Esophageal GIST and Bariatric Surgery in a Patient With Severe Obesity, GERD and Gastric Metaplasia

10 Dec 2020 02:10 02:10
Geneva
Minoa Jung  Host
Peter Grimminger Host
Stefan Moenig Host

Case 1: Giant Gastrointestinal Stromal Tumor (GIST) of the Distal Esophagus

Patient Profile & Clinical Presentation

  • Patient: 73-year-old female

  • Diagnosis: Giant gastrointestinal stromal tumor (GIST) of the distal esophagus.

  • Clinical Presentation: Two-month history of dysphagia associated with spasm.

  • Gastroesophageal Reflux: Absence of symptoms of gastro-esophageal reflux.

Diagnostic Workup

  • Upper Gastrointestinal Endoscopy with Ultrasound and Fine Needle Biopsies: Submucosal tumor corresponding immunohistochemically to GIST.

  • Thoraco-abdominal Computed Tomography and Positron Emission Tomography: Confirmed an esophageal tumor measuring 7 cm.

Surgical Treatment

Surgical treatment was decided at the Board meeting.

  • Procedure: Subtotal Ivor Lewis hybrid esophagectomy (laparoscopy and right-side thoracotomy) with intrathoracic end-to-side circular esogastric anastomosis.

  • Postoperative Course: Uneventful postoperative period. Patient discharged after 10 days.

Histopathology

  • Pathological Stage: pT3 N0 L0 V0 PN0 R0.

  • Tumor: Low-grade distal esophageal wall GIST, 6.5 cm.

  • Mitotic Activity: Low mitotic activity (MA).

  • Molecular Findings: No mutations of c-KIT and PDGFRA.

Follow-up

Clinical, radiological, and endoscopic patient follow-up was performed.

Total recovery 15 months after esophagectomy without signs of oncological recurrence or functional disorders.

Panel of Experts for Discussion

Surgery: Olivier Huber | Minoa Jung | Stefan Mönig | Beat Müller | Ralph Peterli | Johannes Zacherl

Oncology/Gastroenterology: Markus Möhler

Pathology: Rupert Langer

Discussion Points

  1. With endoscopic/echographic diagnosis of esophageal submucosal tumor of the esophagus, would you recommend a biopsy?

  2. What additional investigations are necessary (CT scan, PET)?

  3. In which cases is neoadjuvant treatment recommended?

  4. What would your surgical strategy be for esophageal GIST? Do you propose radical esophagectomy for all cases? What are the alternative surgical options?

  5. Is systematic lymph node dissection mandatory?

Case 2: Patient With Severe Obesity, Gastroesophageal Reflux, and Gastric Metaplasia

Presentation of the Case: Minoa Jung

Moderator: Ralph Peterli

Barrett Esophagus and Reflux-Esophagitis 5 Years After Laparoscopic Sleeve Gastrectomy and Roux-Y Gastric Bypass

Patient Profile & Clinical History

  • Patient: 48-year-old male of Spanish origin

  • BMI: 38.4 kg/m2

  • Medical History: Metabolic syndrome, obstructive sleep apnea, depression, and gastroesophageal reflux.

Initial Evaluation

  • Esophagogastroscopy (2016): Hiatal hernia with gastritis.

  • Helicobacter pylori: Infection eradicated at that time.

  • Consultation at a private practice center specialized in bariatric surgery to discuss options for surgery.

Endoscopic Findings

  • Esophageal Lesion: 10-mm Paris Is superficial lesion of the esophagus above the Z-line.

  • Gastric Lesion: 15-mm Paris IIa–IIb lesion at the incisura angularis.

  • Biopsies: Biopsies of the incisura showed intestinal metaplasia without Helicobacter pylori.

Endoscopic Submucosal Dissection (ESD)

Endoscopic submucosal dissection (ESD) of gastric metaplasia was performed at the private center.

ESD confirmed moderate intestinal metaplasia with low-grade atrophic gastritis (OLGIM 2, OLGA 1) at the antrum level.

University Hospital Consultation

Consultation at the University Hospital for a second opinion on the most appropriate bariatric surgery option.

Panel of Experts for Discussion

Surgery: Peter Grimminger | Olivier Huber | Minoa Jung | Stefan Mönig | Beat Müller | Johannes Zacherl

Oncology/Gastroenterology: Markus Möhler

Pathology: Rupert Langer

Discussion Points

  1. Risk of Gastric Cancer: Are two lesions with moderate-grade gastric metaplasia, at the level of the incisura angularis and at the level of the distal antrum lesser curvature, considered risk factors for gastric cancer?

  2. Which Bariatric Operation to Offer?

    • Sleeve gastrectomy

    • Roux-en-Y gastric bypass

    • Roux-en-Y gastric bypass with removal of the excluded stomach