ITO Shunichi

SERIZAWA Akiko

SUZUKI Kazuomi

TANIGUCHI Kiyoaki

YAMAMOTO Masakazu

YAMAMOTO Tomoko

Tokyo Women’s Medical University

Multinodular Gastric Leiomyoma withLaparoscopic Minimized Resection Based on aDetermination by Endoscope: A Case Report著者名 SERIZAWA Akiko, TANIGUCHI Kiyoaki, ITOShunichi, SUZUKI Kazuomi, YAMAMOTO Masakazu,YAMAMOTO Tomokojournal orpublication titleTokyo Women's Medical University Journalvolume 3page range 58-62year 2019-12-20URL http://hdl.handle.net/10470/00032479doi: https://doi.org/10.24488/twmuj.2018013|10.24488/twmuj.2018013―58―Case ReportTWMUJ 3: 58-62, 2019Multinodular Gastric Leiomyoma with Laparoscopic Minimized ResectionBased on a Determination by Endoscope: A Case ReportAkiko Serizawa, Kiyoaki Taniguchi, Shunichi Ito,Kazuomi Suzuki, Masakazu Yamamoto, and Tomoko Yamamoto＊Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan＊Department of Surgical Pathology, Tokyo Women’s Medical University, Tokyo, Japan(Accepted March 6, 2019)(Advance Publication by J-STAGE April 24, 2019)Background: Gastric leiomyomas are usually solitary, rounded, and demarcated masses, and multiple leiomyomas (morethan three) are extremely rare. We report a case of a 30-year-old woman who was referred to our hospital for further treat-ment of an enlarging gastric submucosal tumour (SMT).Case Presentation: She underwent laparoscopic gastric partial resection with oesophagogastroduodenoscopy (OGD), whichrevealed a multinodular gastric SMT (10 cm in diameter) located in the upper body of the stomach. Endoscopic ultrasonogra-phy (EUS) revealed a hypoechoic mass located in the fourth layer and multiple nodules approximately 1 cm in diameter. Wesubsequently performed EUS-guided fine-needle aspiration biopsy. The patient underwent laparoscopic gastric partial resec-tion with EGD. Because the tumour was extensive on the lesser curvature of the stomach and was located near the oe-sophagogastric junction, we preserved the gastric function with minimal resection of the stomach. No intraoperative or post-operative complications were observed. The tumour was pathologically diagnosed as gastric leiomyoma. Laparoscopic mini-mized resection used by endoscope, can avoid gastric deformity and preserve gastric function, especially when the gastricSMTs are located near the oesophagogastric junction.Conclusion: Laparoscopic gastric partial resection with EGD is an effective treatment option for complete resection of exten-sive gastric SMT.Key Words: leiomyoma, multinodular type, laparoscopic gastric partial resectionIntroductionGastric leiomyomas represent rare gastric neoplasms, andthe tumours are usually solitary, rounded, and demar-cated masses, and multiple leiomyomas (more than three)are extremely rare. We reported a case of multinodulargastric leiomyoma located at the oesophagogastric junc-tion with unusual shape and peculiar image findings re-ported, and the tumours that was successfully treated bylaparoscopic gastric partial resection with oesophagogas-troduodenoscopy (OGD).We report a case of multinodular gastric leiomyomaCorresponding Author: Akiko Serizawa, Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan. serizawa.ige@twmu.ac.jpdoi: 10.24488/twmuj.2018013CopyrightⒸ 2019 Society of Tokyo Women’s Medical University. This is an open access article distributed under the terms of CreativeCommons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal source is properly credited.―59―Figure　1　Endoscopic findings showing intraluminal growth type of a 10 cm multinodular gastric submucosal tumour at the lesser curvature of the proximal stomach.Figure　2　Endoscopic ultrasound showing a hypoechoic lesion inthe fourth layer and multiple nodules from about 1 cm in diameter and connected with each other in the upper body of the stomach.that was successfully treated by laparoscopic gastric par-tial resection with OGD.Case ReportThe patient was a 30-year-old woman who was referredto our hospital for further treatment of an enlarging gas-tric submucosal tumour (SMT). All haematological val-ues were within normal ranges.OGD revealed a multinodular SMT that was 10 cm indiameter and situated on the wall of the upper body ofthe lesser curvature of the stomach (Figure 1) . Endo-scopic ultrasonography ( EUS ) revealed a hypoechoicmass located in the fourth layer ; multiple nodules ofabout 1 cm in diameter and connected with each otherwere palpable in the upper body of the stomach (Fig-ure 2) . We subsequently performed EUS-guided fine-needle aspiration (EUS-FNA) biopsy. Cytological exami-nation of samples obtained by EUS-FNA showedspindle-shaped cells. An adequate histologic sample wasobtained; immunohistologic examination showed posi-tive smooth muscle actin (SMA) and desmin and nega-tive c-kit, CD34, and S-100 protein. We diagnosed thepatient with gastric leiomyoma. Based on the size of thegastric leiomyoma (10 cm in diameter) and its multi-nodular type, we considered the possibility of malig-nancy of the tumour. The tumour required resection with-out lymphadenectomy. The gross tumour occupied halfof the lesser curvature line, which conventionally re-quires proximal gastrectomy; however, such type of sur-gery is associated with reduced quality of life. Wewanted to retain the gastric function with minimal resec-tion of the stomach, and thus, we performed laparoscopicgastric partial resection with OGD.Treatment courseAfter inducing general anaesthesia, five ports were in-serted into the peritoneal cavity, as required for gastrec-tomy. Blood vessels in the lesser curvature of the stom-ach to the tumour excision area were prepared on the la-paroscopic side using an ultrasonically activated device(Figure 3). However, we were unable to detect the tu-mour on OGD because the tumour was a small noduleand it was an intramural tumour of the stomach. Throughserosal markings visualised by a laparoscope, the edge ofthe tumour was detected by the transmitted light of theendoscope (Figure 3a and 3b). Then, sodium hyaluro-nate solution containing indigo carmine dye was injectedinto the submucosal layer circumferentially by the endo-scope. A circumferential seromuscular incision was per-formed laparoscopically around the serosal markings―60―Figure　3　Laparoscopic-endoscopic cooperative surgery procedure: operation findings. (a) We checked the edge of the tumour as detected by the transmitted light of the endoscope. (b) After prepara-tion of blood vessels, we confirmed by serosal markings via laparoscope under endoscopic light navi-gation. (c) A circumferential seromuscular incision was performed laparoscopically around the serosal markings. (d) Complete resection of the tumour by laparoscopic procedure. (e) Closure of the defect in the gastric wall was performed through laparoscopic hand-suturing technique. (f) We confirmed the absence of deformation or leakage along the gastric wall using an endoscope.a b c d e f with a minimum margin hook knife and an ultrasonicallyactivated device (Figure 3c). A full-thickness resectionwas made laparoscopically using an ultrasonically acti-vated device (Figure 3d). An en bloc-resected specimenwas removed via the abdominal cavity using Endobag™(Covidien, Dublin, Ireland) . The defect of the gastricwall was continuously sutured using V-loc™ (Covidien,Dublin, Ireland) to the minor axis in an all-layer fashionwith the laparoscopic hand-suturing technique ( Fig-ure 3e). After resection of the tumour with a minimalmargin, no deformation or leakage was visualised alongthe gastric wall. After completing the full-thickness clo-sure, the endoscope was inserted into the stomach to con-firm that it passed the suture site easily and that no airleakage had occurred despite insufflations of the stom-ach, and a drain was placed on the suture line of thelesser curvature (Figure 3f). The total operation time was221 minutes.ResultsMacroscopically, a cross-sectional specimen of the tu-mour consisted of multiple white nodules and the tumourwas 8.8×4.7 cm. Pathological examination confirmedthat the tumour was located mainly in the submucosa andconsisted of fascicles of spindle-shaped cells. Immuno-histochemical findings showed positive SMA and desminalong with negative findings for c-kit, CD34, and S-100protein and nearly <0% Ki-67, thus indicating a diagno-sis of leiomyoma (Figure 4).The patient had an uneventful postoperative course,and was well and asymptomatic 2 years after the surgery.DiscussionGastric leiomyomas represent approximately 2.5% ofgastric neoplasms, and it most commonly manifests be-tween 50 and 59 years of age.１In most cases, there are nospecific symptoms or clinical signs of gastric leiomyoma.This tumour is detected incidentally during OGD for can-―61―Figure　4　Microscopic findings of the resected tumours. Haematoxylin and eosin (HE) staining showed that the tumour was located in the submucosal layer, that is, the muscularis propia (a) and fu-nicular spindle cell proliferation (×400) (b). Immunohistochemistry revealed the expression of smooth muscle actin (×40) (c) and non-expression of S-100 (×40) (d).cer screening or endoscopy. When symptoms are present,bleeding and abdominal discomfort are most frequent.Leiomyomas are usually solitary, rounded, and demar-cated masses, and multiple leiomyomas (more than three)are extremely rare. The presence of multiple tumours inthis case was a possible indication of a malignant pheno-type. Therefore, the patient underwent tumour resection.Multinodular leiomyomas are reported as oesophagealleiomyomatosis,２an extremely rare condition, which isassociated with Alport syndrome, a genetic type ofglomerular nephritis associated with sensorineural hear-ing loss and ocular lesions.３This is a very rare condition,and only one similar case has been published before.４Similar to our case, in this case too, many small noduleswere removed and the size of the tumour was 8 cm.When such a tumour has poor protuberance, it is difficultto judge the boundary with a normal gastric wall, and thearea of resection may increase. Gastric leiomyoma is be-nign, and the frequency of lymph node involvement islow; hence, lymphadenectomy is not generally required.Therefore, complete resection with negative surgicalmargins is possible.The treatment strategy for stomach leiomyoma re-mains controversial. Wedge resection is adequate for gas-tric leiomyoma, with no need for gastrectomy and sys-tematic lymph node dissection. According to Sasako etal,５surgery is indicated for gastric leiomyoma with tu-mours larger than 3 cm, with rapid growth, with inhomo-geneous ultrasound pattern, or with ulceration. In thiscase, based on the tumour size and the multinodular type,surgery was indicated.Laparoscopic wedge resection of the stomach is per-formed for resection of stomach tumours.６However, asurgical approach from the outside of the stomach issometimes difficult in gastric SMTs with intraluminal orintramural growth because of difficulty in identificationof the tumours, and an unintentionally large resectionmay result in deformity of the remaining stomach andgastric malfunction, as mentioned above. In our case, wecould avoid conventional proximal gastrectomy becausewe minimised gastric wall resection by using OGD ;moreover, we selected the hand-suturing technique toclose the large defect in the stomach to avoid gastric de-formity and oesophageal stenosis after surgery.７-９We―62―consider that the hand-suturing technique makes it possi-ble to select the best anastomotic axis to avoid transfor-mation of the stomach. The procedure was used to ensureradical cure and maintain the patients’ health-relatedquality of life.１０ConclusionWe report a case of leiomyoma with unusual shape andpeculiar imaging findings.Consent for Publication: Written informed consent wasobtained from the patient for publication of this case reportand any accompanying images.Conflicts of Interest: The authors indicated no conflicts ofinterest.References1．Morgan BK, Compton C, Talbert M et al: Benignsmooth muscle tumors of the gastrointestinal tract. A 24-year experience. Ann Surg 211: 63―66, 19902．Fernandes JP, Mascarenhas MJ, Costa CD et al: Diffuseleiomyomatosis of the esophagus: a case report and re-view of the literature. Am J Dig Dis 20: 684―690, 19753．García-Torres R, Orozco L: Alport-leiomyomatosis syn-drome: an update. Am J Kidney Dis 22: 641―648, 19934．Itaba S, Nakamura K, Goto A et al: Multinodular gastricleiomyoma, report of a case. Stomach and Intestine 44:293―299, 2009 (In Japanese with English abstract)5．Sasako M, Katai H, Sano T et al: Surgical treatment ofgastric leiomyoma. Stomach and Intestine 30 : 1169 ―1174, 1995 (In Japanese with English abstract)6．Choi SM, Kim MC, Jung GJ et al: Laparoscopic wedgeresection for gastric GIST: long-term follow-up results.Eur J Surg Oncol 33: 444―447, 20077．Kim HS, Kim MG, Kim BS et al: Laparoscopic surgeryfor submucosal tumor near the esophagogastric junction.J Laparoendosc Adv Surg Tech A 23: 225―230, 20138．Hoteya S, Haruta S, Shinohara H et al: Feasibility andsafety of laparoscopic and endoscopic cooperative sur-gery for gastric submucosal tumors, includingesophagogastric junction tumors. Dig Endosc 26: 538―544, 20149．Karanicolas PJ, Graham D, Gönen M et al: Quality oflife after gastrectomy for adenocarcinoma: a prospectivecohort study. Ann Surg 257: 1039―1046, 2013

Multinodular Gastric Leiomyoma with Laparoscopic Minimized Resection Based on a Determination by Endoscope: A Case Report

https://twinkle.repo.nii.ac.jp/?action=repository_action_common_download&item_id=24788&item_no=1&attribute_id=22&file_no=1

Multinodular Gastric Leiomyoma with Laparoscopic Minimized Resection Based on a Determination by Endoscope: A Case Report

Abstract

Similar works

Full text

Available Versions

Tokyo Women’s Medical University