D4 Duodenal GIST Presenting with Acute GI Hemorrhage – Case Report

Abstract

Background

A gastro-intestinal stromal tumour is a type of cancer that develops in the wall of the digestive tract. Its origin is a debated topic. The most common location in the gastrointestinal tract is the stomach, small intestine, colon esophagus and in rare occasions in the duodenum (approximately 4% incidence). For the most part GISTs may be asymptomatic, as the volume of the tumor grows, so do complications and signs arise. Current protocols support the treatment by resectional surgery and targeted therapy, most commonly with imatinib. As lymph node involvement is uncommon, lymphatic curage is not recommended and a more conservative surgical approach is possible, depending on the location of the tumor.

Case presentation

Our patient is a 60 years old male admitted to the Gastro-enterology department for the diagnosis of acute gastro-intestinal hemorrhage, manifested with haematochezia. He was treated on the course of 3 days conservatively and resuscitated to correct anaemia. The diagnosis of D4 GIST is confirmed via fibro-gastro-duodenoscopy. The patient is prepared for surgery. Due to clear margins of resection an no involvement of pancreas and superior mesenteric vessels, a segmental resection of D4 and part of D3 is performed, followed by a duodeno-jejunal end-to-end anastomosis. The patient was discharged in good health on the 14^th post-operative day.

Discussion

Due to the complex anatomy of the duodenum and special relationships with adjacent organs many authors recommend a pancreatico-duodenectomy as clear margins are difficult to attain. Other authors support the local excision of the tumor due to the high morbidity and risk of a Whipple procedure. In cases where local excision is feasible, the defect is closed by primary rraphy or Roux-en-Y duodeno-jejunostomy. On the technical aspect, studies do not support the excision of wider clear margins around the tumor. Local recurrence is a more prominent feature of adenocarcinomas, whereas GISTs do recur in distant locations. Surgical resection of GISTs is guided by tumor size, infiltration and adjacency to other organs, most importantly the papilla Vater.

Conclusion

Current protocols for D4 or jejunal GISTs support the segmental resection and end-to-end duodeno-jejunal anastomosis or side-to-side anastomosis. In our case the pancreas and the superior mesenteric vessels were not involved and the tumor was 30mm in size. As a result of the non-infiltrative nature of this tumor and relatively small size its resection was successfully performend, followed by end-to-end anastomosis of the duodenum and jejunum.

Keywords: General Surgery, Duodenal Cancer, GIST, Duodenal Resection, Duodeno-Jejunal Anastomosis.

DOI: 10.7176/JEP/14-29-02

Publication date:October 31^st 2023