Gastric tube-guided and robot-assisted laparoscopic resection of gastroesophageal junction stromal tumors: Two case reports

Abstract

BACKGROUND

Gastroesophageal junction (GEJ) or gastrointestinal stromal tumor (GIST) are located in unfavorable parts of the stomach, due to the anatomical complexity of these regions, protecting the cardia while ensuring R0 resection is a major challenge for surgeons.

CASE SUMMARY

Two cases of GEJ stromal tumors were reported. Abdominal computed tomography scans revealed that both tumors were located at the GEJ, close to the posterior wall, with one tumor measuring greater than 5 cm. Both patients successfully underwent robot-assisted laparoscopic wedge resection of the stomach. The surgeries achieved R0 resection while preserving the cardia sphincter and maximizing gastric tissue preservation. Postoperatively, no symptoms such as gastroesophageal reflux or cardia stenosis were observed. Case 1: Postoperative pathology: GIST. Immunohistochemical results: Tumor cells were positive for CD34, CD117, and DOG1, and negative for SMA, desmin, S-100, and SDHB (normal expression). The Ki-67 proliferation index was approximately 5%. Case 2: Postoperative pathology: GIST. Immunohistochemical results: Tumor cells were positive for CD117 (++), CD34 (++), DOG1 (+++), and focal positivity for SMA. Negative for desmin, S-100 (few cells positive), and SDHB (preserved expression). The Ki-67 proliferation index was approximately 10%.

CONCLUSION

The gastric tube-guided robotic-assisted laparoscopic resection is a safe and effective method for tumor resection while preserving the cardia, and it is worth further promotion in clinical practice.

Key Words: Gastrointestinal stromal tumour; Gastroesophageal junction; Wedge resection; Gastric tube; Laparoscopy; robotic surgery; Case report

Core Tip: Protecting the cardia is a considerable challenge in the surgical management of esophagogastric junction gastrointestinal (GI) stromal tumors. This study aims to investigate and summarize the application value of gastrostomy-guided and robot-assisted techniques in safeguarding the cardia during the resection of GI stromal tumors situated in anatomically unfavorable gastric locations.

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract, with approximately 60% occurring in the stomach[1]. GISTs at the gastroesophageal junction (GEJ) or cardia sphincter present significant challenges due to their complex anatomy, complicating surgical resection. Therefore, achieving R0 resection while preserving the function of the cardia sphincter remains a significant challenge for surgeons[2].

In traditional laparoscopic surgery, the limited operating space and lack of tactile feedback complicate the intraoperative accurate assessment of tumor margins, which can lead to injuring the cardia sphincter[3]. Warner and Sasse[4] have emphasized that nasogastric or calibration tubes not only help in assessing gastric capacity but also protect the cardia sphincter. Recently, robotic surgery has gained recognition because of the flexible robot arms and high-definition visualization, which provide more precise manipulation and better tissue dissection, reducing the incidence of such complications[5]. Solaini et al[6] has shown that the robotic approach offers significant advantages in fine dissection and suturing. Additionally, a single-center study by Furbetta et al[7] demonstrated the role of robotic surgery in resecting GISTs in anatomically complex areas. By combining the advantages of nasogastric tube guidance with robotic surgery, GISTs can be more accurately resected in challenging gastric locations while preserving the function of the cardia sphincter. Inspired by the use of calibration tubes in sleeve gastrectomy[8], here, we report introducing a nasogastric tube guidance technique to enhance tactile feedback and more accurately assess tumor boundaries.

CASE PRESENTATION

Chief complaints

Case 1: A 44-year-old woman who presented with a 2-year history of severe anemia, accompanied by intermittent upper abdominal discomfort, gastroesophageal reflux, and heartburn that began 1 year ago.

Case 2: A 59-year-old male patient presented with upper abdominal pain for over half a month.

History of present illness

Case 1: The patient has been receiving iron supplementation for the past 2 years without significant improvement in her anemia. She began experiencing upper abdominal discomfort, acid reflux, and heartburn 1 year ago.

Case 2: He experienced occasional upper abdominal discomfort, acid reflux, heartburn, nausea, and frequent postprandial symptoms.

History of past illness

No past medical history.

Personal and family history

No past medical history and no personal and family history.

Physical examination

Case 1: On physical examination, the vital signs were as follows: Body temperature, 36.3 °C; blood pressure, 108/60 mmHg; heart rate, 72 beats per minute; respiratory rate, 18 breaths per minute. Additionally, the patient appeared pale (indicating anemia), with mild tenderness in the upper abdomen. The abdomen was soft, without rebound tenderness or muscle rigidity.

Case 2: On physical examination, the vital signs were as follows: Body temperature, 36.3 °C; blood pressure, 112/70 mmHg; heart rate, 73 beats per minute; respiratory rate, 17 breaths per minute. Additionally, there was mild tenderness in the upper abdomen. The abdomen was soft, without rebound tenderness or muscle rigidity.

Laboratory examinations

Case 1: Hemoglobin level: 46 g/L; red blood cell count: 2.03 × 10¹²/L; Fecal occult blood: Positive (+); serum tumor markers: Normal; liver function tests, renal function tests, and urinalysis: Within normal limits.

Case 2: Laboratory examinations including complete blood count, urinalysis, fecal routine, liver function tests, and renal function tests, revealed no significant abnormalities.

Imaging examinations

Case 1: Gastroscopy: A 5.5-cm protrusion was identified on the posterior wall of the gastric fundus, with an associated ulcer and fresh bleeding.

Contrast-enhanced computed tomography (CT) (Figure 1): A soft tissue density mass measuring approximately 5.0 cm × 4.8 cm was detected in the gastric fundus. The mass exhibited clear margins with mild enhancement.

Figure 1 Preoperative radiologic findings: Abdominal computed tomography of Case 1. A: Case 1 abdominal computed tomography (CT) in the coronal plane. The arrow indicates a gastric stromal tumor; B: Case 1 abdominal CT in the sagittal plane. The arrow indicates a gastric stromal tumor.

Abdominal magnetic resonance imaging (Figure 2): A slightly low-signal filling defect was observed in the gastric fundus, measuring approximately 50 mm × 46 mm. The lesion demonstrated a slightly high signal intensity on diffusion-weighted imaging.

Figure 2 Preoperative radiologic findings: Abdominal magnetic resonance imaging of Case 1. A: Case 1 abdominal magnetic resonance imaging (MRI) in the coronal plane. The arrow indicates a gastric stromal tumor; B: Case 1 abdominal MRI in the sagittal plane. The arrow indicates a gastric stromal tumor.

Case 2: Contrast-enhanced CT (Figure 3) showed a well-defined submucosal mass at the cardia, measuring approximately 2.5 cm × 2.7 cm.

Figure 3 Preoperative radiologic findings: Abdominal computed tomography of Case 2. A: Case 2 abdominal computed tomography (CT) in the coronal plane. The arrow indicates a gastric stromal tumor; B: Case 2 abdominal CT in the sagittal plane. The arrow indicates a gastric stromal tumor.

Endoscopic ultrasound revealed a 4-cm hypoechoic, oval-shaped submucosal protrusion extending from the cardia to the gastric fundus, likely originating from the muscularis propria.

FINAL DIAGNOSIS

Considering the symptoms, physical examination, and ancillary tests, a GIST of the GEJ is highly suspected.

TREATMENT

Following the exclusion of surgical contraindications, both patients underwent robotic-assisted laparoscopic gastric wedge resection.

Surgical method

Under general anesthesia, the patient was placed in a supine position with legs abducted in a V-shape. A 1-cm transverse incision was made slightly to the right of the midline below the umbilicus to establish the observation port. The abdominal cavity was insufflated to a pressure of 12 mmHg. Intraoperative exploration revealed no metastatic lesions. A 5.5 cm × 5.0 cm mass was palpated on the posterior wall near the cardia of the upper gastric body. An 8-mm robotic trocar was inserted at the right and left midclavicular lines at the costal margin, and a 12-mm trocar was positioned at the left midclavicular line at the umbilical level to serve as an assistant port (Figure 4). The omentum was retracted cephalad to expose the operative field. The gastroepiploic artery was carefully dissected and ligated. The short gastric and posterior gastric arteries were dissected and ligated using a vascular clip and ultrasonic scalpel. The gastrosplenic ligament was completely mobilized up to the left side of the cardia. After palpating the mass, a nasogastric tube (36F Bougie Tube) was inserted to provide full support to the GEJ and the gastric wall adjacent to the tumor (Figure 5). Gentle dissection was meticulously performed to clearly delineate the tumor margins, with careful preservation of the cardia. A wedge resection of the GIST was executed using an endoscopic stapler. The gastric wall was subsequently reinforced with a continuous suture using a 3-0 barbed suture material (Figure 6). The resected specimen was placed into a retrieval bag and removed in a completely intact manner. One abdominal drain was positioned in the left upper quadrant, and another was placed in the right upper quadrant. After confirming the absence of bleeding and leakage, the trocar sites and surgical incisions were meticulously closed with sutures, thereby completing the procedure.

Figure 4 Distribution of trocar sites during the operation. A and B: Robotic-assisted laparoscopic resection; C and D: Robotic-assisted laparoscopic suturing.

Figure 5 Schematic diagram of the use of a gastroscope. The gastric tube placed during operation is routine used in bariatric surgery. The tube itself is flexible and resilient, with good supporting strength. The tube wall and tip end is smooth to prevent damage to the digestive tract and facilitate the insertion. The tube served as bougie during of laparoscopic sleeve gastrectomy, with a larger diameter of 12 mm. The use of bougie when stapling the incisura angularis will result in decreased incidence of strictures and better preserve the cardiac sphincter function. A: Intraoperative exploration of tumor margins using a gastroscope; B: Schematic diagram of intraoperative exploration of tumor margins using a gastroscope. GIST: Gastrointestinal stromal tumor.

Figure 6 Schematic diagram of surgical trocar distribution.

OUTCOME AND FOLLOW-UP

After a brief period of postoperative treatment with intravenous fluids, antibiotics, and other routine interventions, the drainage tubes were removed on postoperative days 3 to 5. The patients were allowed to resume oral liquid diets without experiencing abdominal pain or bloating, and with normal flatus and bowel movements. They were discharged once their conditions stabilized. Postoperative pathology results: Case 1: Gastric tumor resection specimen GIST. Postoperative risk stratification: Intermediate. No residual tumor was identified at the resection margins. Immunohistochemical results (magnification: × 200): Tumor cells were positive for CD34(+), CD117(+), and DOG1(+), and negative for SMA(-), desmin(-), S-100(-). Normal expression of SDHB was observed, and the proliferation index Ki67 was approximately 5% positive (Figure 7A). Case 2: Gastric tumor resection specimen GIST. Postoperative risk stratification: High. No residual tumor was identified at the resection margins. Immunohistochemical results: Tumor cells were strongly positive for CD117(++), CD34(++), and DOG1(+++), focally positive for SMA(+), and negative for desmin(-). Scattered cells were positive for S-100(+). Normal expression of SDHB was retained, and the proliferation index Ki67 was approximately 10% positive (Figure 7B).

Figure 7 Pathologic finding. A: Gastric tumor resection specimen gastrointestinal stromal tumor (GIST). Postoperative risk stratification: Intermediate. No residual tumor was identified at the resection margins (Case 1); B: Gastric tumor resection specimen GIST (Case 2). Postoperative risk stratification: High. No residual tumor was identified at the resection margins.

DISCUSSION

GISTs are a common type of mesenchymal tumor[1]. GISTs in the lesser curvature of the stomach, the posterior wall of the stomach, and the GEJ are referred to as gastric GISTs in unfavorable locations due to their anatomical characteristics, which make them difficult to resect via laparoscopy or endoscopy[3]. Surgery is the preferred treatment for gastric GISTs, with the choice of surgical approach determined by a comprehensive consideration of the tumor's anatomical location, size, growth pattern (e.g., intraluminal, extraluminal, or intramural), and the potential impact on postoperative gastric function. The primary routes of metastasis for GISTs are hematogenous metastasis and peritoneal seeding, with common metastatic sites including the liver, mesentery, and retroperitoneal space. Lymph node metastasis is extremely rare, hence routine lymphadenectomy is not performed during surgery[9].

GEJ GISTs are defined as GISTs located within 5 cm above or below the GEJ[10,11]. For GEJ GISTs, the current recommended surgical approach is laparoscopic wedge resection of the stomach. However, surgeries in this area face numerous challenges: The complex anatomical structure, the density of important structures, and the complexity of GI reconstruction[12]. During laparoscopic surgery, exposure is difficult, which is not conducive to accurately determining the tumor margins, potentially leading to excessive resection of gastric tissue or tumor residue[13]. Moreover, repeated intraoperative manipulation of the tumor may cause tumor rupture, increasing the risk of peritoneal seeding and metastasis. Given these complexities, a high level of surgical expertise, particularly in suturing, is required. Postoperative complications may include anastomotic leakage, anastomotic stricture, and gastroesophageal reflux. Achieving R0 resection while preserving the cardia and maximizing gastric tissue retention remains a significant challenge for surgeons. Compared with traditional laparoscopic surgery, robotic surgery, with its high-definition imaging, high precision in operation, and high flexibility, has gradually gained recognition for its ability to reduce postoperative complications[14]. Lwin et al[5] also noted that robotic surgery can improve the effectiveness and safety of procedures for gastric GISTs in anatomically challenging locations.

To address the challenge of cardia preservation during wedge resection of GEJ GISTs, we report two cases of gastric GISTs located at the GEJ. During both procedures, we guided the operation by placing a large diameter nasogastric tube routine used in sleeve gastrectomy, and utilized the flexible robotic arms to increase the surgeon's tactile perception of the tumor, facilitating more accurate determination of tumor margins and better preservation of gastric cardia function. Therefore, we not only ensured the R0 resection of the tumor but also preserved the cardia sphincter and retained the maximum amount of gastric tissue. None of the two surgeries was converted to open surgery. The flexible robotic arms played a significant role in GI reconstruction and suturing, enabling the successful completion of the surgeries. In terms of postoperative complications, no patients experienced anastomotic leakage, anastomotic stricture, or gastroesophageal reflux. Regarding operative time, although robotic surgery may take slightly longer than traditional laparoscopic surgery, with continuous technological advancements and increasing proficiency of the surgical team, the operative time is expected to be shortened[15].

In conclusion, robotic-assisted gastric wedge resection guided by nasogastric tube placement achieved R0 resection of the tumor while successfully preserving the cardia and retaining the maximum amount of gastric tissue. This surgical method is warrants further consideration for broader clinical application.

CONCLUSION

The gastric tube-guided robotic-assisted laparoscopic resection is a safe and effective method for tumor resection while preserving the cardia, and it is worth further promotion in clinical practice.

ACKNOWLEDGEMENTS

Thanks to Professor Dai HS and Jiang ZW for his perioperative guidance on the use of “enhanced recovery after surgery”, and Wei Jiang and Liu Jiang and Professor Liu XX for precise surgery.