upfront surgery. A hybrid endoscopic and transgastric laparoscopic resection of the tumor was performed.



Results: The accompanying video demonstrates the technique. Diagnostic laparoscopy and endoscopic evaluation were initially performed. Self-retaining balloon ports were used and placed through gastrotomies to establish trangastric access. Two intraluminal gastric ports for the laparoscope and a working hand are used with low CO2 insufflation and a bowel clamp in place. The endoscopic retraction performs retraction. Partial gastrectomy is performed using a stapler via the working port. 

The patient recovered well postoperatively and was discharged on POD 2. Pathology demonstrated a low-grade GIST with negative margins, and < 1 mitosis per 5 mm². The lesion was low risk for recurrence and no adjuvant therapy was recommended. At follow up, the patient was maintaining his weight on a regular diet and has no symptoms of reflux or dysphagia, and surveillance CT 3 months after surgery shows no evidence of recurrence. 



Conclusions: This video demonstrates successful resection of a GIST located at the GEJ using an endoscopic-assisted laparoscopic transgastric partial gastrectomy.