Laparoscopic wedge resection of gastric leiomyoma.

Gastric leiomyoma is a rare gastric neoplasia. The laparoscopic method may treat various gastric tumors, including benign leiomyoma by wedge resection without opening the gastric cavity. The laparoscopic approach to submucosal tumors of the stomach is technically feasible, is safe, and has good postoperative results. It should be considered a viable alternative to open surgery. Herein, we describe a case of laparoscopic wedge resection of gastric leiomyoma.

INTRODUCTION

Gastric leiomyoma (GLM) is a submucosal lesion that can be intraluminal or extramural and represents 2.5% of gastric neoplasms.[1,2] Usually, most of them are asymptomatic. Sometimes, they can become clinically apparent due to bleeding from ulceration of the overlying gastric mucosa. On upper gastrointestinal contrast, they appear as a filling defect of the gastric wall. On endoscopy, they are seen as a submucosal mass (Schindler's sign).[2] Gastric leiomyomectomy is the standard treatment. The advances in laparoscopic surgery have made it possible to convert open laparotomy to a minimally invasive procedure with obvious benefits for the patients. Laparoscopic wedge resection of gastric leiomyoma is technically feasible, safe, and useful.

CASE REPORT

A 70-year-old female presented to the emergency room with complaints of melena. An upper endoscopy demonstrated a 4-cm tumor on the fornix of the stomach without mucosal lesion. The diagnosis was a submucosal tumor. The patient remained hemodynamically stable without any changes in her hematocrit (26%) and hemoglobin (7g/dL). A contrast upper gastrointestinal series displayed a well-circumscribed mass in the region of the upper gastric body. Laparoscopic diagnosis was a gastric tumor about 6cm in diameter, without a pedicle, that depressed the serosa, (. We performed a gastric wedge resection with a laparoscopic stapling device, Endo-GIA, (. The pathological report revealed a gastric leiomyoma (. The negative expression of the CD117 represents an argument for the exclusion of a stromal gastrointestinal tumor. Postoperatively, the patient recovered well and was discharged in 4 days.

Gastric leiomyoma: laparoscopic view.

Laparoscopic wedge resection of the gastric leiomyoma with a stapler.

Gastric leiomyoma: macroscopic aspects.

Gastric leiomyoma microscopic aspects: A. The localization of the tumor at a level of the muscularis mucosa; B. Fascicles of the tumoral cells with a varied orientation.

DISCUSSION

The first cases of gastric leiomyoma were reported by Morgani in 1762, by Virchow in 1867, and in 1981 Mambrini managed 300 confirmed cases.[3] Large series are exceptional;[4] most reports are of isolated cases.[5-39] GLM is a rare benign tumor with less than 3 new cases per million inhabitants.[40] In the larger group of submucosal gastric tumors, muscular tumors are the most frequent, representing 16% to 45% of all resected benign gastric tumors.[40]

Histologically, they can be leiomyomas (6% of all benign gastric tumors),[41] or leiomyoblastomas (3% to 5% of all benign tumors of the stomach), the latter being defined as a separate entity by Martini in 1960.[40] Both sexes are equally affected, and cases have been reported in patients as young as 2 years[42] and as old as 75 years of age, with a peak incidence in the sixth decade.

Macroscopically, GLM is generally a small, solitary tumor, but tumors as large as 6cm in diameter have been reported.[43-48] Endogastric developed tumors are smooth, rounded, and more or less well circumscribed, but not encapsulated. Mucosa overlaying the tumor may be ulcerated, while peritumoral mucosa is normal. Pedunculated forms are unusual and when located in the distal antrum may present as gastroduodenal intussusception.[49,50] Infiltrative forms thicken the gastric wall with less clear tumoral margins, leaving mucosal and serosal layers generally uninvolved. Exogastric pedunculated tumors have also been described.[51] Microscopically, GLM presents as crossed bundles of large fusiform smooth muscle cells, with eosinophilic cytoplasm, no myofibrillae, and scarce mitotic activity, which defines its benign character.

Most GLM grow slowly, and symptoms reflect in most cases mucosal ulceration, which generates an episode of gastrointestinal hemorrhage. Although unusual, GLM may have cystic degeneration[52] or erratic calcification.[42,53-58] Malignant transformation is exceptional and may be announced by repeated hemorrhages or a rapid growth.[40] Some tumors described histologically as benign may be malignant with local, regional, or metastatic recurrences. Marked mitotic activity, increased cellularity, and the presence of atypical cells are histologic markers for malignant transformation, but no clear-cut criteria can be used for differentiation.[40]

Clinical presentation depends on the size, location, and type of development (endo- or exogastric tumors). Most GLMs are asymptomatic and are found at autopsy or during abdominal surgical exploration for other reasons.[59] Incidental leiomyomas are not rare in resected specimens (3.5%).[60] Symptomatic GLM present with upper gastrointestinal bleeding, atypical epigastric pain or nonspecific dyspepsia. Intraperitoneal hemorrhage is unusual.[61,62] Bleeding is generally produced by mucosal ulceration[63-73] and is the most common complication in all forms, triggering an endoscopic evaluation.[74] Treatment with nonsteroidal anti-inflammatory drugs,[75] corticoids,[76] and anticoagulants[77] have all been described as predisposing factors associated with GLM bleeding. Major hemorrhagic episodes[73] initiate an early endoscopic diagnosis, and hemostasis by local injection of 98% dehydrated ethanol.[78,79] Technetium 99m labeled RBC imaging may be useful in early detection of bleeding from GLM.[80] Other complications are gastroduodenal invagination,[50,81-84] gastric volvulus, gastric tumoral torsion,[85] and gastric perforation.

Diagnosis can only be suspected by radiological methods (double contrast X-ray, endoscopic ultrasonography, computer tomography) but cannot be reached without a histological examination. Furthermore, diagnosis is so frequently based on modern diagnostic possibilities offered by ultrastructural and immunohistochemical examination that a macroscopic diagnosis remains only hypothetical.[86,87] The most typical roentgenological sign of GLM is an oval or round filling defect with even margins approximately 5cm to 6cm in size. Not infrequently, ulcerations are present on the surface like a “niche.” The mucosal folds around the filling defect are moved apart but not disorganized.[88] Endoscopy can suggest a benign submucosal lesion but cannot differentiate a GLM.[89] Transabdominal ultrasound scan and CT-scan will bring additional information in exogastric tumoral forms,[90-92] and endoscopic ultrasound is the best method to characterize small GLM. Preoperative endoscopic markings of tumor-bearing area may help in laparoscopic identification of GLM located on the posterior wall.

The main therapeutic goal is resection using the easiest technique. If the benign character is in doubt, resection with a safety margin should be advocated. The first case of laparoscopic gastric leiomyoma resection was reported in 1992.[1] This leiomyoma was found incidentally during a laparoscopic cholecystectomy. Since then, a few laparoscopic methods have been described for resection of gastric leiomyoma. The traditional surgical approach consists of laparotomy and resection, but pedunculated GLM may benefit from endoscopic polypectomy[63] or laser enucleation.[93] The use of stapling devices has shortened open surgical procedures and made possible a safe laparoscopic approach. According to tumor location, different minimal-access surgical approaches have been validated, for example: (1) laparoscopic wedge resection[94,95] with intraoperative laparoscopic ultrasound scan[96] or under endoscopic intraoperative guidance.[97,98] Resection2 is possible with an endostapling device or by suturing.[99] Endostapling reduces the operative time and avoids peritoneal contamination from a gastrotomy.[100] This simple resection may be difficult for lesions of the posterior gastric wall and those close to the gastroesophageal junction or pylorus; (2) laparoscopic intragastric resection using needlescopic instruments[101] or a flexible Endocutter.[102,103] It is probably best indicated in tumors not accessible for wedge resection. The stomach is accessed laparoscopically without abdominal insufflation by mini-laparoscopic ports (2mm) needing no suturing;[101,104] (3) Laparoscopic gastrotomy and resection under endoscopic guidance.[105] The defect in the gastric wall may be closed by laparoscopic stapling or suturing; (4) Combined approaches (endoscopy, laparoscopy, and laparoscopic ultrasound) have been used in resectioning of GLM.[106] Laparoscopic local excision offers the ideal method to establish a diagnosis and to treat patients with gastric smooth muscle tumors.[107] Intraoperative endoscopy is a useful method for small tumors and in controlling the margins after laparoscopic resection. Another method is enucleation of gastric leiomyomas. However, this method is problematic because it may produce an incomplete resection. Robotic surgery was recently approved[108] for use with the da Vinci Surgical System during laparoscopic procedures (the robotic operative time was 27% of the entire operative time).

After tumor resection, the final immunohistological examination of the specimens may differentiate GLM from gastrointestinal stromal cell tumors or neurinomas or benign neurofibrotic tumors. As less then 60% of endoscopic biopsies are fit for diagnosis, preoperative pathology is frequently inconclusive, and immunohistochemical diagnosis represents the cornerstone of further therapeutic decisions.[109] Benign and malignant gastric stromal tumors require only local excision for definitive treatment. Given that malignant gastric stromal tumors rarely involve lymph nodes and require only excision with negative margins, they appear amendable to laparoscopic excision. Some studies demonstrate no benefit with lymph-node dissection or extensive resection.[110,111] Gastric resection without lymph node dissection to treat leiomyosarcoma may be controversial.

Laparoscopic approaches allow for a combination of surgical techniques. Surgical techniques combined with GLM excision include removal of microcystic pancreatic adenoma,[112] laparoscopic or classic cholecystectomy,[113] or laparoscopic repair of paraesophageal hernia.[114]

CONCLUSION

Minimally invasive surgery has revolutionized the treatment of submucosal gastrointestinal tumors, such as gastric leiomyoma. When selected properly, the laparoscopic approach is considered curative and minimally invasive for resection of localized gastric tumors. Most patients begin eating on the first postoperative day and are discharged a few days later.