GIST Specialist for Glendale, CA
Most gastrointestinal stromal tumors grow in the stomach. A small proportion grow in the rectum, where the operation determines whether you keep normal bowel function. Joshua Ellenhorn, MD, FACS is board certified in both General and Colorectal Surgery.
- Board certified in Colorectal Surgery as well as General Surgery
- Clinical Professor of Surgery, Cedars-Sinai Medical Center
- Sphincter preservation planned from the first consultation
- Twenty five to thirty minutes via the 134 and 101
Rectal GIST Is a Different Operation Entirely
For a gastric GIST the surgical question is how much stomach comes out, and the honest answer is usually very little. For a rectal GIST the question is whether you keep your sphincter, and that is a different order of consequence.
The rectum accounts for around five percent of GIST. That rarity cuts against patients twice over. It means few surgeons have operated on one, and it means the tumor is often approached with instincts borrowed from rectal adenocarcinoma, which demands a much wider clearance than a GIST does. GIST seldom involves lymph nodes, so the extensive nodal dissection a rectal cancer requires is generally unnecessary, and applying it can cost function that could have been preserved.
The other thing borrowed instincts miss is timing. Rectal GIST is the site where several months of imatinib before surgery pays the largest dividend, because shrinking the tumor away from the sphincter complex can convert an operation requiring a permanent stoma into one that does not. That option is frequently not raised, and once an abdominoperineal resection has been performed it cannot be undone.
Why the Same Tumor Is Treated Differently Depending on Where It Grows
Site is one of the three variables that grade risk, and it also dictates the operation. These are the broad patterns.
| Site | Share of GIST | What the operation usually involves |
|---|---|---|
| Stomach | About 60% | Wedge resection taking the tumor with a cuff of wall, frequently laparoscopic and often a day case. The most forgiving site |
| Small intestine | About 30% | Removal of a short segment of bowel with reconnection in the same operation. Higher recurrence risk than gastric at equal size |
| Duodenum | About 4 to 5% | Limited resection preserving the pancreas where possible. The alternative, a Whipple procedure, is often more surgery than the tumor requires |
| Rectum | About 5% | Transanal excision for small tumors, low anterior resection for larger. Sphincter preservation is the central objective |
| Esophagus | About 1% | Uncommon and technically demanding, with enucleation possible for smaller tumors |
| Colon | Uncommon | Segmental resection, similar in principle to small bowel disease |
Percentages are approximate and vary between published series. What is consistent is that non-gastric tumors carry higher recurrence risk than gastric tumors of the same size and mitotic count.
Pelvic MRI Is the Study That Decides
A rectal GIST is usually first seen on colonoscopy as a smooth submucosal bulge under intact lining. That finding establishes something is there but almost nothing about what can be done with it.
MRI of the pelvis is what answers the operative question. It defines the distance between the lower edge of the tumor and the sphincter complex, and that measurement, more than anything else, determines whether the sphincter can be preserved. Endorectal ultrasound adds detail on which layers of the wall are involved. A CT of the abdomen completes staging by looking at the liver.
Biopsy matters more here than in the stomach, because if imatinib is going to be used to gain distance from the sphincter, the mutation subtype has to be known first. A tumor that will not respond should go to surgery without losing months finding out, and one that will respond may be worth waiting for.
Designing Around Function
For rectal GIST the goal is complete removal and preserved continence. Those are usually compatible if the sequence is right.
Transanal Excision
A tumor low in the rectum and small enough can be removed through the anus with no abdominal incision and no effect on continence. Complete removal with an intact capsule is still the standard.
Imatinib First
Several months of targeted therapy can shrink a tumor away from the sphincter, converting a stoma operation into a sphincter sparing one. This is the option most often missed and the one worth asking about explicitly.
Low Anterior Resection
Removal of the affected segment with reconnection, preserving the sphincter. Because GIST rarely involves lymph nodes, the wide nodal clearance a rectal cancer demands is generally unnecessary, which helps preserve function.
The Operations, on Record
Published recordings of real GIST resections narrated by the surgeon who performed them. The technical care visible in these is the same care a rectal case requires.
Laparoscopic Resection of a Gastric GIST
A gastric GIST removed through small incisions with the capsule kept intact.
Gastric GIST Resection: A Simplified Approach
A refined approach that shortens operating time and recovery.
Robotic Resection of a Duodenal GIST
Duodenal GIST removed robotically with the pancreas and bile duct preserved, in anatomy as confined as the pelvis.
Has Imatinib First Been Considered?
If a permanent stoma has been proposed for a rectal GIST, this is the question to ask before agreeing to anything. Shrinking the tumor away from the sphincter first is established practice, and the decision cannot be revisited afterwards.
Two Board Certifications, Both Relevant Here
General Surgery and Colorectal Surgery, a Cedars-Sinai teaching appointment, and membership of the societies that publish the guidelines for this disease.
- American Board of Surgery, certified in General Surgery
- American Board of Surgery, certified in Colorectal Surgery
- California State Medical License
- Florida State Medical License
Joshua Ellenhorn, MD, FACS
Dr. Ellenhorn is a surgical oncologist and Clinical Professor of Surgery at Cedars-Sinai Medical Center, and a collaborative member of the Samuel Oschin Comprehensive Cancer Institute.
For rectal disease the second board certification is the material one. He is certified by the American Board of Surgery in Colorectal Surgery as well as General Surgery, and rectal work is a discipline of its own: low pelvic dissection, transanal technique, and the judgment behind sphincter preservation are not general surgical skills. A rectal GIST sits precisely at the intersection of that training and a practice built around one rare tumor.
He is a Fellow of the American College of Surgeons and a member of the Society of Surgical Oncology and the American Society of Clinical Oncology. He practises with the Surgery Group of Los Angeles.
What Patients Say
Reviews left by patients treated by Dr. Ellenhorn at the Surgery Group of Los Angeles.
★★★★★The staff at the Surgery Group of Los Angeles are wonderful. They are kind, very attentive, the office is clean and I did not have to wait long at all. I cannot say enough great things about Dr. Ellenhorn. He is an excellent surgeon who is highly skilled and very knowledgeable. I cannot thank him enough for all he has done for my family and I.
Erika Frank
★★★★★Very kind stuff, great service. Dr Joshua Ellenhorn is a very calm doctor who takes time with his patient.
Anita Lukacevic
Half an Hour From Glendale
The 134 west to the 101, south through the Cahuenga Pass, then Highland down and west along 3rd Street. From the southern end of Glendale and the Atwater side, the 2 down to the 101 is frequently quicker. From Montrose and the northern foothills, allow a little longer at peak.
The office is in the medical plaza attached to Cedars-Sinai Medical Center. For rectal cases in particular this consolidation is useful, because pelvic MRI, pathology review, and the operation itself happen in one place rather than across separate institutions with separate imaging systems.
Patients travelling from outside the region, including Arizona and Nevada, can have imaging and pathology reviewed remotely before deciding whether to travel.
8635 W 3rd St, Suite 880W
Los Angeles, CA 90048
Monday to Saturday, 11:00am to 8:00pm
Closed Sunday
Frequently Asked Questions
GIST in the rectum sounds unusual. How common is it?
Will I need a permanent stoma?
How can medication help me keep my sphincter?
Is rectal GIST more dangerous than gastric GIST?
What does a colorectal board certification add here?
How is a rectal GIST diagnosed?
How far is your office from Glendale?
Will my Glendale gastroenterologist stay involved?
A Rectal GIST Does Not Have to Mean a Stoma.
If a permanent stoma has been proposed, have the pelvic MRI and mutation status reviewed first. Shrinking the tumor away from the sphincter is established practice and it changes what the operation has to take.
