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Daniel POLETTO

Hospital de Povisa
Vigo, Spain
MD
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Laparoscopic distal pancreatectomy with splenectomy for a recurrent GIST
GISTs are tumors of the gastrointestinal stroma which, although rare, are the most common mesenchymal neoplasms of the digestive tract. They are most common in the stomach and small intestine, in patients aged between 50 and 70 years. The definitive diagnosis is established with immunohistochemistry (CD117), and the risk of postoperative recurrence should be estimated. Studies relate small intestine’s lesions with greater aggressiveness; however, more recent studies emphasize mitotic index and lesion size.
The clinical case is that of a 53-year-old woman with a stage TNM IIIb, AFIP 6b gastric GIST. In 2013, she underwent a sleeve gastrectomy followed by the daily administration of Imatinib (400mg). After 3 years of adjuvant therapy, she stopped treatment. In May 2017, in a follow-up CT-scan, a solid, heterogeneous 6.7cm lesion appeared in the left hypochondrium, separated from the metal suture, invading the lower pole of the spleen, with no evidence of adenopathies or free liquid.
Surgical resection was planned. A splenectomy with distal pancreatectomy, documented in the video, was performed with no complications. The histological examination confirmed a 5.8cm tumor implant, located in the splenic cord, compatible with GIST recurrence (>50 mitoses/50 fields, free margins, prognostic group 6b).
Surgical intervention
11 months ago
2332 views
5 likes
0 comments
14:02
Laparoscopic distal pancreatectomy with splenectomy for a recurrent GIST
GISTs are tumors of the gastrointestinal stroma which, although rare, are the most common mesenchymal neoplasms of the digestive tract. They are most common in the stomach and small intestine, in patients aged between 50 and 70 years. The definitive diagnosis is established with immunohistochemistry (CD117), and the risk of postoperative recurrence should be estimated. Studies relate small intestine’s lesions with greater aggressiveness; however, more recent studies emphasize mitotic index and lesion size.
The clinical case is that of a 53-year-old woman with a stage TNM IIIb, AFIP 6b gastric GIST. In 2013, she underwent a sleeve gastrectomy followed by the daily administration of Imatinib (400mg). After 3 years of adjuvant therapy, she stopped treatment. In May 2017, in a follow-up CT-scan, a solid, heterogeneous 6.7cm lesion appeared in the left hypochondrium, separated from the metal suture, invading the lower pole of the spleen, with no evidence of adenopathies or free liquid.
Surgical resection was planned. A splenectomy with distal pancreatectomy, documented in the video, was performed with no complications. The histological examination confirmed a 5.8cm tumor implant, located in the splenic cord, compatible with GIST recurrence (>50 mitoses/50 fields, free margins, prognostic group 6b).
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Surgical intervention
11 months ago
3399 views
9 likes
1 comment
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.