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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 4  |  Page : 229-231

Laparoscopic management of gastric neuroendocrine tumor with massive hematemesis


Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Web Publication5-Feb-2018

Correspondence Address:
Nadeem Mushtaque Ahmed
Apollo Hospitals, Room No. 111, Greams Road, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_41_17

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  Abstract 

Gastric neuroendocrine tumor (GNET) usually presents with nonspecific symptoms such as dyspepsia, nausea, and epigastric pain. They are usually diagnosed on histological evaluation of gastric polyps. Gastrointestinal bleed may be seen in large ulcerated polyps. However, massive gastrointestinal bleed leading to hematemesis is uncommon in GNETs. We describe a case of 55 years gentleman who was referred for massive hematemesis. On evaluation he was found to have a large ulcerated bleeding GNET. Laparoscopic resection of GNET was done.

Keywords: Gastric neuroendocrine tumor, gastrinoma, gastrointestinal hemorrhage, hematemesis, laparoscopic resection, neuroendocrine tumors, polyps, stomach


How to cite this article:
Ahmed NM, Dhaduk V, A.Jameel J K, Reddy PK. Laparoscopic management of gastric neuroendocrine tumor with massive hematemesis. Apollo Med 2017;14:229-31

How to cite this URL:
Ahmed NM, Dhaduk V, A.Jameel J K, Reddy PK. Laparoscopic management of gastric neuroendocrine tumor with massive hematemesis. Apollo Med [serial online] 2017 [cited 2021 Oct 20];14:229-31. Available from: https://www.apollomedicine.org/text.asp?2017/14/4/229/224736


  Introduction Top


Gastric neuroendocrine tumor (GNET) are rare lesions representing <10% of neuroendocrine tumors and <1% of all stomach neoplasms.[1] Majority of GNETs present with nonspecific symptoms and are mostly amenable to endoscopic resection. Gastrointestinal bleeding is an uncommon manifestation in GNETs and only few cases have been reported.[2],[3],[4],[5] Large GNET, GNET involving beyond submucosa, GNET with lymph node involvement and GNET associated with complications require surgical resection. Very little literature is available for laparoscopic management of GNET. Here, we report a 55-year-old male presenting with massive hematemesis who was diagnosed with large GNET and underwent laparoscopic resection.


  Case Report Top


A 55-year-old male patient presented with massive hematemesis for 1 day. At presentation, he had tachycardia (pulse rate – 118/min) and hypotension (blood pressure – 90/50 mmHg). The patient was pale and abdomen was soft and nontender. His hemoglobin was 7 g/dl. The patient was resuscitated and two units of blood were transfused. Rest of the investigations including liver function tests were within normal limits. Endoscopy showed a solitary submucosal tumor of size 2.5 cm × 2 cm with central ulceration at the posterior wall of proximal body of the stomach [Figure 1]. The tumor was already bleeding, so biopsy was not taken. Endoscopic ultrasound showed extension up to muscularis propria [Figure 2]. Contrast-enhanced computed tomography (CECT) scan of the abdomen was done which revealed arterial enhancing gastric tumor of size about 2.5 cm × 2 cm with no metastases [Figure 3]. After resuscitation, the patient was planned for surgery. After general anesthesia in supine position with split legs, pneumoperitoneum was established. A 10-mm supraumbilical port was introduced for the telescope. Liver was retracted with Nathanson retractor. Additional ports were placed, two in the left upper quadrant and one in the right upper quadrant. Intraoperative endoscopy was done to locate the tumor. Greater curvature at the level of tumor was mobilized and gastrotomy was made. Tumor was identified [Figure 4] and excised full thickness with Echelon ® 60 stapler taking 1 cm normal margin. Gastrotomy was closed with Echelon® 60 linear stapler. Specimen was delivered out using an Endobag. Postoperative period was uneventful. Liquid diet was started on postoperative day 1. The patient was discharged on the 2nd postoperative day. Histopathology showed neuroendocrine tumor and negative margins. The tumor stained positive for chromogranin A. Ki67 was <3%. Serum gastrin level was normal, and there was no evidence of multiple endocrine neoplasia (MEN) syndrome, and hence, he was diagnosed to have Type III GNET. On follow-up for 1 year, the patient had no evidence of any recurrences or metastasis.
Figure 1: Endoscopic picture showing 2.5×2 cm size, ulcerated mass lesion at posterior wall of proximal body of the stomach

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Figure 2: Endoscopic ultrasound showing mass lesion extending up to muscularis propria (white arrow)

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Figure 3: Computed tomography abdomen showing gastric tumor with no metastases (white arrow)

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Figure 4: Intraoperative view showing mass lesion identified after gastrotomy. Arrow denotes that gastric tumor is grasped with instrument

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  Discussion Top


GNETs are rare tumors. GNET arise from proliferating enterochromaffin-like cells.[1] There are three subtypes of GNET. Type 1 (70%–80%) is associated with autoimmune chronic atrophic gastritis. Type 2 (5%–8%) occurs with gastrinoma along with Zollinger-Ellison Syndrome (ZES) or associated with multiple endocrine Type I (MEN 1). Type 3 is sporadic associated with normal gastrin levels.[6] Type 1 and 2 are usually multiple whereas Type 3 was solitary. Interestingly, these lesions can acquire large sizes even without causing many symptoms as in the present case. Bleeding may be the presenting symptom but occurs only when the lesions become large and ulcerate. Large lesions occurring sporadically as in present case are a feature of Type 3 GNET. These lesions are uncommon and are extremely rare causes of gastrointestinal bleed.[2],[3],[4],[5] Type 3 tumors are usually large at presentation and have higher incidence for metastasis.

The optimal treatment of GNET is not well defined. Endoscopic polypectomy for Type 3 tumor implies a considerable risk of recurrence and progression of disease with as tumors behave significantly divergent with respect to higher incidence of metastasis.[7] Hence, surgery is recommended for Type 3 GNET for complete wide resection.

Laparoscopy is an emerging alternative approach with better patient compliance. Laparoscopic wedge resection for the diagnosis and treatment of gastric submucosal tumors has been previously employed and its efficacy has been established.[8],[9] However, little literature is available regarding role of laparoscopic wedge resection of GNET.[10] In lesions that are situated at difficult areas or lesions that are large for endoscopic resection, laparoscopic wedge resection appears to be safe and easy. Intraoperative endoscopy along with laparoscopy helps in deciding the exact site for gastrotomy and minimizes the percentage of the stomach to be resected.[11]

Laparoscopic resection for GNET is novel alternative to open and endoscopic surgery for large tumors and those failed or not suitable for endoscopic resection as it provides shorter hospital stay and better quality of life without compromising the oncological outcome.


  Conclusion Top


The GNET usually presents with nonspecific symptoms, but rarely, it can present with massive hematemesis and along with large a tumor. Laparoscopy is accepted as oncological safe for stomach tumors, and long-term outcomes are identical with that of open surgery. There is a lack of reports of laparoscopic surgery for GNET. These types of tumors can be managed by laparoscopic wedge resection. Laparoscopic surgery offers all the benefits of minimally invasive surgery without compromising the oncological outcome. Regular follow-up is necessary with medical and endoscopic surveillance to look for recurrences or distant metastasis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nikou GC, Angelopoulos TP. Current concepts on gastric carcinoid tumors. Gastroenterol Res Pract 2012;2012:287825.  Back to cited text no. 1
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2.
Sharma V, Rana SS, Mangat PS, Kaman L, Bhasin DK. Massive gastrointestinal bleed due to multiple gastric neuroendocrine tumours. J Dig Endosc 2015;6:182-4  Back to cited text no. 2
    
3.
Dallal HJ, Ravindran R, King PM, Phull PS. Gastric carcinoid tumour as a cause of severe upper gastrointestinal haemorrhage. Endoscopy 2003;35:716.  Back to cited text no. 3
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Devarbhavi H, Alvares JF. Polypoid gastric carcinoid tumour presenting as hematemesis with prolapse into the duodenum. Gastrointest Endosc 2003;57:618-201.   Back to cited text no. 4
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Aguirre A, Cosme A, Bujanda L, Navascués JE, Larburu S, Larzabal M, et al. Diagnosis, treatment and followup of gastric carcinoid tumours. Analysis of 14 cases. Rev Esp Enferm Dig 2011;103:493-4.   Back to cited text no. 5
    
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Rindi G, Luinetti O, Cornaggia M, Capella C, Solcia E. Three subtypes of gastric argyrophil carcinoid and the gastric neuroendocrine carcinoma: a clinicopathologic study. Gastroenterology 1993;104:994-1006.  Back to cited text no. 6
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Hassan MM, Phan A, Li D, Dagohoy CG, Leary C, Yao JC. Risk factors associated with neuroendocrine tumours: A U.S.-based case-control study. Int J Cancer 2008;123:867-73.  Back to cited text no. 7
    
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Madan AK, Frantzides CT, Keshavarzian A, Smith C. Laparoscopic Wedge Resection of Gastric Leiomyoma. JSLS 2004;8:77-80.  Back to cited text no. 8
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9.
Otani Y, Ohgami M, Igarashi N, Kimata M, Kubota T, Kumai K, et al. Laparoscopic wedge resection of gastric submucosal tumours. Surg Laparosc Endosc Percutan Tech 2000;10:19-23.  Back to cited text no. 9
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10.
Ozao-Choy J, Buch K, Strauchen JA, Warner RR, Divino CM. Laparoscopic antrectomy for the treatment of type I gastric carcinoid tumors. J Surg Res 2010;162:22-5.  Back to cited text no. 10
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11.
Kang WM, Yu JC, Ma ZQ, Zhao ZR, Meng QB, Ye X. Laparoscopic- endoscopic cooperative surgery for gastric submucosal tumours. World J Gastroenterol 2013;19:5720-6.  Back to cited text no. 11
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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