A 46-year-old male, 59kg in weight, complaining of a progressive dysphagia for nearly 3 months, was referred to our department of Gastrointestinal surgery. A large lesion located at the EGJ, about 120mm in diameter, was observed during CT scan. Endoscopic ultrasonography (EUS) identified a mixed echo mass within the submucosal layer. Immunochemistry of biopsy specimens demonstrated a CD34(+) and CD117(+) phenotype, leading to a definitive diagnosis of GIST. Initially, the patient received preoperative IM treatment with a dose of 400mg/day recommended by a previous research[4] but was finally reduced to 300mg/day due to severe leukopenia. The tumor was shrank remarkably during the beginning 4-month of therapy while drug resistance developed after 6 months, leaving a mass approximately 90mm in diameter (Fig. 1). Surgical intervention was attempted after obtaining informed consent. Laparoscopic procedure for GISTs with an extremely large size and a special location was excluded due to its uncertainty of oncological safety. Laparotomy was made by with a midline incision. No peritoneal dissemination, nodal enlargement or hepatic metastasis was observed during intra-abdominal exploration. We operated carefully to detect and free the anterior and posterior trunks of the vagus nerve. The anterior gastric branches of the vagus were transected below the hepatic branch, just preserve the anterior trunk and its hepatic branch intact (Fig. 2). Then, gastric mesentery was divided, the posterior trunk and its celiac branch were preserved. The esophagus was transected 2cm above the mass and the tumor was removed with a preservation of distal 2/3 gastric tissues (Fig. 3). Reconstruction with double-flap technique (DFT) was then performed on the remnant stomach as described by Kuroda et al[5]. Briefly, ①An H-shaped 2.5 × 3.5 cm seromuscular double-flap was created. ②The gastric mucosa was opened for the anastomosis. ③The posterior side of the esophagus was fixed to the gastric remnant at the upper edge of the flap. ④Anastomosis of the esophagus and the remnant stomach was created by hand-sewn. ⑤The flaps were positioned to cover the anastomosis site in a Y-shape (Fig. 4).
The operation was smooth. Oral intake of liquid was resumed 3 days after surgery. The patient was allowed to be discharged on the 8th postoperative day with a body weight of 51kg, complaining of no digestive discomforts. Histopathological immunohistochemistry confirmed an activation of KIT, positivity of CD117, CD34 and Dog1. Two weeks after operation, barium meal X-ray was preserved, indicating a slight anastomotic stricture with no leakage or bleeding (Fig. 5), even though the patient complained of no dysphagia and then restarted IM medication with a same dose as before. During the adjuvant targeted therapy, the patient still suffered from leukopenia owning to IM toxicity. Accordingly, Leucogen tablets with a dose of 60mg t.i.d was prescribed and the leukocyte counts were able to maintain within an average level of 2.4*10^9/L. Gastroscopy was conducted on the 5th postoperative month, revealing a good-shaped pseudo gastric fundus with no severe anastomotic complications but a little erosion closed to the anastomosis (Fig. 6). Nevertheless, the patient had no gastroesphageal reflux symptoms, like heartburn, acid regurgitation, as well as other digestive discomforts. We described the patient as Grade A according to the Los Angeles classification[6]. PPI was prescribed after the exam. Furthermore, a gallbladder contraction text was applied to assess the activity of vagus nerve after 6 month, the volume of gallbladder lessened by 48% before and after the fat mile which demonstrated a normal contractile function. After 9 months of follow-up, the patient regained weight to 59kg with normal hemoglobin and total protein concentrations. Recently, the patient returned to our department for his 12-months recheck. Enhanced CT scan was provided, indicating a normal structure of reconstructed EGJ and there were no signs of relapse of the tumor around the gastric area.