Postoperative encapsulated hemoperitoneum in a patient with gastric stromal tumor treated by exposed endoscopic full-thickness resection: A case report

Abstract

Background: Gastric stromal tumors, originating from mesenchymal tissues, are one of the most common tumors of the digestive tract. For stromal tumors originating from the muscularis propria, compared with conventional endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR) can remove deep lesions and digestive tract wall tumors completely. However, this technique has major limitations such as perforation, postoperative bleeding, and post-polypectomy syndrome. Herein, we report a case of postoperative serous surface bleeding which formed an encapsulated hemoperitoneum in a patient with gastric stromal tumor that was treated with exposed EFTR. Feasible treatment options to address this complication are described.

Case summary: A 47-year-old male patient had a hemispherical protrusion found during gastric endoscopic ultrasonography, located at the upper gastric curvature adjacent to the stomach fundus, with a smooth surface mucosa and poor mobility. The lesion was 19.3 mm × 16.1 mm in size and originated from the fourth ultrasound layer. Computed tomography (CT) revealed no significant evidence of lymph node enlargement or distant metastasis. Using conventional ESD technology for mucosal pre-resection, exposed EFTR was performed to resect the intact tumor in order to achieve a definitive histopathological diagnosis. Based on its morphology and immunohistochemical expression of CD117 and DOG-1, the lesion was proven to be consistent with a gastric stromal tumor. Six days after exposed EFTR, CT showed a large amount of encapsulated fluid and gas accumulation around the stomach. In addition, gastroscopy suggested intracavitary bleeding and abdominal puncture drainage indicated serosal bleeding. Based on these findings, the patient was diagnosed with serosal bleeding resulting in encapsulated abdominal hemorrhage after exposed EFTR for a gastric stromal tumor. The patient received combined treatments, such as hemostasis under gastroscopy, gastrointestinal decompression, and abdominal drainage. All examinations were normal within six months of follow-up.

Conclusion: This patient developed serous surface bleeding in the gastric cavity following exposed EFTR. Serosal bleeding resulting in an encapsulated hemoperitoneum is rare in clinical practice. The combined treatment may replace certain surgical techniques.

Keywords: Abdominal infection; Case report; Complication; Exposed endoscopic full-thickness resection; Gastric stromal tumors; Hemoperitoneum; Postoperative bleeding.

Figure 1

Preoperative endoscopic examination results. A: Endoscopic image showing a hemispherical protrusion, approximately 16 mm in diameter, located at the upper gastric curvature adjacent to the stomach fundus, with a smooth surface mucosa and poor mobility; B: Endoscopic ultrasound image showing a mass 19.3 mm × 16.1 mm in size, derived from the muscularis propria, which partly grew outside the cavity. The echo pattern of the mass was uniform and at a low level.

Figure 2

Abdominal computed tomography examination. A: Gastric computed tomography (CT) illustrated a well-demarcated mass, 16 mm × 15 mm in size, demonstrating mild enhancement, with an intact mucosal line; B: Abdominal CT revealed a large amount of encapsulated fluid and gas accumulation around the stomach.

Figure 3

Postoperative pathological examination results. A and B: The tumor was located in the muscularis propria and was a spindle cell tumor, arranged in a bundle-like interweaving pattern with mild nuclear atypia (H&E, original magnification × 100); C and D: Immunohistochemical staining of tumor cells showed diffuse positivity for CD117 (C) and DOG1 (D), which were diffusely expressed on the surface of cell membranes.