El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
This is the case of a 33 year-old male that comes from the Republic of Honduras. He has U.S nationality and Honduras heritage. He is a retired military, his history has been of severe hemorrhages of the upper digestive system, in four occasions manifesting only with melenas, needing blood transfusions because of the hemoglobin down until 5 gr/dl. The endoscopies in Honduras and Miami did not detect its pathology, including enteroscopy and endoscopic capsule.

Video Endoscopic Sequence 1 of 86.

Jejunal Gastrointestinal Stromal Tumor (GIST).

 This is the case of a 33 year-old male that comes from the
 Republic of Honduras. He has U.S nationality and
 Honduras heritage. He is a retired military, presented with
 recurrent episodes of GI severe hemorrhage in four
 occasions manifesting only with melenas, needing
 blood transfusions because of the hemoglobin down until 5
 gr/dl. The endoscopies in Honduras and Miami did not
 detect that pathology, including colonoscopies enteroscopy
 and endoscopic capsule as well as abdominal computed
 tomography scan and other imaging methods. He came to
 our office for the first time to ask for evaluation we
 performed an upper endoscopy that was negative following
 an enteroscopy finding this lesion.

 A case of a Gastric GIST, is displayed in Stomach chapter.

 Download the video clips by clicking on the endoscopic
 images, if you wish to observe in full screen, wait to be
 downloaded complete then press Alt and Enter for
 Windows media, Real Player Ctrl and 3. 
 Configure the windows media in repeat is optimal.
 All endoscopic images shown in this Atlas contain
 video clips. We recommend seeing the video clips in full
 screen mode.   

This tumor with central ulceration was found at 20 cm. after Treitz angle. Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors originating in the wall of the gastrointestinal tract.

Video Endoscopic Sequence 2 of 86.

Enteroscope view of jejunal tumor

 This tumor with central ulceration was found at 20 cm. after
 Treitz angle.

 Gastrointestinal stromal tumors (GIST) are rare
 mesenchymal tumors originating in the wall of the
 gastrointestinal tract, Nevertheless, some may present
 with a life-threatening hemorrhage or intestinal obstruction.
Gastrointestinal Stromal Tumors (GIST) are rare tumors, accounting for less than 3% of gastrointestinal neoplasms, however, they are the most frequent mesenchymal tumors of the GI tract. All GISTs are defined by the expression of CD117, a tyrosine kinase growth factor receptor, as opposed to other tumors like leiomyomas, leiomyosarcomas and neurogenic tumors. 70-80% are benign, and the majority is located in the stomach and small bowel, but also they can arise from any portion of the GI tract as well as from the mesentery, omentum and retroperitoneum. Malignant GISTs are usually large (>5 cm), with high mitotic index, and can metastasize to the liver and peritoneum.

Video Endoscopic Sequence 3 of 86.

 Gastrointestinal Stromal Tumors (GIST) are rare tumors,
 accounting for less than 3% of gastrointestinal neoplasms,
 however, they are the most frequent mesenchymal tumors
 of the GI tract. All GISTs are defined by the expression of
 CD117, a tyrosine kinase growth factor receptor, as
 opposed to other tumors like leiomyomas,
 leiomyosarcomas and neurogenic tumors. 70-80% are
 benign, and the majority is located in the stomach and
 small bowel, but also they can arise from any portion of the
 GI tract as well as from the mesentery, omentum and
 retroperitoneum. Malignant GISTs are usually large (>5
 cm), with high mitotic index, and can metastasize to the
 liver and peritoneum.

 
Our Patient underwent a laparoscopy surgical resection of the segment harboring the GIST.

Video Endoscopic Sequence 4 of 86.

 Our Patient underwent a laparoscopy surgical resection of
 the segment harboring the GIST. see the video clips of the
 laparoscopic resection below

 More details download the video clip by clicking on the
 image.

 
In cases of obscure gastrointestinal bleeding, when a source for blood loss is not apparent from examination of the colon and upper gastrointestinal tract, the small bowel usually becomes the focus of investigation. A tumor with interesting pathologic features was found in a patient who presented with recurrent episodes of massive obscure gastrointestinal hemorrhage, this case highlights the importance of considering small intestinal tumors as the likely cause of obscure gastrointestinal hemorrhage in young patients and how a noninvasive test, eg, abdominal computed tomography scan, might obviate the need for more invasive testing.

Video Endoscopic Sequence 5 of 86.

 In cases of obscure gastrointestinal bleeding, when a
 source for blood loss is not apparent from examination of
 the colon and upper gastrointestinal tract, the small bowel
 usually becomes the focus of investigation. A tumor with
 interesting pathologic features was found in a patient who
 presented with recurrent episodes of massive obscure
 gastrointestinal hemorrhage, this case highlights the
 importance of considering small intestinal tumors as the
 likely cause of obscure gastrointestinal hemorrhage in
 young patients and how a noninvasive test, eg, abdominal
 computed tomography scan, might obviate the need for
 more invasive testing.

 Gastrointestinal (GI) hemorrhage is considered obscure
 1 when conventional investigations
 (esophagogastroduodenoscopy and colonoscopy) fail to
 detect bleeding lesions. On average, 27% of patients with
 obscure GI bleeding have small intestinal lesions.
 2. Diagnosing these lesions is frequently difficult because
 they tend to be inaccessible to routine endoscopy. Small
 bowel barium studies, radioactive isotope bleeding scans,
 selective visceral angiography, intraoperative enteroscopy,
 exploratory laparotomy, and more recently
 wireless capsule endoscopy all have variable
 sensitivities and specificities for detecting small intestinal
 lesions.
Gastrointestinal stromal tumors (GIST) are rare tumors that may arise anywhere in the tubular gastrointestinal tract, but stomach is the most common site of localization. Surgery is the main stay of treatment and complete resection is achieved in most of cases [1]. The 5 year overall survival ranges from 21% to 88% in different series, depending from risk grading and completeness of surgical resection

Video Endoscopic Sequence 6 of 86.

 Gastrointestinal stromal tumors (GIST) are rare tumors
 that may arise anywhere in the tubular gastrointestinal
 tract, but stomach is the most common site of localization.
 Surgery is the main stay of treatment and complete
 resection is achieved in most of cases. The 5 year overall
 survival ranges from 21% to 88% in different series,
 depending from risk grading and completeness of surgical
 resection.

 
In light of the tendency of these tumors to pursue an indolent clinical course with a significant risk of late relapse, a brisk follow-up is advocated for all patients.

Video Endoscopic Sequence 7 of 86.

 In light of the tendency of these tumors to pursue an
 indolent clinical course with a significant risk of late
 relapse, a brisk follow-up is advocated for all patients.

 Images from upper GI series may demonstrate the lesion
 in up to 29% of cases.CT scan can demonstrate up to 27%
 of benign small bowel tumors, especially of size > 2 cm.
 Upper GI endoscopy has been employed successfully for
 the detection of benign jejunal lesions in 12-30% of cases.

 
GI stromal tumors (GISTs) are a subset of GI mesenchymal tumors of varying differentiation. Previously, these tumors were classified as GI leiomyomas, leiomyosarcomas, leiomyoblastomas, or schwannomas as a result of their histologic findings and apparent origin in the muscularis propria layer of the intestinal wall. With the advent of immunohistochemical staining techniques and ultrastructural evaluation, GISTs now are recognized as a distinct group of mesenchymal tumors. In the present classification, GISTs account for approximately 80% of GI mesenchymal tumors .

Video Endoscopic Sequence 8 of 86.

 GI stromal tumors (GISTs) are a subset of GI
 mesenchymal tumors of varying differentiation. Previously,
 these tumors were classified as GI leiomyomas,
 leiomyosarcomas, leiomyoblastomas, or schwannomas as a
 result of their histologic findings and apparent origin in the
 muscularis propria layer of the intestinal wall. With the
 advent of immunohistochemical staining techniques and
 ultrastructural evaluation, GISTs now are recognized as a
 distinct group of mesenchymal tumors. In the present
 classification, GISTs account for approximately 80% of GI
 mesenchymal tumors.
In as many as 5% of patients with obscure GI bleeding, a source cannot be identified despite extensive examination.5 When a lesion cannot be identified after standard upper endoscopy and colonoscopy, further evaluation depends on the briskness of bleeding (see algorithm). In those with active (brisk) bleeding, technetium-99 radionuclide scanning or angiography should be performed. In patients with a subacute presentation (or intermittent bleeding), the focus of investigation should be broadened to include the small intestine. The lesions most commonly identified as bleeding sites in the small bowel include tumors and vascular ectasias, which vary in frequency depending on age. In patients between 30 and 50 years of age, tumors are the most common abnormalities, whereas in patients less than 25 years of age, Meckel diverticula are the most common source of small bowel bleeding.6 Vascular ectasias predominate in older patients. Other rare causes in the differential diagnosis of obscure GI hemorrhage include hemosuccus pancreaticus, hemobilia, aortoenteric fistula, Dieulafoy lesion, extraesophageal varices, and diverticula (especially of the small intestine).

Video Endoscopic Sequence 9 of 86.

 In as many as 5% of patients with obscure GI bleeding, a
 source cannot be identified despite extensive examination.
 When a lesion cannot be identified after standard upper
 endoscopy and colonoscopy, further evaluation depends on
 the briskness of bleeding (see algorithm). In those with
 active (brisk) bleeding, technetium-99 radionuclide
 scanning or angiography should be performed. In patients
 with a subacute presentation (or intermittent bleeding), the
 focus of investigation should be broadened to include the
 small intestine. The lesions most commonly identified as
 bleeding sites in the small bowel include tumors and
 vascular ectasias, which vary in frequency depending on
 age. In patients between 30 and 50 years of age, tumors
 are the most common abnormalities, whereas in patients
 less than 25 years of age, Meckel diverticula are the most
 common source of small bowel bleeding. Vascular ectasias
 predominate in older patients. Other rare causes in the
 differential diagnosis of obscure GI hemorrhage include
 hemosuccus pancreaticus, hemobilia, aortoenteric fistula,
 Dieulafoy lesion, extraesophageal varices, and diverticula
 (especially of the small intestine).
Small bowel examination can be accomplished with standard small bowel follow-through, enteroclysis, push enteroscopy, Sonde enteroscopy, wireless capsule endoscopy, and intraoperative enteroscopy. In the case described here, small bowel follow-through examination was nondiagnostic most likely because the jejunal lesion was predominantly extramucosal. This case also illustrates that in young patients with obscure small intestinal bleeding the source is frequently tumors rather than arteriovenous malformations. These tumors are problematic because they often grow in an extraluminal direction and only cause intermittent bleeding if they erode or ulcerate through the small bowel mucosa, as occurred in this patient. In a situation such as this, a noninvasive test, such as a computed tomography scan, may obviate the need for more invasive testing.

Video Endoscopic Sequence 10 of 86.

 Small bowel examination can be accomplished with
 standard small bowel follow-through, enteroclysis, push
 enteroscopy, Sonde enteroscopy, wireless capsule
 endoscopy, and intraoperative enteroscopy. In the case
 described here, small bowel follow-through examination
 was nondiagnostic most likely because the jejunal lesion
 was predominantly extramucosal. This case also illustrates
 that in young patients with obscure small intestinal bleeding
 the source is frequently tumors rather than arteriovenous
 malformations. These tumors are problematic because they
 often grow in an extraluminal direction and only cause
 intermittent bleeding if they erode or ulcerate through the
 small bowel mucosa, as occurred in this patient. In a
 situation such as this, a noninvasive test, such as a
 computed tomography scan, may obviate the need for more
 invasive testing.

 
Microscopic view of the parietal tumor and the normal yeyunal mucosa.

 Video Endoscopic Sequence 11 of 86.

 Microscopic view of the parietal tumor and the normal
 yeyunal mucosa.

 
 

 
Fusocelular pattern of tumor.

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 Fusocelular pattern of tumor.

 
IHQ positive for cd117. Low power of cd117 or c-kit, positive at tumor cell and also at the Cajal cells of yeyuno.

Video Endoscopic Sequence 13 of 86.

  IHQ positive for cd117.

Low power of cd117 or c-kit, positive at tumor cell and also at the Cajal cells of yeyuno.

 
A high power of cd117 by IHQ

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A high power of cd117 by IHQ

 High power view of tumor cells positive for c- kit.

 
Patient underwent a laparoscopic termino-terminal bowel resection.

Video Endoscopic Sequence 15 of 86.

Patient underwent a laparoscopic termino-terminal small bowel resection.

 This video sequence shows the laparoscopic steps of this
 surgery.

 The increased use of laparoscopy in the management of
 gastrointestinal problems continues to expand. Procedures
 such as jejunostomies, diagnosis of intestinal obstruction or
 ischemia, resection of the small bowel, and lysis of
 adhesions can be managed with this technique.

Video Endoscopic Sequence 16 of 86.

 Laparoscopic resection was planned after the abdominal
 distension subsided. Pneumoperitoneum was established
 with a Veress needle. A 5mm trocar was introduced in the
 umbilical incision; a 5mm (0°) telescope was introduced and
 the other two 5mm ports were inserted under vision – one
 in the right midclavicular line and the other in the left
 midclavicular line, below the level of the umbilicus.

 
For many GI malignancies, laparoscopic surgery is safe and technically feasible, albeit with a somewhat longer learning curve compared to open surgery. Advanced procedures are technically demanding and require more operative time.

Video Endoscopic Sequence 17 of 86.

 For many GI malignancies, laparoscopic surgery is safe
 and technically feasible, albeit with a somewhat longer
 learning curve compared to open surgery. Advanced
 procedures are technically demanding and require more
 operative time.

 
GistLaparoscope4

Video Endoscopic Sequence 18 of 86.

Laparoscopic resection of small bowel gastrointestinal stromal tumor.

 Surgery remains the standard for nonmetastatic
 gastrointestinal stromal tumors (GISTs). Laparoscopic
 surgery should be considered for these tumors as their
 biologic behavior lends them to curative resection without
 requiring large margins or extensive lymphadenectomies.

                                      Pubmed

This laparoscopic view shows the tumor of the jejuno. Morbidity following laparoscopic staging remains low, and major complications (eg, hemorrhage, visceral perforation, intra-abdominal infection, and shock) occur in less than 2% of cases. Minor complications such as wound infection, port herniation, or urinary retention are also uncommon. At our institution, minor complications have been noted in 1% of these patients.

Video Endoscopic Sequence 19 of 86.

This laparoscopic view shows the tumor of the jejuno.

 Morbidity following laparoscopic staging remains low, and
 major complications (eg, hemorrhage, visceral perforation,
 intra-abdominal infection, and shock) occur in less than 2%
 of cases. Minor complications such as wound infection, port
 herniation, or urinary retention are also uncommon. At our
 institution, minor complications have been noted in 1% of
 these patients.

 
Stromal tumors and lipomas frequently cannot be removed via endoscopy because of their deep intramural location and the subsequent elevated risk of bowel perforation during attempted removal.

Video Endoscopic Sequence 20 of 86.

 Stromal tumors and lipomas frequently cannot be removed
 via endoscopy because of their deep intramural location
 and the subsequent elevated risk of bowel perforation
 during attempted removal.

 
GistLaparoscope7

Video Endoscopic Sequence 21 of 86.

 Gut stromal tumors are the most common symptomatic
 small bowel lesions. They have been found in all areas of
 the small bowel, including within the Meckel diverticulum.

 
Current literature confirms an excellent prognosis for tumors resected prior to tumor perforation or onset of massive GI hemorrhage.

Video Endoscopic Sequence 22 of 86.

 Current literature confirms an excellent prognosis for
 tumors resected prior to tumor perforation or onset of
 massive GI hemorrhage.
Recently, several reports of laparoscopic resections have been published in the literature and seem to be advantageous over laparotomy .

Video Endoscopic Sequence 23 of 86.

 Recently, several reports of laparoscopic resections have
 been published in the literature and seem to be
 advantageous over laparotomy.

 
Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs). Laparoscopic surgery should be considered for these tumors as their biologic behavior lends them to curative resection without requiring large margins or extensive lymphadenectomies.

Video Endoscopic Sequence 24 of 86.

 Surgery remains the standard for nonmetastatic
 gastrointestinal stromal tumors (GISTs). Laparoscopic
 surgery should be considered for these tumors as their
 biologic behavior lends them to curative resection without
 requiring large margins or extensive lymphadenectomies.

Anastomosis was done using a (60mm cartridge) stapler by introducing the 2 limbs in the enterotomy openings. The common opening was closed by another 60mm stapler. The bowel was returned to the abdomen. The incisions were closed. The patient had an uneventful postoperative period. He was discharged on the 5th postoperative day.

Video Endoscopic Sequence 25 of 86.

 Anastomosis was done using a (60mm cartridge) stapler by
 introducing the 2 limbs in the enterotomy openings. The
 common opening was closed by another 60mm stapler. The
 bowel was returned to the abdomen. The incisions were
 closed. The patient had an uneventful postoperative period.
 He was discharged on the 5th postoperative day.

 
Gastrointestinal stromal tumors (GISTs) are rare. Nevertheless, some may present with a life-threatening hemorrhage or intestinal obstruction.

Video Endoscopic Sequence 26 of 86.

 Gastrointestinal stromal tumors (GISTs) are rare.
 Nevertheless, some may present with a life-threatening
 hemorrhage or intestinal obstruction.

 
Stapled laparoscopic resection is a safe and effective treatment option for nonmetastatic primary gastric GIST.

Video Endoscopic Sequence 27 of 86.

 Intraoperative video clip showing the linear stampler
 applied to the bowel. 

 Stapled laparoscopic resection is a safe and effective
 treatment option for nonmetastatic primary jejunal GIST.

 
A laparoscopic approach to surgical resection of jejunal GIST is associated with low morbidity and short hospitalization. As found in historical series of open operative resection, the tumor mitotic index predicts local recurrence. The long-term disease-free survival of 92%..

Video Endoscopic Sequence 28 of 86.

 A laparoscopic approach to surgical resection of jejunal
 GIST is associated with low morbidity and short
 hospitalization. As found in historical series of open
 operative resection, the tumor mitotic index predicts local
 recurrence. The long-term disease-free survival of 92%.

 
GistLaparoscope15

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GistLaparoscope17

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Laparoscopic resections with intracorporeal anastamoses.

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Laparoscopic resections with intracorporeal anastamoses.

 
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The long-term disease-free survival of 92% in some series establishes laparoscopic local and segmental resection as safe and effective in treating jejunal GISTs. Given this degree of efficacy and the advantages afforded by minimally invasive surgery, a laparoscopic approach may be the preferred resection technique.

Video Endoscopic Sequence 83 of 86.

 The long-term disease-free survival of 92% in some series
 establishes laparoscopic local and segmental resection as
 safe and effective in treating jejunal GISTs. Given this
 degree of efficacy and the advantages afforded by
 minimally invasive surgery, a laparoscopic approach may
 be the preferred resection technique.

 
In light of their biologic behavior, GISTs should be considered for laparoscopic resection. This minimally invasive approach to these tumors can be performed safely and reliably.

Video Endoscopic Sequence 84 of 86.

 In light of their biologic behavior, GISTs should be
 considered for laparoscopic resection. This minimally
 invasive approach to these tumors can be performed safely
 and reliably.

 
In light of their biologic behavior, GISTs should be considered for laparoscopic resection. This minimally invasive approach to these tumors can be performed safely and reliably.

Video Endoscopic Sequence 85 of 86.

 In light of their biologic behavior, GISTs should be
 considered for laparoscopic resection. This minimally
 invasive approach to these tumors can be performed safely
 and reliably.

 
The small bowel tumour that was revealed by enteroscopy was successfully resected laparoscopically. Long-term follow up is essential for all patients with GISTs independent of a benign or malignant designation since these tumors have an uncertain biologic behavior. While an active postoperative surveillance program is important, there is no consensus on a standard protocol for following patients.

Video Endoscopic Sequence 86 of 86.

 The small bowel tumour that was revealed by enteroscopy
 was successfully resected laparoscopically.

 Long-term follow up is essential for all patients with GISTs
 independent of a benign or malignant designation since
 these tumors have an uncertain biologic behavior. While an
 active postoperative surveillance program is important,
 there is no consensus on a standard protocol for following
 patients.

 Gastrointestinal stromal tumors (GISTs) represent a rare
 but distinct histopathologic group of intestinal neoplasms of
 mesenchymal origin. Historically, most of these tumors
 were classified as leiomyomas, leiomyoblastomas, and
 leiomyosarcomas due to the mistaken belief that they were
 of smooth muscle origin. However, with the advent of
 electron microscopy and immunohistochemistry, a
 pleuropotential intestinal pacemaker cell, the interstitial
 cell of Cajal, was identified as the origin of GISTs. These
 cells have myogenic and neurogenic architecture and are
 found within the myenteric plexus, submucosa, and
 muscularis propria of the gastrointestinal (GI) tract. The
 recent discovery and identification of the CD117 antigen, a
 c-kit proto-oncogene product, and CD34, a human
 progenitor cell antigen, in the majority of GIST have led to
 further delineation of the cellular characteristics of these
 neoplasms.