A report describes a case of a 36-year-old male patient who presented with anorexia, easy fatigability, and melena for three months. His clinical examination was insignificant. A digital rectal examination showed melena. An upper GI endoscopy showed a large mass projecting into the gastric lumen, arising from the posterior gastric wall, closer to the lesser gastric curvature. The mass also had a bleeding mucosal ulcer (the cause of melena). 

An endoscopic ultrasound-guided needle aspiration showed stromal cells on cytology. An abdominal CT revealed a well-defined, intramural mass, appearing close to the lesser gastric curvature with a small mucosal defect at the superolateral aspect of the lesion. The soft-tissue fat planes were intact, without any enlarged or abnormally enhancing lymph nodes. 

The surgeons carried out a diagnostic laparoscopy, which showed a large tumor mass that made gastric retraction difficult. The tumor base at the posterior gastric wall showed increased vascularity without any evidence of invasion into adjacent tissues. 

The surgeons created a liberal, longitudinal anterior gastrotomy at the summit of the tumor using ultrasonic shears. Manipulating the tumor mass had caused brisk bleeding from the ulcer, which remained uncontrolled with bipolar energy. They delivered the tumor through the gastrotomy and pivoted over the shaft of a grasper placed parallel to the splenic axis, which caused the gastric wall adjacent to the tumor base to a tent, prompting the application of several linear staplers across it. 

The surgeons applied all sequential stapler fires in close apposition to the tumor to save the maximum of the uninvolved posterior gastric wall; furthermore, this not only allowed them to resect the lesion, which halted bleeding, but also helped reconstruct the posterior gastric wall simultaneously. They oversew staple line on its luminal aspect with 2–0 polydioxanone suture continuously after placing the resected lesion in an endo bag and parking adjacent to the right hepatic lobe. They closed the anterior gastrotomy using a 2–0 delayed-absorbable barbed suture in two layers. 

Further, they placed the patient in a steep Trendelenburg position and installed saline into the upper abdomen. Intraoperative gastroscopy with intraluminal CO2 insufflation confirmed the integrity of the gastrotomy closures. They suctioned saline, placed a drain adjacent to the stomach through the flank port, and retrieved the specimen (9.5 × 8.5 × 7.5 cm) through a Pfannenstiel incision. 

The patient was initiated oral fluids on the second postoperative day and a blenderized soft diet on day 4. The surgeons pulled his abdominal drain on day four and discharged him from the hospital on day five. The patient suffered a superficial surgical site infection (SSI) at the extraction site, which responded well to oral antibiotics. His histopathology report confirmed a GIST with negative margins, with 10 to 12 mitosis per 10 high-powered fields, indicating a high potential for malignancy. The tumor showed positive staining for CD34 and DOG-1, weak positivity for c-kit, and negativity for S100 and desmin on immunohistochemistry. The patient then received adjuvant imatinib therapy.

Arora E, Gala J, Nanavati A, Patil A, Bhandarwar A. Laparoscopic Transgastric Resection of a Large Gastric GIST: A Case Report and Review of Literature. Surg J (N Y). 2021 Dec 15;7(4):e337-e341. doi: 10.1055/s-0041-1739116. PMID: 34934813; PMCID: PMC8679662