Laparoscopic intragastric resection of melanoma cardial lesion

Background: Gastrointestinal tract involvements of metastatic melanoma are rare; 7% of gastrointestinal tractmetastases of melanoma concerns the stomach [1]. Actually, bleeding from gastric melanoma metastasis is veryrare. For the first time in Literature, this video shows a laparoscopic intragastric resection [2] of a cardial lesionof melanoma. A 64-year old patient with history of a skin melanoma resection with lung and liver metastaticdisease confirmed by FDG PET, stable after repeated cycles of Pembrolizumab, presented anemia with gastro-intestinal 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 bloodtransfusions because Jehovah's Witness. Since the tumor position so close to the cardias contraindicated bothtypical endoscopic and laparoscopic approaches, we proposed laparoscopic intragastric solution in order toavoid risk related to a total gastrectomy.Methods: Procedure was performed by 3 intragastric trocars placed under endoscopic view. The primary surgicalintent was to excise the tumor in order to avoid further bleeding. Actually, during dissection we verified thepossibility to radically resect the lesion. After removal (with partial fragmentation) of the lesion, residual freefragments have been accurately removed to reduce the risks of tumor implantation on gastric mucosa and amucosal suture was completed. Two-layer running sutures were applied on gastric holes. After completion ofprocedure, suture and cardial gastric wall were tested for leakage with satisfying result. Finally, lesser sac wasopened 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 R0resection was achieved.Conclusions: In the general strategy of a palliation treatment of a largely metastastic tumor, the specific aim ofthis procedure was to stop gastric bleeding and to allow the continuation of systemic therapies effective in thedisease control. After 6 months from surgery, patient resumed chemotherapy without any documented gastricrecurrence