Jejunal Gastrointestinal Stromal Tumor (GIST)
Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 1 of 86.

Jejunal Gastrointestinal Stromal Tumor (GIST).

This is the case of a 33 year-old male that comes from the Republic of Honduras. He has U.S nationality and Honduras heritage. He is a retired military, presented with recurrent episodes of GI severe hemorrhage in four occasions manifesting only with melenas, needing blood transfusions because of the hemoglobin down until 5 gr/dl.

The endoscopies in Honduras and Miami did not detect that pathology, including colonoscopies enteroscopy and endoscopic capsule as well as abdominal computed tomography scan and other imaging methods.

He came to our office for the first time to ask for evaluation we performed an upper endoscopy that was negative following an enteroscopy finding this lesion.

A case of a Gastric GIST, is displayed in Stomach chapter.

Download the video clips by clicking on the endoscopic images, if you wish to observe in full screen, wait to be downloaded complete then press Alt and Enter for Windows media, Real Player Ctrl and 3.

Configure the windows media in repeat is optimal.
All endoscopic images shown in this Atlas contain video clips. We recommend seeing the video clips in full screen mode.

 

 

GIST

Video Endoscopic Sequence 2 of 86.

Enteroscope view of jejunal tumor

This tumor with central ulceration was found at 20 cm. after Treitz angle.

Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors originating in the wall of the gastrointestinal tract, Nevertheless, some may present with a life-threatening hemorrhage or intestinal obstruction.

 

 

GIST

Video Endoscopic Sequence 3 of 86.

Gastrointestinal Stromal Tumors (GIST) are rare tumors, accounting for less than 3% of gastrointestinal neoplasms, however, they are the most frequent mesenchymal tumors of the GI tract.

All GISTs are defined by the expression of CD117, a tyrosine kinase growth factor receptor, as opposed to other tumors like leiomyomas, leiomyosarcomas and neurogenic tumors.

70-80% are benign, and the majority is located in the stomach and small bowel, but also they can arise from any portion of the GI tract as well as from the mesentery, omentum and retroperitoneum.

Malignant GISTs are usually large (>5 cm), with high mitotic index, and can metastasize to the liver and peritoneum.

 

 

 

GIST

Video Endoscopic Sequence 4 of 86.

Our Patient underwent a laparoscopy surgical resection of the segment harboring the GIST.

See the video clips of the laparoscopic resection below

More details download the video clip by clicking on the image.

GIST

Video Endoscopic Sequence 5 of 86.

In cases of obscure gastrointestinal bleeding, when a source for blood loss is not apparent from examination of the colon and upper gastrointestinal tract, the small bowel usually becomes the focus of investigation.

A tumor with interesting pathologic features was found in a patient who presented with recurrent episodes of massive obscure gastrointestinal hemorrhage, this case highlights the importance of considering small intestinal tumors as the likely cause of obscure gastrointestinal hemorrhage in young patients and how a noninvasive test, eg, abdominal computed tomography scan, might obviate the need for more invasive testing.

Gastrointestinal (GI) hemorrhage is considered obscure
1. when conventional investigations (colonoscopy and esophagogastroduodenoscopy) fail to detect bleeding lesions. On average, 27% of patients with obscure GI bleeding have small intestinal lesions.

2. Diagnosing these lesions is frequently difficult because they tend to be inaccessible to routine endoscopy.

Small bowel barium studies, radioactive isotope bleeding scans, selective visceral angiography, intraoperative enteroscopy, exploratory laparotomy, and more recently wireless capsule endoscopy all have variable sensitivities and specificities for detecting small intestinal lesions.

 

 

GIST

Video Endoscopic Sequence 6 of 86.

Gastrointestinal stromal tumors (GIST) are rare tumors that may arise anywhere in the tubular gastrointestinal tract, but stomach is the most common site of localization.

Surgery is the main stay of treatment and complete resection is achieved in most of cases.

The 5 year overall survival ranges from 21% to 88% in different series, depending from risk grading and completeness of surgical resection.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 7 of 86.

In light of the tendency of these tumors to pursue an indolent clinical course with a significant risk of late relapse, a brisk follow-up is advocated for all patients.

Images from upper GI series may demonstrate the lesion in up to 29% of cases.CT scan can demonstrate up to 27% of benign small bowel tumors, especially of size > 2 cm.

Upper GI endoscopy has been employed successfully for the detection of benign jejunal lesions in 12-30% of cases.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 8 of 86.

GI stromal tumors (GISTs) are a subset of GI mesenchymal tumors of varying differentiation. Previously, these tumors were classified as GI leiomyomas, leiomyosarcomas, leiomyoblastomas, or schwannomas as a result of their histologic findings and apparent origin in the muscularis propria layer of the intestinal wall.

With the advent of immunohistochemical staining techniques and ultrastructural evaluation, GISTs now are recognized as a distinct group of mesenchymal tumors. In the present classification, GISTs account for approximately 80% of GI mesenchymal tumors.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 9 of 86.

In as many as 5% of patients with obscure GI bleeding, a source cannot be identified despite extensive examination.
When a lesion cannot be identified after standard upper endoscopy and colonoscopy, further evaluation depends on the briskness of bleeding (see algorithm).

In those with active (brisk) bleeding, technetium-99 radionuclide scanning or angiography should be performed. In patients with a subacute presentation (or intermittent bleeding), the focus of investigation should be broadened to include the small intestine.

The lesions most commonly identified as bleeding sites in the small bowel include tumors and vascular ectasias, which vary in frequency depending on age.

In patients between 30 and 50 years of age, tumors are the most common abnormalities, whereas in patients less than 25 years of age, Meckel diverticula are the most common source of small bowel bleeding.

Vascular ectasias predominate in older patients. Other rare causes in the differential diagnosis of obscure GI hemorrhage include hemosuccus pancreaticus, hemobilia, aortoenteric fistula, Dieulafoy lesion, extraesophageal varices, and diverticula (especially of the small intestine).

 

 

 

 

 

 

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 10 of 86.

Small bowel examination can be accomplished with standard small bowel follow-through, enteroclysis, push enteroscopy, Sonde enteroscopy, wireless capsule endoscopy, and intraoperative enteroscopy. In the case described here, small bowel follow-through examination was nondiagnostic most likely because the jejunal lesion was predominantly extramucosal.

This case also illustrates that in young patients with obscure small intestinal bleeding the source is frequently tumors rather than arteriovenous malformations.

These tumors are problematic because they often grow in an extraluminal direction and only cause intermittent bleeding if they erode or ulcerate through the small bowel mucosa, as occurred in this patient. In a situation such as this, a noninvasive test, such as a computed tomography scan, may obviate the need for more invasive testing.

 

 

 

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 11 of 86.

Microscopic view of the parietal tumor and the normal yeyunal mucosa.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 12 of 86.

Fusocelular pattern of tumor.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 13 of 86.

IHQ positive for cd117.

Low power of cd117 or c-kit, positive at tumor cell and also at the Cajal cells of yeyuno.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 14 of 86.

A high power of cd117 by IHQ

High power view of tumor cells positive for c- kit.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 15 of 86.

Patient underwent a laparoscopic termino-terminal small bowel resection.

This video sequence shows the laparoscopic steps of this surgery.

The increased use of laparoscopy in the management of gastrointestinal problems continues to expand.

Procedures such as jejunostomies, diagnosis of intestinal obstruction or ischemia, resection of the small bowel, and lysis of adhesions can be managed with this technique.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 16 of 86.

Laparoscopic resection was planned after the abdominal distension subsided. Pneumoperitoneum was established with a Veress needle.

A 5mm trocar was introduced in the umbilical incision; a 5mm (0°) telescope was introduced and the other two 5mm ports were inserted under vision - one in the right midclavicular line and the other in the left midclavicular line, below the level of the umbilicus.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 17 of 86.

For many GI malignancies, laparoscopic surgery is safe and technically feasible, albeit with a somewhat longer learning curve compared to open surgery.

Advanced procedures are technically demanding and require more operative time.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 18 of 86.

Laparoscopic resection of small bowel gastrointestinal stromal tumor.

Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs).

Laparoscopic surgery should be considered for these tumors as their biologic behavior lends them to curative resection without requiring large margins or extensive lymphadenectomies.

 

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 19 of 86.

This laparoscopic view shows the tumor of the jejuno.

Morbidity following laparoscopic staging remains low, and major complications (eg, hemorrhage, visceral perforation, intra-abdominal infection, and shock) occur in less than 2% of cases.

Minor complications such as wound infection, port herniation, or urinary retention are also uncommon. At our institution, minor complications have been noted in 1% of these patients.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 20 of 86.

Stromal tumors and lipomas frequently cannot be removed via endoscopy because of their deep intramural location and the subsequent elevated risk of bowel perforation during attempted removal.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 21 of 86.

Gut stromal tumors are the most common symptomatic small bowel lesions. They have been found in all areas of the small bowel, including within the Meckel diverticulum.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 22 of 86.

Current literature confirms an excellent prognosis for tumors resected prior to tumor perforation or onset of massive GI hemorrhage.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 23 of 86.

Recently, several reports of laparoscopic resections have been published in the literature and seem to be advantageous over laparotomy.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 24 of 86.

Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs).

Laparoscopic surgery should be considered for these tumors as their biologic behavior lends them to curative resection without requiring large margins or extensive lymphadenectomies.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 25 of 86.

Anastomosis was done using a (60mm cartridge) stapler by introducing the 2 limbs in the enterotomy openings. The common opening was closed by another 60mm stapler.

The bowel was returned to the abdomen. The incisions were closed. The patient had an uneventful postoperative period. He was discharged on the 5th postoperative day.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 26 of 86.

Gastrointestinal stromal tumors (GISTs) are rare. Nevertheless, some may present with a life-threatening hemorrhage or intestinal obstruction.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 27 of 86.

Intraoperative video clip showing the linear stampler applied to the bowel.

Stapled laparoscopic resection is a safe and effective treatment option for nonmetastatic primary jejunal GIST.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 28 of 86.

A laparoscopic approach to surgical resection of jejunal GIST is associated with low morbidity and short hospitalization.

As found in historical series of open operative resection, the tumor mitotic index predicts local recurrence. The long-term disease-free survival of 92%.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 29 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 30 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 31 of 86.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 32 of 86.

Laparoscopic resections with intracorporeal anastamoses.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 33 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 34 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 35 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 36 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 37 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 38 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 39 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 40 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 41 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 42 of 86.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 43 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 44 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 45 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 46 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 47 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 48 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 49 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 50 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 51 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 52 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 53 of 86.

Gastrointestinal Stromal Tumor (GIST)

Bronchoscopyxz1

Video Endoscopic Sequence 54 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 55 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 56 of 86.

Gastrointestinal Stromal Tumor (GIST)

Bronchoscopyxz1

Video Endoscopic Sequence 57 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 58 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 59 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 60 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 61 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 62 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 63 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 64 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 65 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 66 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 67 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 68 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 69 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 70 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 71 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 72 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 73 of 86.

Gastrointestinal Stromal Tumor (GIST)

Bronchoscopyxz1

Video Endoscopic Sequence 74 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 75 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 76 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 77 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 78 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 79 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 80 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 81 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 82 of 86.

Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 83 of 86.

The long-term disease-free survival of 92% in some series establishes laparoscopic local and segmental resection as safe and effective in treating jejunal GISTs.

Given this degree of efficacy and the advantages afforded by minimally invasive surgery, a laparoscopic approach may be the preferred resection technique.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 84 of 86.

In light of their biologic behavior, GISTs should be considered for laparoscopic resection. This minimally invasive approach to these tumors can be performed safely and reliably.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 85 of 86.

In light of their biologic behavior, GISTs should be considered for laparoscopic resection. This minimally invasive approach to these tumors can be performed safely and reliably.

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 86 of 86.

The small bowel tumour that was revealed by enteroscopy was successfully resected laparoscopically.

Long-term follow up is essential for all patients with GISTs independent of a benign or malignant designation since these tumors have an uncertain biologic behavior.

While an active postoperative surveillance program is important, there is no consensus on a standard protocol for following patients.

Gastrointestinal stromal tumors (GISTs) represent a rare but distinct histopathologic group of intestinal neoplasms of mesenchymal origin.

Historically, most of these tumors were classified as leiomyomas, leiomyoblastomas, and leiomyosarcomas due to the mistaken belief that they were of smooth muscle origin.

However, with the advent of electron microscopy and immunohistochemistry, a pleuropotential intestinal pacemaker cell, the interstitial cell of Cajal, was identified as the origin of GISTs.

These cells have myogenic and neurogenic architecture and are found within the myenteric plexus, submucosa, and muscularis propria of the gastrointestinal (GI) tract.

The recent discovery and identification of the CD117 antigen, a c-kit proto-oncogene product, and CD34, a human progenitor cell antigen, in the majority of GIST have led to further delineation of the cellular characteristics of these neoplasms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2000 - 2017 gastrointestinalatlas.com
San Salvador, El Salvador | Contact