Laparoscopic resection of a periampullary villous adenoma

Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature

BACKGROUND

Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.

CASE SUMMARY

A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.

CONCLUSION

Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.

Robotic transduodenal ampullectomy: Case report and review of the literature

Ampullary neoplasms are relatively uncommon lesions with a risk of progression to malignancy. Depending on its nature, size and location, it may be best treated with endoscopic papillotomy, pancreaticoduodenectomy or transduodenal ampullectomy. Transduodenal ampullectomy offers a higher chance of complete resection compared to endoscopic papillotomy, and carries lower morbidity than a pancreaticoduodenectomy, making it the ideal choice for localised ampullary tumour not involving the ducts but not amenable to complete endoscopic resection. While traditionally performed via open surgery, it has been attempted via laparoscopic approach and more recently robotic approach. We present a case of a 63-year-old man who underwent a robotic transduodenal ampullectomy for ampullary adenoma with high grade dysplasia, and review the literature surrounding robotic transduodenal ampullectomy.

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.

Robotic transduodenal ampullectomy: A novel minimally invasive approach for ampullary neoplasms

BACKGROUND

The adoption of minimally invasive surgery for transduodenal ampullectomy has been slow because of special characteristics and complexity of this procedure.

METHODS

Six patients underwent robotic transduodenal ampullectomy. We employed novel methods to facilitate exposure of the ampulla.

RESULTS

All patients completed robotic transduodenal ampullectomy, but one patient was immediately converted to robotic pancreaticoduodenectomy because of presence of invasive carcinoma on frozen biopsy. The final pathologic report revealed high-grade dysplasia in four patients, low-grade dyplasia in one, and T2N0 in one patient who converted to pancreaticoduodenectomy. There was no immediate postoperative complication or mortality. One patient was readmitted after 3 months because of stricture of the bile duct outlet. There was no recurrence over a median follow-up period of 20 months.

CONCLUSION

An appropriate combination of patient positioning and retraction method helps the robot surgical system to provide competent performance for sophisticated and precise manipulation of ampullary lesions.

Robotic transduodenal excision of ampullary tumour

Ampullary tumours are uncommon lesions with potential risk of malignancy. The management is excision by either endoscopic ampullectomy, pancreaticoduodenectomy or transduodenal excision. Endoscopic ampullectomy offers a less invasive approach, whereas pancreaticoduodenectomy allows radical excision of the tumour. They both carry their own limitations. Transduodenal excision of ampullary tumour offers significantly lower risks with low recurrence rate, and can be offered for benign or early grade tumours. Limited cases of laparoscopic transduodenal excision of ampullary tumours were reported in the literature, probably due to the technical difficulties in performing the operation, especially during the reconstruction of the pancreaticobiliary ducts with the laparoscopic approach. In the era with robotic surgical systems, the technical demanding procedures are greatly facilitated. Hence, we are writing to report a case of transduodenal excision of ampullary tumour with the robot assisted laparoscopic approach.

Laparoscopic partial resection for hemangioma in the third portion of the duodenum

Benign duodenal tumors are rare and less common than malignant tumors. Furthermore, vascular lesions of the duodenum, including hemangiomas, are rare causes of gastrointestinal bleeding. This report describes a case with bleeding hemangiomas in the third portion of the duodenum and jejunum and their successful treatment using a laparoscopic approach. There is no report of totally laparoscopic resection for tumor in the third portion of duodenum. After performing a laparoscopic Kocher maneuver, the location of the duodenal hemangioma was confirmed by endoscopic and laparoscopic observation. The lesion was excised using ultrasonic coagulating shears and the defect in the duodenal wall was sutured laparoscopically. The hemangioma of the jejunum was treated extracorporeally through a 3.0 cm umbilical incision. The operating time was 241 min and blood loss was negligible. The postoperative course was uneventful. For benign duodenal tumors in the third portion, if endoscopic resection is not adapted, this less invasive technique may be a standard treatment.

Laparoscopic transduodenal local resection of periampullary neuroendocrine tumor: A case report

Studies on laparoscopic transduodenal local resection have not been readily available. Only three cases have been reported in the English-language literature. We describe herein a case of 25-year-old woman with periampullary neuroendocrine tumor (NET). Endoscopic ultrasonography revealed a duodenal papilla mass originated from the submucosa and close to the ampulla. The periampullary tumor was successfully managed with laparoscopic transduodenal local resection without any procedure-related complications. Pathological examination showed a NET (Grade 2) with negative margin. The patient was followed up for six months without signs of recurrence. This case suggests that laparoscopic transduodenal local resection is a feasible procedure in selected patients with periampullary tumor.

Ampullary adenoma

Ampullary adenoma is a premalignant lesion involving the major papilla and surrounding mucosa of the second duodenum. These lesions may arise sporadically or in the setting of familial adenomatous polyposis syndrome. Ampullary adenoma may be found because of symptoms, at the time of adenomatous polyposis syndrome surveillance, or incidentally when upper endoscopy is performed for other reasons. Management options include observation, local or extended surgical resection (including pancreaticoduodenectomy), and endoscopic resection. Endoscopic resection is being performed more often and involves techniques similar to those of colonoscopic polypectomy. Preventing post-endoscopic resection pancreatitis is important and can be achieved with placement of temporary pancreatic duct stents.

Robotic resection of duodenal adenoma

BACKGROUND

Duodenal sporadic adenomatous polyps are rare findings during upper endoscopy. Resection is indicated due to their malignant potential.

METHODS

A 55 year-old male patient was diagnosed with a 3 cm duodenal adenomatous polyp with low-grade dysplasia, which could not be safely resected by endoscopy. A transduodenal submucosal robotic-assisted polypectomy was performed.

RESULTS

The operative time was 4.5 h, with an estimated blood loss of 200 ml. The patient had a normal bowel transit on postoperative day 3 and he was discharged on postoperative day 7. Three months follow-up was uneventful. The final histological finding revealed a completely resected duodenal adenomatous polyp without signs of malignancy.

CONCLUSION

Robotic-assisted resection of duodenal polyps is a feasible technique that may be indicated for the local excision of duodenal lesions that cannot be endoscopically resected. Compared to the open and laparoscopic approach, it offers many technical advantages.