Gastric GIST: A Rare Cause of Upper GI Bleeding

Gastrointestinal stromal tumours are the most common mesenchymal tumours of the gastrointestinal tract. This case report highlights the necessity of early surgical intervention in such cases to avoid mortality due to bleeding and to raise the awareness of rare causes of upper gastrointestinal bleed and their management. A 19 year old male presented in the surgery department of Shaheed Suhrawardy medical College Hospital with complaints of recurrent episodes of melena with anorexia and weight loss for 6 months. Apart from anaemia no significant findings were noted on physical examination. Investigations including upper GI endoscopy was not conclusive. So he underwent laparotomy which revealed an exophytic growth along the lesser curvature. Lower partial gastrectomy was done and histopathological and immunohistochemistry report showed evidence of benign low risk GIST. As the tumor was benign with no malignant potential imatinib therapy was not advocated. J Shaheed Suhrawardy Med Coll 2020; 12(2): 119-122

Single Surgical Approach for Gastric Gastrointestinal Stromal Tumor and Cholecystolitiasis by Laparoscopic Procedure

Introduction: Gastrointestinal stromal tumor (GIST) is a rare neoplasm representing 80% of gastrointestinal neoplasms. Laparoscopic resection is only recommended for GIST less than 2 cm and 5 cm for laparoscopic wedge resection. Thus, a large GIST is recommended to complete resection through laparotomy. A large GIST of the gastric fundus can be found in patients, which coincides with an upper right abdominal quadrant pain caused by cholecystolithiasis. A suggested laparotomy for tumor resection and cholecystectomy may result in poor recovery in the postoperative period. Therefore, one approach surgery with minimally invasive laparoscopic partial gastrectomy using Endoflex stapler and cholecystectomy was performed to achieve the optimal outcome.Case Presentation: A 43-year-old male had a major complaint of hematemesis and melena for one month and colicky pain in the right upper quadrant of the abdomen with increased intensity in the last two months. Contrast-enhanced abdominal MSCT revealed a solid 4.6 x 4 x 5.6 cm exophytic mass on the gastric fundus, added with 0.5 cm gall bladder stone. Laparoscopic partial gastrectomy and cholecystectomy were performed in a single minimal invasive surgical procedure. The post-operative period was uneventful. The patient experienced minimum pain, early mobilization, and better diet tolerance. He was discharged on day four after the surgery. Besides, the histopathologic result revealed a malignant mesenchymal tumor according to GIST with a tumor-free margin of resection.Conclusions: Single approach surgery with minimal laparoscopic partial gastrectomy and cholecystectomy has provided optimal outcomes for patients with large GIST and cholecystolithiasis.

Billroth II procedure for the treatment of spontaneous gastrointestinal perforation in two cats

CASE DESCRIPTION A 9-year-old castrated male domestic shorthair cat (cat 1) and a 10-year-old castrated male Maine Coon cat (cat 2) were presented for recurrent feline lower urinary tract disease after receiving outpatient care from their primary veterinarians. CLINICAL FINDINGS Physical examination findings for both cats were initially within reference limits. After a short period of hospitalization, both cats developed peritoneal effusion; results of cytologic analysis of a sample of the fluid were consistent with septic peritonitis. During exploratory laparotomy, perforation of the pylorus or proximal portion of the duodenum secondary to ulceration was identified. TREATMENT AND OUTCOME Both cats underwent partial duodenectomy, partial gastrectomy (pylorectomy), and gastrojejunostomy (Billroth II procedure). The cats recovered from surgery and returned to a normal quality of life; however, each had mild episodes of anorexia but maintained a stable body weight. Cat 2 required additional surgery for trichobezoar removal 7 weeks later but recovered quickly. At 7 months after trichobezoar removal, cat 2 developed intermittent vomiting, but clinicopathologic, abdominal ultrasonographic, and upper gastrointestinal tract endoscopic findings were within reference limits. At 9 (cat 2) and 13 (cat 1) months after the Billroth II procedure, both cats were reported to be in good general health and without gastrointestinal signs. CLINICAL RELEVANCE In both cats, the Billroth II procedure was technically straightforward and associated with a full recovery and good medium- to long-term quality of life. A Billroth II procedure could be considered for treatment of cats with large mural lesions in the pyloroduodenal region.

The type of gastrectomy and modified frailty index as useful predictive indicators for 1-year readmission due to nutritional difficulty in patients who undergo gastrectomy for gastric cancer

Background Patients who undergo gastrectomy for gastric cancer (GC) are likely to have nutritional difficulty after surgery. Readmission due to nutritional difficulty is common in such patients. Thus, in this study, we aim to identify the predictive indicators for readmission due to nutritional difficulty in patients who underwent gastrectomy for GC. Methods We retrospectively reviewed surgical outcomes in 516 consecutive patients who underwent gastrectomy for GC. Results The readmission rate within 1 year was 13.8%. Readmission due to nutritional difficulty was observed in 20 patients (3.9%); it was determined as the second leading cause of readmission. Multivariate analysis revealed that the type of gastrectomy and the modified frailty index (mFI) were independent predictive indicators of readmission due to nutritional difficulty. Patients were assigned 1 point for each predictive indicator, and the total points were calculated (point 0, point 1, or point 2). The readmission rates due to nutritional difficulty were 1.2%, 4.7%, and 11.5% in patients with 0, 1, and 2 points, respectively (P = 0.0008). Conclusions The readmission rate due to nutritional difficulty was noted to be high in patients who underwent total or proximal partial gastrectomy with high mFI. Intensive follow-up and nutritional support are needed to reduce readmissions due to nutritional difficulty. Reduced readmission rates can improve patient quality of life and reduce medical costs.

Development and validation of a novel diagnostic model for initially clinical diagnosed gastrointestinal stromal tumors using an extreme gradient-boosting machine

Introduction Gastrointestinal stromal tumor (GIST) is the most common gastrointestinal soft tissue tumor. Clinical diagnosis mainly relies on enhanced CT, endoscopy and endoscopic ultrasound (EUS), but the misdiagnosis rate is still high without fine needle aspiration biopsy. We aim to develop a novel diagnostic model by analyzing the preoperative data of the patients. Methods We used the data of patients who were initially diagnosed as gastric GIST and underwent partial gastrectomy. The patients were randomly divided into training dataset and test dataset at a ratio of 3 to 1. After pre-experimental screening, max depth = 2, eta = 0.1, gamma = 0.5, and nrounds = 200 were defined as the best parameters, and in this way we developed the initial extreme gradient-boosting (XGBoost) model. Based on the importance of the features in the initial model, we improved the model by excluding the hematological features. In this way we obtained the final XGBoost model and underwent validation using the test dataset. Results In the initial XGBoost model, we found that the hematological indicators (including inflammation and nutritional indicators) examined before the surgery had little effect on the outcome, so we subsequently excluded the hematological indicators. Similarly, we also screened the features from enhanced CT and ultrasound gastroscopy, and finally determined the 6 most important predictors for GIST diagnosis, including the ratio of long and short diameter under CT, the CT value of the tumor, the enhancement of the tumor in arterial period and venous period, existence of liquid area and calcific area inside the tumor under EUS. Round or round-like tumors with a CT value of around 30 (25–37) and delayed enhancement, as well as liquid but not calcific area inside the tumor best indicate the diagnosis of GIST. Conclusions We developed a model to further differential diagnose GIST from other tumors in initially clinical diagnosed gastric GIST patients by analyzing the results of clinical examinations that most patients should have completed before surgical resection.

Extramedullary relapse in a patient with multiple myeloma: a rare cause of gastrointestinal perforation and massive bleeding

Multiple myeloma (MM) patients live longer due to more effective treatment, and we now see previously uncommon manifestations of MM, like extramedullary disease. We present a case of a 74-year-old man known with MM that relapsed with extramedullary manifestations at different locations. One of them as a gastric plasmacytoma (GP). He was successfully treated with chemoradiotherapy (Daratumumab, Bortezomib and Dexamethasone), which resulted in clinical response for 8 months, confirmed by biopsy and histopathology. Perforation of the GP occurred, and he underwent partial gastrectomy (Billroth II gastrojejunostomy). The patient’s disease progressed again 5 months after surgery, and he did not want any additional treatment. He accepted palliative care and died 10 months after the operation. A lack of knowledge about the characteristics and treatment of extramedullary MM exists, and prospective studies to investigate incidence, prognosis and treatment for extramedullary MM are needed for improving the poor prognosis of this manifestation.