Clinical Gastroenterology and Hepatology
Volume 7, Issue 9 , Pages e53-e54, September 2009

Endoscopic Hemostasis using Endoloop for Bleeding Gastric Stromal Tumor

published online 10 April 2009.

Article Outline

 

An 80-year-old man presented to our unit with a 2-day history of tarry stool. On admission his blood pressure was 100/60 mm Hg and pulse rate 100 per minute. The initial hematocrit was 30%. Urgent upper endoscopy revealed an active bleeding arising from an ulcer crater over a polypoid submucosal tumor situated at the gastric fundus (Figure A). Endoscopic hemostasis was achieved by application of the endoloop. An endoloop ligation was performed with standard, single-accessory channel endoscope in a retroflected position. After correctly placing the loop, the loop was then tightened around the tumor base (Figure B). Tumor tissue protruded through the ulcerated top of the lesion. There was no clinical recurrence of bleeding. The patient subsequently underwent elective wedge resection of the tumor. The resected tumor measured 45 × 45 × 50 mm. Histological and immunohistochemical studies on the surgical resection specimen revealed gastrointestinal stromal tumor (GIST) with low malignant potential (Figures C and D). The postoperative course was uneventful and the patient was discharged on postoperative day 12.

GISTs are rare neoplasms that arise from the mesenchymal layer of hollow organs, most commonly the stomach and small bowel. In some cases, a central ulceration may occur and it may penetrate deeply in the tumor mass, causing potential life-threatening bleeding.

There are scarce reports on primary endoscopic hemostasis for bleeding GISTs.1, 2

From our experience, epinephrine injection is not an effective means of hemostasis in the case of bleeding gastric stromal tumors. Furthermore, we believe that numerous technical details preclude precise application of hemoclips in those patients (need for clear endoscopic view, identification of bleeding vessel, meticulous technique for targeting the lesion with endoscope positioned in a retroverted manner).

Our treatment included endoloop ligation of bleeding gastric stromal tumor. The endoloop, a detachable snare made of nylon, has been widely used in variable therapeutic endoscopic practices to prevent hemorrhaging after polypectomy, to control gastric or esophageal variceal bleeding, and for transection of pedunculated submucosal tumors.3 To our knowledge, this is the first report of endoloop ligation for bleeding gastric stromal tumor.

Endoscopic therapy may play a role in achieving primary hemostasis in a bleeding gastric stromal tumors. Endoloop ligation of bleeding polypoid gastric stromal tumors technically is a feasible and effective method. Successful primary endoscopic hemostasis for bleeding GIST can convert an emergency surgical resection into an elective operation.

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References 

  1. Cheng AW, Chiu PW, Chan PC, et al. Endoscopic hemostasis for bleeding gastric stromal tumors by application of hemoclip. J Laparoendosc Adv Surg Tech A. 2004;14:169–171
  2. Giorcelli W, Rodi M. Injection therapy for bleeding gastric leiomyoma. Gastrointest Endosc. 1992;38:730–731
  3. Lee SH, Park JH, Park DH, et al. Endoloop ligation of large pedunculated submucosal tumors. Gastrointest Endosc. 2008;67:556–559

 Conflicts of interest The authors disclose no conflicts.

PII: S1542-3565(09)00323-1

doi:10.1016/j.cgh.2009.04.003

Clinical Gastroenterology and Hepatology
Volume 7, Issue 9 , Pages e53-e54, September 2009