Laparoscopic intragastric resection of melanoma cardial lesion.

BACKGROUND: Gastrointestinal tract involvements of metastatic melanoma are rare; 7% of gastrointestinal tract metastases of melanoma concerns the stomach [1]. Actually, bleeding from gastric melanoma metastasis is very rare. For the first time in Literature, this video shows a laparoscopic intragastric resection [2] of a cardial lesion of melanoma. A 64-year old patient with history of a skin melanoma resection with lung and liver metastatic disease confirmed by FDG PET, stable after repeated cycles of Pembrolizumab, presented anemia with gastrointestinal bleeding signs. Endoscopy and CT scans documented a 4-cm subcardial metastatic melanoma lesion. Endoscopic ultrasound evaluation confirmed no full-thickness involvement of gastric wall. Patient refused blood transfusions because Jehovah's Witness. Since the tumor position so close to the cardias contraindicated both typical endoscopic and laparoscopic approaches, we proposed laparoscopic intragastric solution in order to avoid risk related to a total gastrectomy.

METHODS: Procedure was performed by 3 intragastric trocars placed under endoscopic view. The primary surgical intent was to excise the tumor in order to avoid further bleeding. Actually, during dissection we verified the possibility to radically resect the lesion. After removal (with partial fragmentation) of the lesion, residual free fragments have been accurately removed to reduce the risks of tumor implantation on gastric mucosa and a mucosal suture was completed. Two-layer running sutures were applied on gastric holes. After completion of procedure, suture and cardial gastric wall were tested for leakage with satisfying result. Finally, lesser sac was opened up to expose the right diaphragmatic pillar in order to exclude eventual posterior gastric wall damage.

RESULTS: Pathologic evaluation demonstrated a diffuse submucosal invasion by melanoma, confirming that R0 resection was achieved.

CONCLUSIONS: In the general strategy of a palliation treatment of a largely metastastic tumor, the specific aim of this procedure was to stop gastric bleeding and to allow the continuation of systemic therapies effective in the disease control. After 6 months from surgery, patient resumed chemotherapy without any documented gastric recurrence.