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ROBOTIC ASSISTED RESECTION OF LARGE GASTROINTESTINAL STROMAL TUMOR (GIST) PRESENTING AS ACUTE HEMATOCHEZIA
Nupur Savalia
*, Sevag Hamamah, Faizi Hai
Internal Medicine, Scripps Mercy Hospital San Diego, San Diego, CA
Introduction: Gastrointestinal stromal tumors represent about 1% of the tumors of the digestive tract. Clinical presentation varies between asymptomatic and diffuse symptoms such as abdominal pain, dyspepsia, and gastrointestinal bleeding. Complete surgical resection remains the mainstay of treatment for GIST and is likely the only curative therapy.
Case Description/Methods: A 66 year old male with history of polycystic kidney disease, end stage renal disease on hemodialysis, and anemia of chronic disease presented with a 3 day history of hematochezia and loose, watery stools twice a day. Patient denied non steroidal anti inflammatory drug (NSAID) or anticoagulation use and review of systems was otherwise negative. He had a normal colonoscopy two years prior to presentation and no history of upper endoscopy. Computed Tomography (CT) of abdomen and pelvis without contrast on admission revealed a 10 cm soft tissue mass in the left lower quadrant. A colonoscopy showed luminal narrowing due to extrinsic compression in the sigmoid colon at approximately 25 cm and a possible fistula to an external structure which intermittently spurted blood colored fluid into the colon lumen. The following day, the patient was taken for a robot assisted sigmoid colectomy to resect the mass seen on CT. Operative findings included a 12 cm vascularized mass extrinsic to the sigmoid colon that was growing into the anterior surface and creating a fistula as well as significant hemoperitoneum. There was no evidence of active bleeding from elsewhere and the tumor appeared to be the origin of the bleeding. Surgical pathology revealed a low grade KIT+ GIST. Oncology was consulted who started the patient on adjuvant imatinib for three years to reduce risk of recurrence.
Discussion: Traditionally, open surgery has been recommended for management of GISTs due to concern for tumor rupture and peritoneal seeding. However, the role of minimally invasive surgery has been growing in recent years and our case demonstrates successful robotic assisted surgical intervention for a larger GIST. While GISTs have potential to be malignant, these tumors rarely spread to the lymph nodes and a lymphadenectomy is seldom required. As a result, these tumors are good candidates for minimally invasive surgery. The literature reveals that laparoscopic surgery for GIST with attention to oncologic principles may also have better short term outcomes in terms of decreased surgical complications and shorter hospital stay.
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