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

nPTD classification: an updated classification of gastric cancer location for function preserving gastrectomy based on physiological lymphatic flow

Background The correlation between tumor location and lymphatic flow distribution in gastric cancer has been previously reported, and PTD (Proximal – Transitional – Distal) classification was proposed. Our group updated and developed the nPTD classification. Method We retrospectively studied gastric cancer patients who underwent the dye method sentinel node biopsy from 1993 to 2020. The inclusion criteria were a single lesion type 0 cancer of ≤5 cm in the long axis, clinically node-negative, and invasion within the proper muscle layer pathologically. In this study, the distribution of dyed lymphatic flow was evaluated for each occupied area of the tumor. Results We included 416 patients in this study. The tumors located in the watershed of the right and left gastroepiploic arteries near greater curvature had extensive lymphatic flow; therefore, a newly circular region with a diameter of 5 cm is set on the watershed of the greater curvature between P and T zone as the ‘n’ zone. In addition, for cancers located in the lesser P curvature, lymphatic flow to the greater curvature was not observed. Therefore, the P zone was divided into two: the lesser curvature side (PL) and the greater curvature side (PG). Conclusions The advantage of the nPTD classification is that it provides not only proper nodal dissection but also adequate function-preserving gastrectomy. If the tumor is localized within the PL, the proximal gastrectomy resection area can be further reduced. In contrast, for cancers located in the ‘n’ zone, near-total gastrectomy is required because of the extensive lymphatic flow.

A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

Background Risk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy. Methods First, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed. Results We utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases. Conclusion Our technique of NGT placement is simple, safe, and feasible.

Gastric examination using a novel three-dimensional magnetically assisted capsule endoscope and a hand-held magnetic controller: A porcine model study

Magnetically assisted capsule endoscopy (MACE) is a noninvasive procedure and can overcome passive capsule movement that limits gastric examination. MACE has been studied in many trials as an alternative to upper endoscopy. However, to increase diagnostic accuracy of various gastric lesions, MACE should be able to provide stereoscopic, clear images and to measure the size of a lesion. So, we conducted the animal experiment using a novel three-dimensional (3D) MACE and a new hand-held magnetic controller for gastric examination. The purpose of this study is to assess the performance and safety of 3D MACE and hand-held magnetic controller through the animal experiment. Subsequently, via the dedicated viewer, we evaluate whether 3D reconstruction images and clear images can be obtained and accurate lesion size can be measured. During real-time gastric examination, the maneuverability and visualization of 3D MACE were adequate. A polypoid mass lesion was incidentally observed at the lesser curvature side of the prepyloric antrum. The mass lesion was estimated to be 10.9 x 11.5 mm in the dedicated viewer, nearly the same size and shape as confirmed by upper endoscopy and postmortem examination. Also, 3D and clear images of the lesion were successfully reconstructed. This animal experiment demonstrates the accuracy and safety of 3D MACE. Further clinical studies are warranted to confirm the feasibility of 3D MACE for human gastric examination.

Intraluminal pyloric duplication cyst- a rare cause of non-bilious vomiting in a neonate: A case report

Background: Duplications of the alimentary tract are rare congenital malformations, out of which, true pyloric duplications constitute only 2.2%. They present with non-bilious vomiting and mimic hypertrophic pyloric stenosis (HPS). Pyloric duplications that are intraluminal are not separately visible at laparotomy, making their diagnosis difficult. Case presentation: Our case is a neonate with an intraluminal pyloric duplication cyst who presented with recurrent vomiting. The radiological evaluation suggested a duplication cyst medial to the second part of the duodenum towards the stomach’s lesser curvature with features of gastric outlet obstruction. Intraoperatively, a cystic mass of 1 x 2 cm intraluminally was found on opening the pylorus which was excised and pyloroplasty was done. Postoperatively the baby was discharged in a stable condition. Conclusion: Intraluminal pyloric duplication cysts are rare and the clinical presentation mimics HPS. They should be considered as a differential diagnosis in a neonate presenting with features of gastric outlet obstruction.

649 EFFECTS OF THE PREPARATION METHOD ON THE ICG FLUORESCENCE BLOOD FLOW IN THE GASTRIC CONDUIT AFTER ESOPHAGECTOMY

In this study, we investigated how the blood flow of gastric conduit changed due to the difference in the lesser curvature cut line using ICG fluorescence imaging in patients with esophageal cancer. Methods A total of 193 cases of esophageal cancer surgery with gastric conduit reconstruction were included. (Conventional method) The lesser curvature cut line of the stomach was started from a distance of 5 cm from the pylorus (141 cases). (Current method) Gastric lesser curvature dissection was started from the last branch of the left gastric artery (52 cases). Blood flow of the gastric conduit was measured by the ICG fluorescence imaging, and the correlation between the changes in the gastric conduit and both blood flow and anastomotic failure was examined. Results Median length of the lesser curvature cut line was 10 cm from the pylorus in the current method, which was significantly longer than that in the conventional method (P < 0.001). Congestion at the tip of the gastric conduit were more observed in the conventional method (P = 0.02). The ICG fluorescent blood flow speed in the gastric conduit wall was 2.54 cm/s by the conventional method and 2.82 cm/s by the current method (P = 0.03). There were 23 cases (16.3%) of anastomotic leakage in the conventional method and 4 cases (7.7%) in the current method (P = 0.09). Conclusion By preserving the right gastric artery and vein, improvement of venous return is expected, and it is suggested that blood flow in the gastric conduit wall can be well maintained.

CLINICAL OBSERVATION OF THE DEVELOPMENT OF ACUTE RENAL INJURY IN ADOLESCENTS AGAINST A BACKGROUND OF DIFFICULT TO DIAGNOSE STOMACH ULCER

A clinical observation of the development of acute kidney injury (AKI) (stage III) in a 17-year-old girl is presented. The cause of AKI was dehydration of the body against the background of ulcer of the lesser curvature of the stomach. This localization of ulcerative damage and certain social factors caused the delayed diagnosis of the disease, which led to the development of AKI. Duration of anuria was 20 hours. The creatinine level reached 902 μmol/l. Appointment of adequate infusion therapy led to the restoration of renal function, and pathogenetic therapy to ulcer scarring.

Dieulafoy's Lesion in the Gaster Secondary to the Resection of Lung Cancer: A Rare Case Report Presentation

Background: Dieulafoy’s lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without obvious ulceration. Dieulafoy's lesion is a rare disease, meanwhile the lesion secondary to resection of lung cancer is even extremely rare. It is most commonly located in the lesser curvature of the stomach but rarely occurrences in extragastric sites have also been reported. To summarize the key points in the diagnosis and treatments of this disease, we present a clinical case of acute gastrointestinal bleeding due to Dieulafoy's lesion in the gaster secondary to resection of lung cancer.Case presentation: An 58-year-old woman presented with a clinical condition of haematemesis and haematochezia associated with anaemia and haemodynamic instability, needing blood transfusion. After many changes of body position, when the patient was in prone position, we finally found jet bleeding on the gastric body near the great curvature of gastric fundus under gastroscopy, and then we performed successfully with hemostatic clip placement. Hospitalization occurred without further com plications. There was no recurrence after 18 months follow-up.Conclusion: It is essential to be aware of this lesion as a possible cause of gastrointestinal bleeding and especially thoracic postoperative acute gastrointestinal appears. Timely and effective endoscopy can improve the diagnosis rate of these lesions and reduce the related mortality. At the same time, we need to pay attention to the patients with the risk factors in the perioperative period to reduce the incidence of Dieulafoy's lesion.

nPTD Classification: An Updated Classification of Gastric Cancer Location for Function Preserving Gastrectomy Based on Physiological Lymphatic Flow

Background: The correlation between tumor location and lymphatic flow distribution in gastric cancer has been previously reported, and PTD (Proximal – Transitional – Distal) classification, proposed. We updated and developed the nPTD classification.Method: We retrospectively studied gastric cancer patients who underwent the dye method sentinel node biopsy from 1993 to 2020. The inclusion criteria were a single lesion type 0 cancer of ≤5 cm in the long axis, clinically node-negative, and invasion within the proper muscle layer pathologically. In this study, the distribution of dyed lymphatic flow was evaluated for each occupied area of the tumor.Results: We selected 416. The tumors located watershed of the right and left gastroepiploic artery near greater curvature had extensive lymphatic flow; therefore, a newly circular region with a diameter of 5 cm is set on the watershed on greater curvature between P and T zone as the ‘n’ zone. In addition, for cancers located in the lesser P curvature, lymphatic flow to the greater curvature was not observed. Therefore, the P zone is divided into two: the lesser curvature side (PL) and the greater curvature side (PG).Conclusions: The advantage of the nPTD classification is that it provides not only proper nodal dissection, but also adequate function-preserving gastrectomy. If the tumor is localized within the PL, the proximal gastrectomy resection area can be further reduced. In contrast, for cancers located in the ‘n’ zone, near-total gastrectomy is required because of the extensive lymphatic flow.

Geospatial Assessments of DNA Adducts in the Human Stomach: A Model of Field Cancerization

Background: Field cancerization is a popular concept regarding where cancer cells arise in a plane, such as the opened-up gastrointestinal mucosa. The geospatial distribution of DNA adducts, some of which are believed to initiate mutation, may be a clue to understanding the landscape of the preferred occurrence of gastric cancer in the human stomach, such that the occurrence is much more frequent in the lesser curvature than in the greater curvature. Methods: Seven DNA adducts, C5-methyl-2′-deoxycytidine, 2′-deoxyinosine, C5-hydroxymethyl-2′-deoxycytidine, N6-methyl-2′-deoxyadenosine, 1,N6-etheno-2′-deoxyadenosine, N6-hydroxymethyl-2′-deoxyadenosine, and C8-oxo-2′-deoxyguanosine, from different points and zones of the human stomach were semi quantitatively measured by liquid chromatography/tandem mass spectrometry. The differences in the quantity of these DNA adducts from the lesser and greater curvature, the upper, middle and lower third zones, the anterior and posterior wall of the stomach, and the mucosae distant from and near the tumor were compared to determine whether the location preference of cancer in the stomach could be explained by the distribution of these DNA adducts. Comparisons were conducted considering the tumor locations and operation methods. Conclusions: Regarding the DNA adducts investigated, significant differences in quantities and locations in the whole stomach were not noted; thus, these DNA adducts do not explain the preferential occurrence of cancer in particular locations of the human stomach.