dr. Muhammad Sayuti, Sp.

B (K) BD
Bedah Digestif RSUD Cut Meutia/
FK UNIMAL
• Benign : (L, benignus) : Not malignant; not recurrent, favorable
for recovery
• Neoplasm : any new and abnormal growth; specifically a new
growth of tissue in wich the growth is uncontrolled and
progressive

• Dorland’s Illustrated Medical Dictionary, 30th Edition, Philadelphia, Saunders,

2000
• I. Non Neoplastic Polyps
• A. Metaplastic or Hyperplastic polyps
• B. Hamartomatous polyps
• C. Inflamatory polyps
• D. Benign lymphoid polyp
• II. Neoplastistic polyps
• A. Adenoma

Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• Usually small (2-5 mm)
• Plaque-like
• Same colour
• Aetiology unknown  environmental factor
• Asymptomatic
• Semipedunculated or sessile
• Management  polypectomy
• No follow up ( British Society For GI , 2002)

Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• B.1. Juvenile Polyps
• Infant and children < 10 Y • Simptom :
• Diameter 1-2 cm
• rectal bleeding
• Smooth surface
• Prolap polyp
• 25 % sessile
• Colonic intussusception
• 90 % within 20 cm anal verge
• Diarrhoea
• Tenesmus
• Rectal prolap

Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• Management

• Polypectomy
• Transanal excision
• Sigmoidoscopic snare

• Others:
• Recurrence is uncommon
• Only 10-20 % recurrence
• Neither a malignant
• No routine follow up
(Nugent et.al. 1993)
• B.2. Peutz-Jeghers Syndrome (PJS)

• an autosomal dominant
disease caused by germline mutation of the serine threonine
kinase 11
• Not complete penetrasion of 19p13.3 cromosom
• Hamartomatous polyps in the gastrointestinal tract
• Mucocutaneous melanin pigmentation.

1. Francis M. Giardiello, Jill D. Trimbath. Peutz-Jeghers Syndrome and Management Recommendations. Clinical Gastroenterology
and Hepatology 2006;4:408–415
2. M. Kopacova, I Tachei, S. Rejchrt, J.Bures : PJS: diagnosis and therapeutic approach : Word J Gastroenterol 2009, Nov. 21;
15(43): 5397-5408 avilable in wjg@wjgnet.com
• increased risk for :
• common and unusual types of gastrointestinal tumor ( colon :39 %)
• nongastrointestinal tumors (Breast : 54%)
• Morbidity and complication
• Bleeding and anemia
• Invagination.
(Francis M. Giardiello, Jill D. Trimbath. Peutz-Jeghers Syndrome and Management
Recommendations. Clinical Gastroenterology and Hepatology 2006;4:408–415)
Francis M. Giardiello, Jill D. Trimbath. Peutz-Jeghers Syndrome and
Management Recommendations. Clinical Gastroenterology and Hepatology
2006;4:408–415
Caecum Ileum terminal Kolon Transversum

Desenden Sigmoid Rectum

 Proliveration smooth muscle

Marcela Kopacova, Ilja Tacheci, Stanislav Rejchrt, Jan Bures. Peutz-Jeghers

syndrome: Diagnostic and therapeutic approach. World J Gastroenterol 2009
November 21; 15(43): 5397-5408
• scattered worm
• Or thread-like (Filiform)
• Adjacent mucosa and formation of mucosal tag of various
shapes and sizes
• Superficial ulceration white slough
• Not a malignant
• Lymphoid hyperplasia
• Most present in 1/3 distal of rectum
• Smooth, round, submucosal lession
• Majority are sessile
• Usually Single

Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• ADENOMA
• Most important polyp
• Main precursor colorectal cancer
• Catagories on basis of size:
• Early (type I) : Small , ≤ 0,5 cm, APC mutation, 10 % LOH on
Cromosome 18q
• Intermediate (II) : Medium, 0,6- 1 cm , 50 % K-ras mutation
• late(III), Large > 1 cm, 50 % LOH on cromosome 18q
• Catagories on basis of shape:
• Tubular
• Tubulovillous
• villous
Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• Tubular Adenoma
• Pedunculated or sessile
• 1 mm until 5 cm
• Small  smooth contour
• Larger  lobular pattern
• Darker than mucosa
• Pedicle 1-3 cm

Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• Villous Adenoma

• Usually large and sessile

• Shaggy surface
• Soft
• Edge are ill-define
• Flat or protude
• Extends  carpet like lession
• Often circumferential
• Darker than surrounding mucosa

Keighley, Williams, Surgery of The anus, rectum and colon, 3rd Ed, 2008
• Simptom and Sign • Rectal Examination
• Bleeding
• Diarrhoea and passage of mucous • Must be done
• Prolaps • Soft  difficult to
palpate
• Abdominal colic
• Velvety
• pedunculated
• Laboratorium Finding
• Anemia
• Mucous diarrhoea  Fluid and electrolid depletion Syndrome
• Hypokalaemia
• Hyponatraemia
• Instrument
• Acidosis
• Ureaemia • Rigid Sigmodoscopy
• Flexible sigmoidoscopy
• Colonoscopy
• Chromoscopic colonoscopy
• Double contras barium
enema
• Peranal Excision of • Polypectomy Trough Rigid
Pedunculated Polyp Sigmoidoscope
Colonoscopic Polypectomy
 Trananal Endoscopic
Tran Anal Incision Microsurgery (TEM)
• Hemorrage
• Minor : 53%
• Major : 1-2 %
• Perforation : 1-3 %
• Gas Explotion
• After prepared using mannitol
• Polypectomy Syndrome
• Abdominal pain
• Distension
• Brief period fever
• Mortality 0,05%
FOLLOW UP AND SURVEILANCE OF
ADENOMA
Ca Colon
• Age : - 6 th decade of life
• - trend for younger age
• Sex : - colon carcinoma : female more than male
• - rectal carcinoma : male more than female
• Macroscopic features : - ulcerative
• - protuberant
• - annuler stenosing
• - polypoidal
• Microscopic features : more than 90% is adenocarcinoma
Differentiation : - well differentiated
- moderatelly differentiated
- undifferentiated
- signet ring cell carcinoma
- mucoid carcinoma

Distribution : - rectum : 50%

- sigmoid colon : 20 %
- cecum & ascending colon : 18%
- transverse colon : 8%
- descending colon : 6%
- synchronous carcinoma : 5%
- metachronous carcinoma : 3%
Presdisposing factor : - low fiber’s diet
- adenomatous lesions
- familial adenoma polyposis
- ulcerative colitis
- granulomatous colitis
Colon carcinoma
1. Direct : circular, longitudinal, and penetrating the
wall
2. Lymphatic : epicolic, paracolic, intermediate, and
para aortic nodes.
3. Blood spread : portal, lumbar, and vertebral vein.
4. Transperitoneal / gravitational spread
5. Intra luminar spread
6. Along nerve fibers
Rectal carcinoma :
1. Direct : longitudinal, penetrating the wall
2. Lympatic : - haemorrhoidal nodes
- hypogastric nodes
- inguinal nodes
3. Blood spread : portal vein, hypogastric vein
4. Along nerve fibers
Staging Duke’s A : mucosal and submucosal layer
B : infiltrating to the serosa
C : involve regional lyph nodes
D : distance metastasis
Symptomes
1. Carcinoma of the right colon :
- abdominal pain or discomfort
- weight loss and anaemia
- bowel obstruction
- mass in the right iliac fossa
2. Carcinoma of the left colon :
- alterations of bowel habit
- large bowel obstruction (colicky pain of lower abdominal)
3. Carcinoma of the rectum :
- anal bleeding
- alteration of bowel habit
- tenesmus
- feeling of incomplete defecation
Signs
1. Right colon carcinoma
- tenderness in the right iliac fossa
- palpable mass in the right iliac fossa
- occult blood in the faces
2. Left colon carcinoma
- palpble tumor in the left iliac fossa is unusual
- abdominal distention
3. Rectal carcinoma
- about 75% rectal carcinoma palpable on rectal
- digital examination
• Tanda obstruksi atau peritonitis
• Tumor masa intra abdomen (ukuran, lokasi, mobilitas,
konsistensi)
• Pembesaran hepar
• Sr Marie Nodule (nodule sekitar umbilicus): terdapat peritoneal
seeding
• L.n. inguinal
• Rectal toucher
X-ray examination
- plain x ray of the abdomen
- thorax foto
- barium enema & contrast double
- IVP
Others
- USG, CT scan, MRI (to search distance metastasis)
• Irritable Bowel Disease
• Colitis Ulceratif
• Crohn Disease
• Hemmoroid
• Fissura Ani
• Divertikulosis
• Polip Recti
Three modality of treatment :
1. Surgical treatment ( cutting )
2. Radiation treatment ( burning )
3. Chemotherapy ( poisoning )
(Neoadjuvant/ Adjuvant)
1. Surgical treatment
A. resectable
- right hemicolectomy
- extended right hemicolectomy
- transverse colon resection
- left hemicolectomy
- sigmoid colon resection
- for rectal carcinoma :
- anterior resection
- low anterior resection
- abdomino perineal resection (mile’s op)
B. non resectable
- ileotransversostomy
- transversocolostomy
- sigmoidostomy
• RIGHT HEMICOLECTOMY
(EXTENDED)
• TRANSVERSECTOMY
• LEFT HEMICOLECTOMY
• SIGMOIDECTOMY
• SUBTOTAL/TOTAL COLECTOMY
• ANTERIOR RESECTION
• SPHINCTER PRESERVING
SURGERY
• ABDOMINO-PERINEAL
RESECTION
• INTERNAL DIVERSION
• COLOSTOMY
SURGICAL APPROACH:
1. OPEN SURGERY
2. LAPAROSCOPIC SURGERY

The American Society of Colon and

Rectal Surgeon (ASCRS):
The absence of 5-years survival
data makes it premature to
endorse laparoscopic colon
resection for cancer. If laparoscopic
colon resection is performed, it is
important to follow traditional During ELSA meeting, September 2005,
surgical principles and standard. some report showed that regarding
ASCRS encourages the survival and recurrent were comparable
development of randomized, between open and laparoscopic surgery
prospective studies to evaluate the for colorectal cancer. Port recurrence can
safety, efficacy and benefit of this be prevented by protecting the wound
alternative (Corman. Handbook of from contact with tumor during resected
colon & rectal surgery 2002) bowel delivery
 TOTAL MESORECTAL EXCISION
• Conventional rectal cancer
surgery: removal of the
rectum by techniques
combination of blunt digital
dissection and traction. This
method has great potential of
leaving substantial amount of
mesorectal tissue behind
leading for recurrence.
• TME: complete remove entire
rectal/ mesorectal package
using sharp disection to
separate visceral an parietal
fascial layer
(Birbeck et al. Pathology and Staging. In Audisio et al).
Modern Management of Cancer of the Rectum 2001)
 TOTAL MESORECTAL
EXCISION
Dot line:
Line dissection
(between Waldeyer/
presacral fascia and
fascia propria of the
rectum)
Ovoid injury of
hypogastric nerve and
its branches
Tumour at or within
1mm of the
circumferential margin
should be regarded as
incomplete excision

(Birbeck et al. Pathology and

Staging. In Audisio et al). Modern
Management of Cancer of the
Rectum 2001)
2. Irradiation treatment :
- pre operative irradiation
- post operative irradiation
- sandwich iradiation

3. Chemotherapy :
- FOLFOX
- FOLFIRI
- CAPEOX
- 5 FU
- Capecitabine
- 5 FU + leucovorine
GASTROINTESTINAL
STROMAL TUMOR
(CLINICAL DIAGNOSIS)
DEFINITION
Gastrointestinal stromal tumors (GISTs) are the most
common mesenchymal tumors of the gastrointestinal
tract, resulting from activating mutations in one of the
receptor protein tyrosine kinases, KIT (CD117) or
platelet-derived growth factor receptor alpha
(PDGFRA).

 KIT-positive : 80% ,
 Mutations in the PDGFRA gene 5% to 10%
 no detectable KIT or PDGFRA mutations (wild-type
GIST).: 10-15%

Soft Tissue Sarcoma, Version 2. 2012 Featured Updates to the NCCN Guidelines J Natl Compr Canc Netw . 2012;10:951-960
GIST ? MALIGNANT SCHWANOMA?
LEIOMYOSARCOMA?

GIST : FROM ICC

(Interstitial Cells of Cajal)

LEIOMYOSARCOMA
From smooth muscle
 KIT AND PDGFRA MUTATIONS:
OVERALL MUTATION FREQUENCY 86%

KIT (~70%) PDGFRA (~6.5% total)

(~30% of KIT-WT)

Exon 9 (9%)

Exon 11 (67%) Exon 12 (2%)

Exon 13 (1%) Exon 14 (rare)

Exon 17 (1%) Exon 18 (5.5%)

Abbreviation: PDGFRA, platelet-derived growth factor receptor α. 7

Corless Cl, et al. Annu Rev Pathol. 2008;3:557-586.
5
HISTOLOGIC FEATURES OF GISTS
 spindle cell pattern : 60 – 70%,
 epithelioid cytology : 20 - 30%
 pleomorphic pattern : <5%
MICROSCOPIC
APPEARANCE
OF GASTRIC
GIST
MICROSCOPIC
APPEARANCE
OF INTESTINAL
GIST
IMMUNOHISTOC
HEMICAL
STAINING
KIT POSITIF
HISTORY OF GIST
 Early years- smooth muscle tumor
(leiomyoma, leiomyosarcoma)
 1970-1980s (electron microscope &
immunohistochemistry):
-Partial smooth muscle differentiation, neural,
mixed or null phenotypes
-GANT (gastrointestinal associated neural
tumor)
 1980s- term GIST widespread used

Hornick JL: Mesenchymal tumor of the GI tract: an update, 2011

HISTORY OF GIST
 1998 : KIT activating mutations
 1998: KIT immunoreactivity
 2002: Imatinib mesylate (gleevec) RCT
 2003: PDGFRA activating mutation
 2006: sunitinib malate (sutent) RCT
 2009: adjuvant imatinib after resection of
localized GIST RCT
 2011: genotyping to guide TKI therapy

Hornick JL: Mesenchymal tumor of the GI tract: an update, 2011

EPIDEMIOLOGY OF GIST
 United States: about 5000 new cases annually, providing
15–20 cases per million per year, and the black race is a
risk factor
 Data obtained from 14 different countries from all over
the world participating in the EORTC study the incidence
rate was calculated as approximately 4–5 cases per
million per year
 Similar in men and women
 The mean age at the diagnosis is 55–63 years , rare
before 40 and very rare in children
 Metastatic disease is more common in younger patients

POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2008; 118 (4)

* EGIST: Extra Gastro Intestinal Stromal Tumor
FREQUENCY OF GIST
Less 1% of Gastrointestinal tumor

LOCATION PERCENTAGE

STOMACH 60%

SMALL INTESTINE 30%

DUODENUM 5%

COLORECTAL < 5%

ESOPHAGUS & APPENDIX <1%

OUT SIDE OF GI TRACT RARE

Behazin. Gastrointestinal Stromal Tumor. Medscape 2013

 MUTATION SUBTYPES ACCORDING
TO THE PRIMARY LOCATION

Stomach Small Bowel

Genotype (n = 738) (n = 261)
KIT mutation 65.2% 79.7%
Exon 9 1.8% 23%
Exon 11 61.4% 54%
Exon 13 1.2% 2.3%
Exon 17 0.8% 0.4%

PDGFRA mutation 22.9% 1.2%

Exon 12 3.1% 0%
Exon 14 0.5% 0.4%
Exon 18 19.3% 0.8%
Wild type 11.9% 19.1%

Abbreviation: PDGFRA, platelet-derived growth factor receptor α. 8

Data from Wardelmann E, et al. Pathologe. 2010;31(3):195-198.
5
STAGING OF GIST
AMERICAN JOINT COMMITTEE ON CANCER
(AJCC)

 T: The size of the primary tumor, and whether it

has spread to nearby organ
 N: The extent of which the cancer has spread to
nearby lymph nodes
 M: Whether the cancer has spread, or
metastasized, to distant parts of the body
 Mitotic rate: The measure of how fast the cancer
cells are growing and dividing
CLASSIFICATION OF GIST
In the SSGXVIII/AIO trial, risk stratification was based
on:tumor size, site, mitotic count, and rupture;

patients with high-risk of recurrence:

- mitotic count > 5 mitoses/50 HPF;
- size > 5 cm;
- nongastric location; and
- tumour rupture
Joensuu H, JAMA 2012;307:1265-7
POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2008; 118 (4)
HUMAN PATHOLOGY Volume33, No. 5 (May 2002)
 NIH CLASSIFICATION
FOR RISK OF
RECURRENCE
Very Low Risk Low Risk Intermediate Risk High Risk
NIH Tumor size < 2 Tumor size 2-5 cm Tumor size 5-10 cm Tumor size > 5 cm
consensus cm Mitotic index < 5 Mitotic index < 5 Mitotic index > 5
criteria1 Mitotic index < 5 OR OR
Tumor size < 5 cm Tumor size > 10 cm
Mitotic index 6-10 Mitotic index, any
OR
Tumor size, any
Mitotic index > 10
Modified NIH Any location: Any location: Any location: Any location:
consensus Tumor size < 2 Tumor size 2.1-5 cm Tumor size < 5 cm Tumor rupture
classification2 cm Mitotic index  5 Mitotic index 6-10 OR
Mitotic index  5 Tumor size > 10 cm
Gastric: OR
Tumor size 2.1-5 cm Mitotic index > 10
Mitotic index > 5 OR
OR Tumor size > 5 cm
Tumor size 5.1-10 cm Mitotic index > 5
Mitotic index  5
Nongastric:
Tumor size 2.1-5 cm
Mitotic index > 5
OR
Tumor size 5.1-10 cm
Mitotic index  5
Abbreviations: Mitotic index, number of mitoses per 50 high-power fields; NIH, National Institutes of health.
8
1. Fletcher CD, et al. Hum Pathol. 2002;33(5):459-465; 2. Joensuu H. Hum Pathol. 2008;39(10):1411-1419.
9
 SYMPTOMS OF GIST
 GIST is often asymptomatic until it reaches a
certain location, grows to a certain size or
bleeds.
 Not infrequently, GIST is discovered incidentally
during radiologic imaging for an unrelated
condition or as a secondary finding in a surgical
resection, which is the removal of all or part of
an organ.
 At diagnosis, approximately half of malignant
GIST are metastatic.
SYMPTOMS OF GIST (cont’s)
Smaller GISTs, may have no symptoms or vague, nonspecific
abdominal pain or discomfort.
Large, aggressive GISTs may cause some of the following
symptoms:
 Pain or discomfort in the abdomen, the area of the body
that contains the stomach, intestines, and other organs
 Nausea and vomiting
 Blood in the stool or vomiting blood
 Fatigue due to low red blood cell counts (anemia)
 Diarrhea
 Intestinal obstruction
 Weight loss
 Abdominal mass
RELATIONSHIP BETWEEN TUMOR
SIZE AND TIME OF DETECTION

TIME OF TUMOR DETECTION MEAN DIAMETER

(CM)
Based on symptom 8.9
Incidental finding 2,7
During autopsy 3.4

Behazin. Gastrointestinal Stromal Tumor. Medscape 2013

SYMPTOMS OF
ESOPHAGEAL GIST
 Small GIST
no symptom
found
incidentally
 Moderate
size GIST:
dysphagia
 Large GIST:
obstruction
SYMPTOMS OF GASTRIC GIST
 Upper GI Bleeding (due to ulcer forming) :40-65%
 Epigastric pain
 Anorexia
 Nausea
 Vomiting
 Weight loss
 Epigastric fullness
 Early satiety
 Epigastric mass
SYMPTOMS OF DUODENAL
GIST

 Symptom as in gastric GIST may present

 Obstructive jaundice
SYMPTOMS OF SMALL BOWEL
GIST
 Diarrhea
 Bleeding
 Intestinal obstruction
 Abdominal mass
 Some find during emergency surgery for perforated
viscus
SYMPTOM COLORECTAL GIST
 Hematoscezia
 Diarrhea
 Constipation
 Intestinal obstruction
 Some find during emergency surgery for perforated
viscus
DIAGNOSTIC MODALITY

 Contras gastrointestinal imaging

 Endoscopy & biopsy
 Imaging (CT with iv contras)
 Endoscopic ultrasonography
 SPACE
OCCUPAYING
LESSION

SMOOTH
ROUND NODULE
WITH NICE
SMOOTH ROUND
NODULE WITH
NICHE
IMMUNOHITOCHEMISTRY
STAINING
cKIT (+)
 ENDOSCOPIC ULTRASONOGRAPHY

Useful diagnostic method in the identification of

malignant tumors

Features associated with malignant GIST are

independently:
- size more than 40 mm,
- an irregular outer margin,
- the presence of cysts and
- non-homogenous echo pattern

POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2008; 118 (4)

 Tumor identified  biopsy is typically
reserved for cases of :
◦ Diagnostic uncertainly
◦ Unresectable lesions
◦ When Neoadjuvant therapy is being considered
 Biopsy
◦ Prevent rupture of pseudocapsule and
intraperitoneal tumor dissemination
◦ Fine-needle aspirates / Core-needle biopsy 
inconclusive  because of the submucosal
location and the necrotic centers
 Surgical Management of GIST depending :
◦ The Size
◦ The exact anatomical Location
◦ Specific location of the GIST relative to the blood
supply of the involved organ
◦ Wheter or not the GIST has adhered to
surrounded or invaded adjacent structures
◦ The patient’s overall medical condition
 Small (<2cm) asymptomatic tumors
(incidentally)  controversy treatment
Primary Resectable Disease

Primary Unresectable
Disease

Recurrent and Metastatic

Disease
 Surgery : mainstay treatment of Localized
resectable GIST
 A complete gross resection with preservation
of an intact (pseudo) capsule and negative
microscopic margins (R0)
 Wide margins not improve outcomes
 Lymphadenectomy is not routinly required
 En bloc resection is needed when adjacent
organs appear to be involved
 The abdomen should be thoughly explored
for evidence of metastatic disease
 GIST tend to displaced stucture (most
sarcomas) rather than invade them
 Final pathologic examination reveals
microscopically positive margins
◦ Contoversy
◦ Reoperation and marginal resection ?
◦ R0 and R1  long term outcome : similar
◦ R2  worst outcome  subtotal resection should
be avoided
 Microscopically (+) Margins :
◦ Risk and benefit of re-exicision
◦ Watchful waiting
◦ Postoperative Imatinib
 Laparoscopy has emerged as a helpful tool
in the treatment of GIST (<5/10 cm)
◦ Safe and feasible
◦ Oncologic safety
◦ Minimizing tumor manipulation
 Tumor Rupture
 Intraperitoneal Spread
◦ Wound protecting device (hand port)
◦ Endobag
 Endoscopic resection in not recomended (>2cm)
◦ Risk of positive margins
◦ Perforation and Tumor spillage
 GIST <2cm  EUS no High Risk
◦ Surveillance endoscopy every 6-12 months
◦ Endoscopi resection
 High Risk on EUS  Surgical resection
◦ Large size
◦ Irregular extraluminal border
◦ Heterogenous echo pattern
◦ Presence of cystic spaces
◦ Echogenic foci
 85% of Px with Localised Primary GIST :
Complete resection
 70-95% : Negative microscopic margins
 Surgery alone  recurrence rate ± 50%
(irrespective of negative margins)
 5-year survival : 50%
 Most common site (70%)
 Surgical approach :
◦ Size and Location
◦ Biopsy is not necessary (unless with M1)
 Omentectomy : not routinly
 Location :
◦ Greater Curv/Fundus : Sleeve or Wedge gastrectomy
◦ Incisura/Antrum : Distal Gastrectomy
◦ Lesser Curv/GE junction : Partial Gastrectomy/Total
Gastrectomy
 En-bloc resection : splenectomy and/or distal
pancreatectomy
 Second most common (20%) : Jejunal - Ileal
- Duodenal
 Resection of the involved bowel with
Negative Margins  Primary Anastomosis
 Can be performed Laparoscopically  either
intra- or extracorporeal anastomosis
 Duodenal Lesions : <5%
 Difficult surgical problem
 Location :
◦ Small Proximal D1/D2 Tumor : Wide excision
◦ Large tumor/Close to the major papilla :
Pancreaticoduodenectomy
◦ Distal D3/D4 : Segmental resection +
duodenojejunostomy anastomosis
 Rare : 3-5%
 Increases in the more distal colon, rectum for
majority of tumor
 Rectal GIST : difficult
◦ Involvement of surrounding structure
◦ R0 difficult to obtain
◦ Average positive margin up to 40%
 Operative plan : depends on proximity of the
tumor to the internal sphincter
◦ LAR
◦ APR
 Mesorectal excision and wide margin are not
needed
 Colonic GIST
◦ Marginal resection with primary anastomosis
◦ In the setting of perforation and gross
contamination  colostomy and mucous fistula
may be prefered  risk of anastomotic
dehiscence
◦ Formal lymphadenectomy is not necessary
 Rare : <5%
 Operative approach : tumor size and
location  relation to the GE junction
◦ Small lession (<2cm) : Transmurally resected
alonf the longitudinal axis w/ Transverse closure
◦ Larger lession/within GE junction :
esophagectomy
 Treatment options were very limited in the
pre-TKI era
 GIST : respond poorly to chemo-tx or
radiation-tx
 General rule :
◦ R1/R2 resection
◦ Debulking Surgery Not recommended
◦ Mutilating Surgery
 Imatinib is the standart treatment
 Neoadjuvant Imatinib
 2 CT scan evaluation  surgical option
 Incomplete resection/debulking  only
performed in the setting of palliation for
bleeding, obstruction, perforation
 Timing of resection : imatinib for 6 months
 Cytoreductive Surgery :
◦ Stable or responsive to TKI therapy when
complete gross resection is possible
◦ Emergencies situation : hemorrhage,
perforation, obstruction or abscess
CONCLUSION

 GIST IS ICC MALIGNANCY AND DIFFER FROM

LYOMYOSARCOMA
 MUTATION OF KIT (70%) OR PDGFRA (20%)
 NO SYMPTOM IN SMALL GIST OR JUST VAGUE
ABDOMINAL PAIN AND FOUND INCIDENTALLY
DURING GASTROINTESTINAL SERIES OR
ENDOSCOPY
 LARGE GIST GIVE SYMPTOM ACCORDING TO
LOCATION: BLEEDING OR OBSTRUCTION OR JUST
MASS
 INCREASE AWARRNESS FOR SUBMUCOSAL
INTESTINAL TUMOR  IHC FOR KIT
• Semoga Bermanfaat