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Il Giornale di Chirurgia

Asportazione laparoscopica di GIST duodenale

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Abstract
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Il GIST (gastrointestinal stromal tumor) è la neoplasia mesenchimale più frequente ad origine del tratto gastroenterico. Il trattamento di scelta è la resezione chirurgica. Il 20% dei GIST gastroenterici originano nel duodeno.
Scopo: Descrivere una tecnica innovativa mini-invasiva per l’asportazione di GIST duodenale originante in sede inusuale, nella parte prossimale della III porzione del duodeno, contraente stretti rapporti con la testa del pancreas.
Case report: Una donna di 27 anni è giunta alla nostra osservazione in seguito al riscontro TC di una msssa paraduodenale, che all’esame eco endoscopico risultava compatibile con GIST. Veniva data indicazione all’esecuzione di una resezione del sospetto GIST per via laparoscopica.
L’intervento è stato condotto in anestesia generale con la paziente con gli arti inferiori divaricati. Eseguita la manovra di Kocher si individuava la lesione i cui rapporti con la papilla venivano individuati con gastroscopia peroperatoria. La resezione parziale duodenale
è stata condotta mediante ausilio di bisturi armonico. La sutura della parete duodenale è stata eseguita in duplice strato. Il pezzo operatorio è stato estratto con endobag. La durata dell’intervento è stata pari a 200 minuti e le perdite ematiche pari a 50 ml. Il decorso post-operatorio è stato privo di complicanze. La paziente è stata dimessa in terza giornata. L’esame istologico ha evidenziato un GIST del duodeno con margini di sezione liberi.
Conclusioni: La chirurgia mini-invasiva è una valida opzione per il trattamento del GIST, anche se localizzato al duodeno.

English version
GIST are the most common mesenchymal tumors arising within the gastrointestinal tract and the treatment of choice of these tumor is surgical resection. The small intestine is the second most common site of
GIST, of which approximately 20% are found in the duodenum. Our aim was to describe a minimally invasive technique used for the wedge resection of duodenal GIST located near the pancreatic head, compressing the junction of D2 and D3.
Case report: A 27-year- old woman presented with nonspecific upper gastrointestinal system symptoms. The endoscopic ultrasound revealed a submucosal tumor arising from the muscolaris propria, located in the proximal part III of the duodenum, 2 cm distal of the papilla of Vater. A laparoscopic operation under general anaesthesia was undertaken with the patient in supine position with the legs abducted.
Therefore, a laparoscopic Kocher maneuver was performed. The retroperitoneum was entered using the harmonic scalpel and the dissection extended beyond the vena cava and the duodenum. The location and the size of the lesion have been confirmed using an intraoperative endoscopic examination. The excision of the lesion was performed by use the harmonic scalpel. Then, the duodenal wall was sutured by use endoscopic stitches. The resected lesion was then placed in a retrieval bag and extracted through the port incision. Operating time was 200 min and blood loss 50 ml. The postoperative course was uneventful and she was discharged well on the 6th postoperative day. Histological findings showed a low grade of malignancy GIST and clear microscopic margins. The minimally invasive technique may be a valid alternative to open surgery in the treatment of duodenal GIST. Laparoscopic wedge resection with primary closure can be performed if the resulting lumen is adequate and the ampulla of Vater can be preserved

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