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ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

Print version ISSN 0102-6720

ABCD, arq. bras. cir. dig. vol.28 no.1 São Paulo  2015

https://doi.org/10.1590/s0102-67202015000100023 

Letter To The Editor

Endoscopic hemostasis of a bleeding gastric gastrointestinal stromal tumor (GIST) with endoloop placement

Felipe Alves RETES1 

Bruno da Costa MARTINS1 

Mauricio Paulin SORBELLO1 

Cezar Fabiano Manabu SATO1 

Fabio Shiguehissa KAWAGUTI1 

Fauze MALUF-FILHO1 

Ulysses RIBEIRO-JUNIOR1 

1Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo (Cancer Institute of São Paulo State, Faculty of Medicine, University of São Paulo), São Paulo, SP, Brazil


INTRODUCTION

Gastrointestinal bleeding due to gastric neoplasia is difficult to manage and may provoke dramatic situations. For the most part, therapeutic endoscopic methods provide only temporary success in controlling bleeding. Often, a poor clinical condition and an advanced stage of the neoplastic disease mean these patients will receive exclusively palliative clinical care. Hence, surgical procedures are often contraindicated, either due to lack of clinical conditions or the increased mortality resulting from surgical trauma. In such cases, alternative endoscopic techniques have been described as minimally invasive means of controlling tumor-induced bleeding.

CASE REPORT

A 79 year-old man with gastric GIST, receiving Imatinib for the presence of multiple hepatic (Figure 1), pulmonary and bone metastases, was admitted to the Cancer Institute of the University of São Paulo Medical School,São Paulo, SP, Brazil after presenting massive hematemesis, followed by syncope.

Figure 1 - Multiple hepatic metastases 

An upper gastrointestinal endoscopy was indicated. The exam revealed fresh blood in the gastric chamber and a 4 cm submucosal ulcerated lesion, partially covered with adherent clots in the cardia region. Since there was no ongoing bleeding, endoscopic therapy was not performed at that time. However, after multidisciplinary discussion, it was decided to attempt endoscopic hemostasis due to the high risk involved in using anesthesia to perform surgical resection. An endoloop was placed at the base of the lesion in a retroflexed position (Figure 2).

Figure 2 - Endoscopic retroflexion: bleeding GIST and endoloop placement 

One week later, an endoscopic review exam was performed, demonstrating the successful hemostastic procedure (Figure 3).

Figure 3 - Endoscopic follow-up: GIST looped, with ischaemic appearance and necrosis 

The patient was then referred to and followed by the palliative care group and died two months later, without further bleeding.

DISCUSSION

Endoscopic hemostasis of tumoral lesions is a challenging situation, since no endoscopic therapy has been proved to be superior3. Choice of therapy will be dictated by the tumor's appearance and the personal experience of the endoscopist. Reports show that hemoclips have been applied in both successful2 and failed4 attempts to achieve hemostasis. In the present case, the tumor appeared to be friable and an attempt to apply hemoclips could have led to mucosal tearing and recurrent bleeding. Endoloop ligation of such lesions has been described to treat bleeding tumors and also to resect lesions in patients deemed non-surgical candidates, through ischemic necrosis (loop-and-let-go)1. Although the surgical approach is considered the treatment of choice for such lesions, the endoloop technique is a useful, feasible, cheap and safe alternative for patients considered unsuitable for surgery or as a temporary measure to stabilize patients before the surgical treatment.

REFERENCES

1. Arezzo A, Verra M, Miegge A, Morino M. Loop-and-let-go technique for a bleeding, large sessile gastric gastrointestinal stromal tumor (GIST). Endoscopy. 2011;43 Suppl 2 UCTN:E18-9. [ Links ]

2. Cheng AW, Chiu PW, Chan PC, Lam SH. Endoscopic hemostasis for bleeding gastric stromal tumors by application of hemoclip. J Laparoendosc Adv Surg Tech A. 2004;14:169-71; [ Links ]

3. Savides TJ, Jensen DM, Cohen J, Randall GM, Kovacs TO, Pelayo E, Cheng S, Jensen ME, Hsieh HY. Severe upper gastrointestinal tumor bleeding: endoscopic findings, treatment, and outcome. Endoscopy. 1996;28:244-8; [ Links ]

4. Seya T, Tanaka N, Yokoi K, Shinji S, Oaki Y, Tajiri T. Life-threatening bleeding from gastrointestinal stromal tumor of the stomach. J Nihon Med Sch. 2008;75:306-11 [ Links ]

Financial source: none

Received: January 21, 2014; Accepted: December 09, 2014

Correspondence: Mauricio Paulin Sorbello E-mail: sorbello.mauricio@gmail.com

Conflicts of interest: none

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.