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CASE REPORT
Year : 2022 | Volume
: 55
| Issue : 4 | Page : 154-157
Merendino procedure as an alternative to total gastrectomy in the treatment of gastrointestinal stromal tumors of the gastroesophageal junction: A case series
Nakhieeran Nallasamy1, Theiyallen Ambikapathi1, Wei Keat Ooi1, Firdaus Hayati2
1 Department of Surgery, Queen Elizabeth Hospital, Ministry of Health Malaysia, Sabah, Malaysia
2 Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
Correspondence Address:
Firdaus Hayati
Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah
Malaysia
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/fjs.fjs_190_21
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the alimentary canal and are postulated to have originated from the interstitial cells of Cajal. We present three patients with an age range from 43 to 63 years old diagnosed with GIST of the gastroesophageal junction (GEJ). All patients were noted to have submucosal lesions through gastroscopy, in which the largest was 5 cm × 7 cm in size. All of them underwent emergent surgery due to various reasons, and the Merendino procedure was performed as the surgery of choice. All of them recovered well and were discharged on days 10–12. The histopathological examination demonstrated a GIST. Merendino procedure can improve patients' digestive functions and nutritional status, leading to a better quality of life after surgery with a reduction in postoperative complications. This case series demonstrated proximal gastrectomy with Merendino procedure reconstruction as a safe, efficient, and feasible approach in treating gastric GISTs at the GEJ.
Keywords: Esophagogastric junction, gastrectomy, gastrointestinal stromal tumors, Merendino
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the alimentary canal and originate from the interstitial cells of Cajal, accounting for 0.1%–3% of all gastrointestinal malignancies with up to 60% arising in the stomach and 30% in the small intestine.[1] Surgical resection is the mainstay of treatment for GIST. The primary goal is complete tumor resection with a negative microscopic margin. Lymphadenectomy is inappropriate as metastasis is mainly through the hematogenous route and transabdominal implantation.[2]
There are no clear protocols about the selection of a specific surgical approach for gastric GIST. In every case, the most appropriate approach is tailored to the site, size, and local invasion of the tumor to achieve optimal resection. Laparoscopic wedge resection and laparoscopic exogastric wedge resection are the recommended operative methods in treating gastric GISTs. However, proximally located tumors, especially at or near the gastroesophageal junction (GEJ), are technically difficult to access and resect with adequate margins and carry risks of gastric inlet stenosis or lower esophageal sphincter trauma.[3],[4] Commonly, GEJ tumors have been subjected to formal gastric resections such as proximal gastrectomy (PG) and total gastrectomy (TG). However, TG is associated with significant morbidity and impairment of gastrointestinal function, including postoperative anemia and failure to thrive, whereas PG without reconstruction leads to a poor quality of life (QoL) due to increased incidence of gastroesophageal reflux.[5] In this case series, we seek to demonstrate PG with Merendino procedure reconstruction as a safe, efficient, and feasible approach in treating GEJ gastric GISTs.
Case SeriesCase no 1
A 53-year-old gentleman presented with melenic stool and anemic symptoms for 4 days. Gastroscopy revealed a 5 cm × 5 cm submucosal lesion with central umbilication and adherent clot at the cardia, 3 cm from the GEJ. No biopsy was taken as this was an emergency procedure for a bleeding tumor. Computed tomography (CT) scan showed a solid tumor at the fundus involving the GEJ, 4 cm away [Figure 1]. The patient was initially planned for downstaging with imatinib followed by curative surgery but proceeded with an emergent Merendino procedure and feeding jejunostomy due to tumor bleed [Figure 2]. Post surgery, the patient started on jejunostomy feeding, eventually weaning off to oral feeding. The patient was discharged home well on day 10. Histopathological examination (HPE) confirmed the tumor as a GIST, with the Ki-67 proliferative index being 20%–30% and positive for CD117, DOG-1, and CD34. On follow-up, the patient was well and had no active complaints. Adjuvant therapy with imatinib was planned.
Figure 1: Axial section of the CT scan showing a solid mass with heterogeneous contrastenhancement at the fundus. CT: Computed tomographyCase no 2
A 43-year-old female presented with vomiting and dysphagia for 4 months. Gastroscopy revealed a large submucosal tumor at GEJ extending to the fundus. CT scan showed a large mass measuring approximately 5 cm × 7 cm [Figure 3]. Biopsy reported a locally advanced cardiac GIST with mutations in exon 11 of the c-kit gene. Neoadjuvant therapy with imatinib was originally planned, but emergent PG and reconstruction with Merendino surgery took place due to worsened symptoms and general condition. The postoperative period was uneventful, and the patient was discharged home well on day 12. HPE confirmed the tumor as GIST, positive for CD117, CD34, and DOG-1.
Figure 3: Large heterogeneous mass (*) at the fundus on an axial view of CT scan. CT: Computed tomographyCase no 3
A 63-year-old male presented with progressive dysphagia and loss of weight for 3 months. Gastroscopy revealed 2 cm × 2 cm submucosal tumor with central umbilication within 1 cm from GEJ. CT scan showed a solid tumor with no distant metastasis [Figure 4]. The gastroenterology team attempted an endoscopic submucosal dissection, but it was complicated with perforation. Emergent surgery with Merendino procedure was performed. Postoperative recovery was smooth, and the patient was successfully discharged on day 10. HPE confirmed the tumor as GIST with exon 11 mutation with clear margins.
Figure 4: Coronal view of the CT scan showing a contrast-enhanced solid mass (*). CT: Computed tomography Discussion Merendino procedure refers to the reconstructive technique after PG. It is the interposition of a jejunal pedicle conduit between the distal esophagus and the remnant of the stomach after resection of the GEJ. First, an upper midline laparotomy is made, followed by a wide frenotomy through incision of the left diaphragmatic crus, to expose the lower posterior mediastinum. Once safe access is established, partial gastrectomy is done. The jejunum is then divided at 60–70 cm distal to the ligament of Treitz. A 20–30 cm jejunal limb, with the preservation of two supplying arterial arcade vessels of the mesentery, is created and brought up through the retrocolic route. The jejunal stump is closed and reinforced using a linear stapler. The three anastomoses, an end-to-side esophagojejunostomy, an end-to-side gastrojejunostomy, and an end-to-end jejunojejunostomy, are then made using linear staplers as well [Figure 5].
Merendino is an ideal procedure for our cases as the duodenal passage is preserved and the gastric reservoir is maintained, in addition to its anti-reflux property. Merendino is an ideal indication for resectable GIST of the GEJ.[6] There is no optimal reconstructive method following a PG, but Merendino has been proven to have a similar or lesser complication rate than other methods.[7] In our case series, the patients had not experienced any postgastrectomy complications up to 1 month of follow-up. Thus far, we find that with a good volume of remnant stomach and a good length of jejunum, a reduced rate of reflux syndrome is noted due to dilatation of the interpositioned jejunum in our patients. Regardless of the reconstructive technique, most patients still require some form of proton-pump inhibitors for a certain duration. However, a longer monitoring period, substantiated with a prospective study, is necessary to validate our findings.
As opposed to a TG, Merendino procedure retains part of the gastric reservoir and pylorus, hence preserving the physiological function of the remnant stomach. Although oncological outcomes and long-term survival rates are similar to TG, this technique improves patient's digestive function and nutritional status, leading to a better postoperative QoL and reducing postoperative complications such as reflux esophagitis and anastomotic stricture.[5] The disadvantage, however, is that nodal harvest does not yield as many nodes as TG. Since GIST spreads hematogenously, this disadvantage does not impact our patients' overall survival. Although similar, PG with no reconstruction method causes severe reflux esophagitis, leading to worsened QoL, as the cardia, which prevents reflux of gastric contents, is removed.[8]
The Kamikawa procedure, also known as the double-flap technique (DFT), is a reconstructive method using the esophagogastric anastomosis demonstrating a superior anti-reflux effect and an improved nutritional status postoperatively compared to other reconstructive approaches. Multiple studies reported successful implementation of the DFT with a reduced rate of complications.[8],[9] However, DFT is time-consuming and is a complicated method that needs to be done by handsewn. In addition, most of the studies were single-centered studies with small sample sizes, hence cannot be made universally representative.
The double-tract method is another reconstruction technique following PG that is reported to be slightly superior to the jejunal-interposition method as a function-preserving gastrectomy.[10] However, this finding is based on a small sample size with unclear mechanisms, which necessitates the need for further studies to validate this recommendation. Nevertheless, we find this method very interesting and forthcoming with many surgeons advocating it mainly on the Eastern side of the globe such as China, Japan, and South Korea where there are many well-established upper gastrointestinal centers with a high volume of cases. This technique is not familiar to us in our institution, rendering the postoperative care challenging. Although this method is more simple and is mainly done in laparoscopic surgery, we did not want to experiment with new techniques as our cases were performed in emergent settings. Therefore, we proceeded with Merendino procedure, which was a well-established technique.
Alternative surgical approaches such as laparoscopic intragastric or transgastric resections are shown to provide sufficient operative field, be safe, and more effective in treating GEJ tumors with nil or minimal complications while eliminating the necessity of anti-reflux surgery.[3],[4] Although the latest NCCN Guidelines suggest that these laparoscopic techniques can be performed in patients with tumor sizes ranging from 2 to 5 cm, it is not applicable in our setting due to a multitude of factors: (1) large tumor size and (2) emergent setting, both limitations in this case series. The size of the tumor in most of the studies is reported to be <2 cm and these techniques cannot be utilized for tumors larger than 4 cm, which often require extensive resections, especially in emergent scenarios, where the risk of tumor rupture and spillage is high.[11] Hence, this further justifies the application of the Merendino procedure in our cases. Moreover, these results are of isolated retrospective studies with a small number of cases. A prospective study will be essential to validate the findings. No randomized studies comparing each type of reconstructive method exist in the literature. For this method to be considered a recommended approach for the treatment of GEJ tumors in the future, a full-scale randomized prospective study must be done.
Another common strategy is the usage of tyrosine kinase inhibitor in large gastric GISTs, enabling follow-up surgery for resection of a smaller lesion and avoidance of multivisceral resection, thus achieving the objective of complete curative surgery. However, this was not possible in our cases as the patients presented with emergent conditions requiring urgent intervention.
ConclusionMerendino procedure is a viable approach in treating benign GEJ tumors. It improves the QoL postsurgery with excellent anti-reflux efficacy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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