Robotic resection of duodenal adenoma

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

Robotic limited local resection of duodenal juxta-ampullary neoplasms

BACKGROUND

The unique and complex anatomical location of duodenal juxta-ampullary neoplasms complicates selection of the appropriate surgical strategy. For benign or borderline tumours, surgical local resection can be an appropriate treatment option, and robotic surgical systems can help perform minimally invasive local resection of these lesions.

METHODS

Between December 2014 and December 2019, 10 patients who underwent robotic local resections for duodenal juxta-ampullary tumours were reviewed.

RESULTS

All patients successfully underwent robotic local resection of the duodenum, preserving the ampulla of Vater without conversion. The mean tumour size was 2.2 cm. Final pathology consisted of gastrointestinal stromal tumour, neuroendocrine tumour, low grade and high grade dysplasia, ectopic pancreas, and well-differentiated adenocarcinoma (T1a). There were no postoperative complications or recurrences.

CONCLUSION

With accurate preoperative diagnosis and careful selection of patients, local resection of the duodenum for juxta-ampullary benign or borderline tumours using robotic surgical system is an attractive treatment option.

Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010–2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3–21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.

Laparoscopy-assisted full-thickness resection of the duodenum for patients with gastrointestinal stromal tumor with ulceration

INTRODUCTION

Gastrointestinal stromal tumor (GIST) with ulceration may potentially disseminate into the peritoneal cavity after laparoscopic local wedge resection (full-thickness resection) when the intestinal wall is opened under the aeroperitoneum. To prevent this intraoperative tumor seeding, we developed laparoscopy-assisted full-thickness resection (LAFTR) of the duodenum for GIST with ulceration. Here, we present the preliminary results of LAFTR.

METHODS

Three patients with duodenal GIST with ulceration underwent LAFTR. LAFTR consists of four major procedures: (i) a laparoscopic Kocher maneuver (mobilization of the pancreatoduodenum); (ii) the creation of a small upper median laparotomy; (iii) the extracorporeal completion of the full-thickness resection under direct vision; and (iv) extracorporeal hand-sewn closure of the duodenal defect.

RESULTS

LAFTR was successfully performed without any intraoperative adverse events. The mean operating time and estimated blood loss were 182 min and 34 mL, respectively. Postoperative contrast roentgenography showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. None of the patients developed peritoneal recurrence.

CONCLUSIONS

LAFTR can eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracoporeally. Meticulously hand-sewn closures of the duodenal defect can minimize the possibilities of anastomotic insufficiency and deformity. LAFTR is a feasible, safe, and minimally invasive treatment for patients with GIST with ulceration in the first and second portions of the duodenum.

Safety and efficacy of cap-assisted EMR for sporadic nonampullary duodenal adenomas

BACKGROUND AND AIMS

Eradication of sporadic nonampullary duodenal adenomas (SNADAs) is essential because of their high rate of malignant transformation. EMR techniques are the alternative to the traditional surgical treatments of SNADAs. There are very limited data on the safety and efficacy of cap-assisted EMR (C-EMR) in the treatment of SNADA.

METHODS

The medical records of patients who underwent C-EMR for SNADAs between July 2002 and April 2013 were retrospectively reviewed. Eradication was defined as no residual adenoma on follow-up or en bloc resection on pathology. Recurrence was defined as finding adenoma after a negative follow-up.

RESULTS

Fifty-nine C-EMR sessions were performed on 49 SNADAs (flat, 46; sessile, 3); 39 polyps were treated in piecemeal fashion and 10 polyps with en bloc resection. The polyp histology was tubular adenoma (63.3%) and tubulovillous adenoma (36.7%), with 16.3% of lesions showing high-grade dysplasia. Initial eradication rate was 90.5%; residual adenomas were successfully treated with repeat C-EMR/snare, resulting in 100% ultimate eradication rate without any recurrences (median follow-up of 17 months). The overall adverse events rate was 16.9%: intraprocedural bleeding (10.2%), delayed GI bleeding (5.1%), and perforation (1.7%). Among large polyps (≥15 mm), the initial and ultimate eradication rates were 87.9% and 100%, respectively, and the adverse event rate was 17%. Initial eradication rate for small polyps was higher than in large polyps (100% vs 87.9%, respectively; P = .02).

CONCLUSION

C-EMR is a highly efficient and safe method for the treatment of SNADAs. We recommend that endoscopists should learn C-EMR on esophageal, gastric, rectal, or left-sided colonic lesions before attempting C-EMR in the duodenum.

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

AIM: To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors.

METHODS: A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach.

RESULTS: The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described.

CONCLUSION: Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.

Laparoscopy-assisted transduodenal excision of superficial non-ampullary duodenal epithelial tumors

INTRODUCTION

Transduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low-grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy-assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non-ampullary duodenal epithelial tumors.

METHODS

Three patients with superficial non-ampullary duodenal epithelial tumors (mucosal adenocarcinoma, n = 1; tubular adenoma, n = 2) underwent LATDE. LATDE consists of four major procedures: (i) laparoscopic wide Kocher maneuver (mobilization of the pancreaticoduodenum); (ii) extracorporeal approach to the fully mobilized duodenum through the upper median longitudinal incision (4 cm in length); (iii) tumor excision by submucosal dissection under direct vision through longitudinal duodenotomy (4 cm in length); and (iv) hand-sewn closure of the mucosal defect and duodenotomy.

RESULTS

LATDE was successfully carried out without any intraoperative or postoperative adverse events. The mean operating time and estimated blood loss were 155 min and 17 mL, respectively. Contrast roentgenography on postoperative day 4 showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients.

CONCLUSIONS

LATDE could eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracorporeally. The meticulously hand-sewn closures of the mucosal defect and duodenotomy can minimize the possibility of postoperative hemorrhage and/or anastomotic leakage. LATDE is a feasible, safe, and minimally invasive treatment for patients with superficial non-ampullary duodenal epithelial tumors that have no risk of lymph node metastasis in the first and second portions of the duodenum.

Robotic surgery for benign duodenal tumors

INTRODUCTION

Benign duodenal and periampullary tumors are uncommon lesions requiring careful attention to their complex anatomic relationships with the major and minor papillae as well as the gastric outlet during surgical intervention. While endoscopy is less morbid than open resection, many lesions are not amenable to endoscopic removal. Robotic surgery offers technical advantages above traditional laparoscopy, and we demonstrate the safety and feasibility of this approach for a variety of duodenal lesions.

METHODS

We performed a retrospective review of all robotic duodenal resections between April 2010 and December 2013 from two institutions. Demographic, clinicopathologic, and operative details were recorded with special attention to the post-operative course.

RESULTS

Twenty-six patients underwent robotic duodenal resection for a variety of diagnoses. The majority (88 %) were symptomatic at presentation. Nine patients underwent transduodenal ampullectomy, seven patients underwent duodenal resection, six patients underwent transduodenal resection of a mass, and four patients underwent segmental duodenal resection. Median operative time was 4 h with a median estimated blood loss of 50 cm(3) and no conversions to an open operation. The rate of major Clavien-Dindo grades 3-4 complications was 15 % at post-operative days 30 and 90 without mortality. Final pathology demonstrated a median tumor size of 2.9 cm with a final histologic diagnoses of adenoma (n = 13), neuroendocrine tumor (n = 6), gastrointestinal stromal tumor (GIST) (n = 2), lipoma (n = 2), Brunner's gland hamartoma (n = 1), leiomyoma (n = 1), and gangliocytic paraganglioma (n = 1).

CONCLUSION

Robotic duodenal resection is safe and feasible for benign and premalignant duodenal tumors not amenable to endoscopic resection.

Surgical management of superficial non-ampullary duodenal tumors

BACKGROUND AND AIM

We present our experiences with the so-called 'limited resections' such as transduodenal excision and local full-thickness resection for superficial non-ampullary duodenal tumors (SNADT). The optimal surgical management for SNADT is also discussed.

METHODS

Six patients with SNADT (adenoma, n=1; mucosal carcinomas, n=2; submucosal carcinoma, n=1; carcinoids, n=2) were included in this study. Four patients underwent transduodenal excision, one local full-thickness resection, and one laparoscopy-assisted endoscopic full-thickness resection as a modification of local full-thickness resection.

RESULTS

All patients were successfully treated by these limited resections without any adverse events.

CONCLUSIONS

Surgical resection is the treatment of choice for SNADT not amenable to endoscopic resection in terms of technical and/or oncological reasons. However, the optimal surgical management for SNADT remains controversial because of the complexity of the relevant anatomy of the duodenum, its rarity, the not well-known incidence of nodal metastasis, and the wide spectrum of pathologies that can be encountered.

Cap-assisted EMR of large, sporadic, nonampullary duodenal polyps

BACKGROUND

EMR is an effective alternative to surgery for the removal of nonampullary duodenal polyps (NADPs). Cap-assisted EMR (EMR-C) has been rarely performed in the duodenum because of the risk of perforation.

OBJECTIVE

To evaluate the safety and effectiveness of EMR-C for the removal of large (≥ 15 mm) NADPs.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral center.

PATIENTS

Between 2000 and 2010, 26 consecutive patients with sporadic NADPs underwent EMR-C.

INTERVENTION

EMR with the cap technique.

MAIN OUTCOME MEASUREMENTS

Complete eradication of polyps, complications, and recurrence.

RESULTS

A total of 14 sessile polyps (53.8%), 7 lateral spreading type nongranular tumors (26.9%), and 5 lateral spreading type granular tumors (19.2%) were treated. The median size of lesions was 15 mm. Five lesions involved one-half of the luminal circumference. Post-EMR histologic assessment showed low-grade dysplasia in 5 patients (19.2%) and high-grade dysplasia in 18 patients (69.2%). Three patients (11.5%) had well-differentiated endocrine tumors. Complete eradication was obtained in 25 of 26 (96%) patients. No perforations occurred. Three cases of intraprocedural bleeding were managed endoscopically. Median follow-up was 6 years (range 1-10 years). Residual adenomatous tissue was observed in 3 patients in lesions of 50 mm. In one of these cases, an adenocarcinoma occurred after 8 months, which was managed surgically.

LIMITATIONS

Retrospective design, single center.

CONCLUSION

This study supports the efficacy and safety of EMR-C for removing NADPs. Regular follow-up is mandatory because of the high risk of residual or recurrent adenomatous tissue and even cancer.