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Unexpected Subserosal Gastrointestinal Stromal Tumor Encountered During Laparoscopic Hiatal Hernia Repair
Robert Wright*1, Hallie Wurst2
1Meridian Surgery Center, Puyallup, WA; 2University of Arizona, Tuscon, WA
IMPORTANCE: Gastrointestinal Stromal Tumors (GIST) are most commonly found in the upper parts of the stomach and its incidence is not known during hiatal hernia repair. Subserosal occurrence of GIST is not commonly appreciated.
OBJECTIVE: Determine the incidence of subserosal GIST discovered incidentally during primary laparoscopic repair of paraesophageal hernia and Gastroesophageal Reflux Disease (GERD) related hiatal hernia.
DESIGN SETTING AND PARTICIPANTS: This is a retrospective, single surgeon evaluation in the private practice setting utilizing hiatal hernia repair chart information from the years 2011 through 2013, all inclusive.
MAIN OUTCOMES AND MEASURES: Incidence of subserosal GIST during laparoscopic surgery was noted for GERD patients with moderate sized hiatal hernias and compared with those patients undergoing paraesophageal hernia repair. Gender, age, presence and absence of tumor were analyzed. The diagnoses of GIST were confirmed by a c-KIT test. The differences between the groups were evaluated by Fisher’s Exact Test. An age confounding factor was analyzed by a two-way ANOVA analysis.
RESULTS: A total of 184 patients underwent laparoscopic hiatal hernia repair in a three-year calendar timeframe. Nine out of the 7 subserosal lesions were biopsied at the anterior Gastroesophageal (GE) junction and seven were proven to be GIST by a c-KIT test. The median size of GIST was found to be 0.4 cm, with a range from 0.3 to 0.6 cm. All of these tumors were classified low grade, with mitotic rates less than 5 mitoses per 50 High-Powered Fields (HPF). Five of the seven patients found to have a subserosal GIST were female, which is not significant for gender. Of the 184 total patients, 121 had surgery primarily performed for GERD and 63 for paraesophageal hernia. The incidence of subserosal GIST at the GE junction was 2.5% among patients undergoing GERD surgeries and 6.3% among patients undergoing paraesophageal hernia repair for an overall incidence of 3.8%. The differences between these two groups were not significant by Fisher’s Exact Test. GISTs were found to be more common with advanced age (P=0.010). Age was also related to risk of paraesophageal hernia (P=0.037). By two-way ANOVA analysis the interaction term between age and paraesophageal hernia was not significant (P=0.289).
CONCLUSIONS AND RELEVANCE: The overall incidence of subserosal GIST is 3.8% in patients undergoing hiatal hernia repair for any indication. These are subserosal tumors visible at surgery found to have a median size of 0.4 cm and of low-grade classification, with mitotic rates less than 5 mitoses per 50 HPF. The incidence of GIST is higher as the patient’s age increases. These tumors all have malignant potential and need to be recognized and resected by the surgeon while performing the primary procedure. The lesions are not otherwise detectable by endoscopy.
Serosal GIST
  Serosal GIST
Serosal GIST
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