Surgical Management of Perforated GIST at the Greater Curvature
For a perforated Gastrointestinal Stromal Tumor (GIST) located at the greater curvature of the stomach, wedge resection with negative margins is the preferred surgical approach, avoiding tumor rupture and preserving gastric function. 1, 2
Initial Management Considerations
- Complete surgical resection with negative margins (R0) is the cornerstone of treatment for perforated GIST 1, 2
- The perforation significantly increases recurrence risk, automatically placing the patient in a high-risk category 2
- Emergency surgery is required to control contamination and achieve complete tumor removal 2
Specific Surgical Approach for Greater Curvature GIST
- Wedge resection is particularly well-suited for GISTs located at the greater curvature 1
- Segmental or wedge resection to obtain negative margins is appropriate, as extended anatomic resections are rarely indicated 1
- Laparoscopic approach is considered appropriate for GISTs at the greater curvature when performed by surgeons with adequate experience 1, 3, 4
Technical Considerations During Surgery
- Avoid direct handling of the tumor to prevent further rupture or seeding 1, 2
- Use plastic bags for specimen removal during laparoscopy to prevent tumor seeding 1
- Preserve the pseudocapsule and avoid additional tumor spillage beyond what has already occurred due to perforation 1
- Lymphadenectomy is generally not required as lymph node metastasis is rare in GISTs 1, 5
Surgical Options Based on Tumor Size and Location
For smaller tumors (≤5 cm) at the greater curvature:
- Laparoscopic wedge resection is feasible and safe 1, 3, 4
- Endoscopically-assisted techniques can help guide resection margins 3, 6
For larger tumors (>5 cm) at the greater curvature:
- Open surgical approach may be preferred 4
- Consider the extent of perforation and local contamination 2
Post-Surgical Management
- Adjuvant imatinib therapy is mandatory after resection of perforated GISTs due to high risk of recurrence 2
- Standard dose is 400 mg daily, with consideration for 800 mg daily for KIT exon 9 mutations 1, 2
- Duration of adjuvant therapy should be at least 3 years, with consideration for longer treatment due to perforation 2
Potential Pitfalls and Complications
- Underestimating the significance of tumor rupture in risk stratification can lead to inadequate adjuvant therapy 2
- Not performing mutational analysis may result in ineffective targeted therapy 2
- Excessive resection of gastric tissue should be avoided to preserve function 1, 4
Follow-up Protocol
- More intensive surveillance is required for perforated GISTs due to high recurrence risk 2
- Follow-up should include contrast-enhanced CT scans every 3-4 months for the first 2-3 years 2
- Then every 6 months for years 4-5, and annually thereafter up to 10 years 2
The greater curvature location is actually advantageous for surgical management of GIST, as it allows for straightforward wedge resection with minimal impact on gastric function compared to tumors near the GE junction or pylorus 4, 6.