Single-Incision Laparoscopic Surgery for a Small-Intestinal Gastrointestinal Stromal Tumor: Report of a Case

Our report concerns a 64-year-old man with a small-intestinal gastrointestinal stromal tumor (GIST), which was successfully treated with single-incision laparoscopic surgery (SILS). Small-bowel endoscopy detected a submucosal tumor located approximately 10 cm from the ligament of Treitz in the wall of the proximal jejunum. Contrast-enhanced computed tomography revealed a tumor (diameter, 4 cm) containing high- and low-density areas in the proximal jejunum. On 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET), the tumor demonstrated intense FDG uptake (maximum standard uptake value, 3.82), whereas it displayed high signal intensity on diffusion-weighted magnetic resonance images. No metastatic lesions were observed. The patient was diagnosed with a jejunal GIST. Wedge resection of the jejunum was performed using the SILS procedure. The tumor was histopathologically diagnosed as a low-grade malignant GIST. SILS is a useful resection technique for small-intestinal GIST.Key words: SILS, Small intestine, GIST, Laparoscopic, FDG-PET, DWIA 64-year-old man with a past history of diabetes mellitus was admitted to our hospital because of a suspected tumor in the small bowel, which was subsequently revealed by an abdominal ultrasonography screening examination. He had no digestive symptoms. He had a history of cigarette smoking and alcohol use, but his family history was unremarkable, and he did not display elevated tumor marker levels. Small-bowel endoscopy showed a submucosal tumor located approximately 10 cm from the ligament of Treitz in the wall of the proximal jejunum. Contrast-enhanced computed tomography (CT) revealed a tumor (diameter, 4 cm) containing high- and low-density areas in the proximal jejunum. On 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/CT, the tumor showed increased FDG uptake [maximum standard uptake value (SUV) = 3.82; Fig. 1a], whereas it displayed high signal intensity on diffusion-weighted magnetic resonance imaging (DWI Fig. 1b). No metastatic lesions were observed. The patient was diagnosed with a jejunal gastrointestinal stromal tumor (GIST).Open in a separate windowFig. 1(a) FDG-PET/CT scan showing that a tumor (diameter, 4 cm) displayed increased FDG uptake in the proximal jejunum (arrow). (b) Diffusion-weighted MRI showing that the tumor displayed high signal intensity (arrow).We treated the tumor with single-incision laparoscopic surgery (SILS). In this procedure, an extra-small wound retractor (ALEXIS wound retractor XS, Applied Medical, Rancho Santa Margarita, California) was inserted through a 3-cm umbilical incision, and a surgical glove was used as the single port. Three 5-mm trocars were inserted into the surgical glove, which was then fixed to the outer ring of the wound retractor. The section of the small bowel close to the tumor was pulled toward the incision site, and the tumorous area of the jejunum was extracted through the incision. Wedge resection of the jejunum and closure of the enterotomy were performed outside the abdominal cavity (Fig. 2a and ​and2b).2b). The tumor was elastic and had not invaded any adjacent structures. The dimensions of the tumor were 42 × 43 × 20 mm.Open in a separate windowFig. 2(a) Intraoperative appearance after the tumor had been extracted through the umbilical incision. (b) Postoperative appearance of the umbilical incision.A histopathologic examination revealed the bundle-like growth of spindle-shaped tumor cells with a mitotic rate of 3/50 high-power fields (HPF; Fig. 3). In immunohistochemical staining, the tumor was found to be positive for c-kit and CD34, but negative for keratin, smooth muscle actin, and s-100. In addition, 3.5% of the tumor cells were positive for Ki-67. As a result, we diagnosed the tumor as low-grade malignant GIST. After 6 months'' follow-up, the patient is asymptomatic and displays no clinical evidence of tumor recurrence or metastasis.Open in a separate windowFig. 3Histologic examination detected the bundle-like growth of spindle-shaped tumor cells (×66).