Robotic surgery for benign duodenal tumors

The Characteristics and Treatment Outcomes of 71 Duodenal Brunner's Gland Adenomas with Endoscopic Submucosal Dissection

INTRODUCTION

The aim of this study was to investigate outcomes of patients with duodenal Brunner's gland adenomas (BGAs) that were treated endoscopically.

METHODS

We identified 71 consecutive patients treated at our center with endoscopic submucosal dissection (ESD) for their duodenal tumors diagnosed pathologically as BGAs over the period between January 1, 2011 and December 31, 2021. We retrospectively analyzed our experience and short- and long-term outcomes of ESD therapy on patients with BGAs.

RESULTS

Among 71 BGA patients with an average age of 57 ± 11.7 years (range: 30-82), 48 (67.6%) were male and 23 (32.4%) were female. The accuracy of preoperative diagnosis with endoscopic ultrasonography was 44.0% (22/50). The H. pylori infection was found in 29 patients (29/71, 40.8%). The median size of BGAs was 1.5 cm (interquartile range [IQR] 0.8-2.7 cm). The most common location was the duodenum bulb (50/71, 64.8%). For the ESD procedure, the median operation time was 15.0 min (IQR 9.5-25.5 min). The en bloc and the complete resection rates were 97.2% and 92.3%, respectively. ESD-related mild acute obstructive pancreatitis was present in 2 patients (2/4, 50%) with BGAs located in the ampulla region. During the follow-up period, 1 patient with a positive peripheral margin experienced tumor recurrence 2 years after the initial ESD. There was no disease-related death for the cohort.

CONCLUSION

ESD was an effective and safe therapeutic option for BGA patients with excellent outcomes. Long-term follow-up is needed.

Robot-assisted distal gastrectomy for duodenal gastrointestinal stromal tumors adhering to the pancreas: a case report

Duodenal gastrointestinal stromal tumors (D-GISTs) are uncommon and account for 3-5% of all GISTs. Currently, no established surgical strategy for D-GISTs exists, which mostly depends on tumor size, relation to the ampulla and invasion of the adjacent organ. We report a case of large D-GIST resected by robotic distal gastrectomy. A 62-year-old woman was diagnosed with a 5-cm D-GIST located at posterior wall of the duodenal bulb. Computed tomography findings indicated possible tumor invasion of the pancreas head. Robot-assisted distal gastrectomy was firstly planned and pancreatoduodenectomy was also considered when the tumor was invading to the pancreas. Although tumor was tightly adherent to the pancreas, it could be dissected from the pancreatic head without capsule damage and resected by robotic distal gastrectomy with no postoperative complication. The large D-GIST tightly adherent to the pancreas could be resected by efficiency of the robotic surgery.

Laparoscopic Transduodenal Ampullectomy: How We Have Standardized the Technique (with Video)

BACKGROUND

The procedure of choice for the resection of ampullary tumors comprises transduodenal ampullectomy (TDA), endoscopic papillectomy (EP), and pancreaticoduodenectomy (PD).¹ For neoplasms with low-grade dysplasia, TDA and EP have equivalent efficacies and lower morbidities than PD¹. Compared with EP, also as an organ-preserving procedure, TDA could be applicable for tumors involving the pancreatic ducts or common bile ducts.² Because TDA has a lower incidence of postoperative gastrointestinal bleeding and a higher R0 resection rate, its use could avoid the need to use multiple endoscopic procedures for larger lesions.³ Furthermore, during TDA, surgeons could convert to PD as necessary. However, TDA has rarely been performed using a minimally invasive approach that addresses the shortcomings of both the endoscopic and open surgical techniques without adding significant morbidity or compromising outcomes.^2,4 Conventional laparoscopic TDA (LTDA) remains limited due to the complexity of the surgical anatomy of the ampulla and the reconstruction required compared with robot-assisted procedures.^2-5 However, robot-assisted surgery is less popular and much more expensive than laparoscopic surgery. This report with a video describes the LTDA approach to standardize and simplify the surgical processes.

METHODS

A 48-year-old man was admitted to the hospital with epigastric pain. He had a history of cholecystolithiasis with chronic cholecystitis. A tumor approximately 2.2 cm in diameter located in the duodenal papilla was diagnosed by an enhanced computed tomography (CT) scan. The endoscopic biopsy result indicated a villous adenoma with moderate dysplasia. Laparoscopic TDA and cholecystectomy were planned. However, if the frozen sample analysis showed adenocarcinoma, laparoscopic PD (LPD) would be applied. The patient was placed in the supine position with both legs apart. Trocars were distributed in the same manner as in the authors' previous study to facilitate conversion to LPD.⁶ The procedure began with kocherization and dissection of the gastrocolic ligament to explore the second and third portions of the duodenum. A figure-eight suture was made using 4-0 prolene in the seromuscular layer, and then the duodenum was retracted to the left side of the patient. A longitudinal duodenotomy was made, and the ampulla of Vater was identified. A transfixing suture was placed through the tumor. Submucosal injection of norepinephrine (1:500) was performed to divide the mucosa from the muscular planes. Ampullectomy was performed by first dissecting in the submucosal plane with a harmonic scalpel at the 6 o'clock position until the pancreatic duct was reached. A 6-Fr plastic catheter was inserted into the pancreatic duct for subsequent reconstruction. Continued dissection around the tumor identified the bile duct. Another 6-Fr plastic catheter was inserted into the bile duct. The dissection was completed in the submucosal plane, and the specimen was retrieved for frozen sectioning. After confirmation of villous adenoma with moderate dysplasia and the proximal margin without residual tumor on frozen biopsy, reconstruction was performed. The septum between the ducts was plastered, and the bile and pancreatic ducts were reconstructed on the duodenal wall with 5-0 PDS-II interrupted sutures to ensure that these ducts remained patent and connected. After reconstruction, the plastic catheter was kept in the pancreatic duct but removed from the bile duct. Then, cholecystectomy was applied. Finally, the duodenum was closed obliquely in two layers, and two drains were routinely placed.

RESULTS

The operation time was 139 min, and the estimated blood loss was 50 ml. Final pathology confirmed villous adenoma with mild to moderate dysplasia. The postoperative course was uneventful, with a hospital stay of 9 days. There was no evidence of recurrence or patency of the reimplanted ducts 5 months after surgery. From February 2022 to May 2022, four cases of LTDA with the same surgical processes were managed by the authors, and all the patients recovered quickly without any postoperative complications.

CONCLUSION

After standardization of the surgical processes, laparoscopic TDA was safe for highly selected patients. However, long-term follow-up is required to observe the quality of life and survival of patients.

Survival comparison between endoscopic and surgical resection for non-ampullary duodenal neuroendocrine tumor (1-2 cm)

The treatment plan for non-ampullary duodenal neuroendocrine tumors (d-NETs) with diameters 1-2 cm remains controversial. We therefore aimed to compare the prognostic effects of endoscopic treatment and surgical resection on non-ampullary d-NETs with 1-2 cm diameters. A total of 373 eligible patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to match patients 1:1 according to clinicopathological characteristics. Disease-specific survival (DSS) and overall survival (OS) were calculated. Before PSM, there was no significant difference in DSS or OS (all P > 0.05), but the T stage, N stage, and TNM stage were significantly different between the two surgical methods (all P < 0.05). After 1:1 PSM, the differences in clinicopathological characteristics were significantly reduced (all P > 0.05). Survival analysis showed that tumor grade was correlated with DSS and that age was correlated with OS (all P < 0.05); however, the surgical method and other clinicopathological characteristics were not correlated with prognosis (all P > 0.05). Subgroup survival analysis of patients with T2N0M0 disease and tumors invading the lamina propria or submucosa showed that the 5-year DSS and OS rates were not significantly different according to the surgical approach (all P > 0.05). The surgical approach has no significant effect on the prognosis of patients with non-ampullary d-NETs with 1-2 cm diameters, especially those with T2N0M0 disease. This suggests that endoscopic treatment may be a preferred option for these patients.

Which one will you choose; open, laparoscopic, or robotic transduodenal ampullectomy?: a case report

Transduodenal ampullectomy (TDA) is the treatment of choice for large premalignant lesions of the ampulla of Vater (AoV). With the development of surgical techniques, various methods, including the open, laparoscopic, and robotic approaches, for performing TDA have emerged. Herein, we report four consecutive cases treated with open, laparoscopic, and robotic TDA, with technical pitfalls and future perspectives of TDA in treating premalignant lesions of the AoV. The surgical techniques and principles for TDA were the same regardless of the surgical approaches. After surgery, none of the patients showed any abnormal findings or complications, except for digestive problems. All these surgical approaches are appropriate for patients requiring TDA; however, minimally invasive TDA, particularly the robotic approach is ideal. Considering the surgical complexity of TDA, the robotic approach is considered to be effective.

Transduodenal resection of periampullary neuroendocrine tumor: A case report

Introduction and importance

Periampullary tumors are characterized as tumors that emerge nearby to the major papilla in the duodenum. They are rare lesions with an incidence rate of 0.4–0.48 per 100,000. Neuroendocrine tumors (NETs) constitute only 3% of all duodenal tumors. Their proximity to the major and minor papillae along with the gastric outlet raises a surgical challenge.

Case presentation

Our patient is a 40-year-old, male, medically free. He presented with history of a testicular mass. A CT scan of the abdomen and pelvis was done and showed a large retroperitoneal lymph node. A biopsy of the epididymal mass showed no evidence of malignancy. Excision of the left para-aortic mass revealed a metastatic lymph node of a well-differentiated neuroendocrine tumor. Further evaluation by gallium-68 PET-CT scan showed a periampullary neuroendocrine tumor. The decision to operate was concluded in a multidisciplinary team meeting, and intraoperatively the duodenum showed a well-defined mass between the first and second part of the duodenum which was excised via a trans-duodenal submucosal approach. A frozen section confirmed a negative margin. The final histopathology report showed a grade 2 metastatic well-differentiated neuroendocrine tumor. The latest follow-up was 3 years post-op via fluorine-18 fluorodeoxyglucose PET-CT and it showed no FDG avid disease at the duodenum or pancreases with no FDG avid lymphadenopathy or distant metastasis.

Conclusion

Periampullary tumors that fall under certain parameters could be resected via transduodenal local resection. This procedure yields equivalent results to more invasive surgeries, such as a Whipple's procedure, with less morbidity.

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Ampullary neuroendocrine tumors (NETs) are rare in compare to duodenal NETs, as they are highly metastatic and aggressive regardless of the size.

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These tumors present a diagnostic challenge in addition to being a topic of contention regarding surgical resection options.

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The controversy resides in main surgical options; the first being a pancreaticoduodenectomy (PD), and the second is a transduodenal local resection.

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Certain conditions must be met to achieve a satisfactory outcome for transduodenal local resection in case of periampullary NETs.

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For patients who have met the criteria, transduodenal local resection is believed to be a less invasive, safe, and useful alternative for PD.

Favorable long-term outcomes of endoscopic resection for nonampullary duodenal neuroendocrine tumor

BACKGROUND AND AIM

The long-term outcomes of endoscopic resection for nonampullary duodenal neuroendocrine tumors are limited. We aimed to clarify it.

METHODS

Consecutive patients with nonampullary duodenal neuroendocrine tumors endoscopically treated at our institute between January 2005 and June 2020 were included in this retrospective study. En bloc and R0 resection rates and adverse events were evaluated as short-term outcomes of endoscopic resection. The 5-year overall and recurrence-free survival rates of patients after endoscopic resection were calculated as long-term outcomes.

RESULTS

Of 34 patients with 34 lesions, 33 patients (97%) underwent endoscopic mucosal resection, and one (3%) underwent endoscopic submucosal dissection. En bloc resection was achieved in 33 lesions (97%). R0 resection was achieved in 20 lesions (59%). The median tumor size was 6 mm (range: 3-13). Thirty-one lesions (91%) and three lesions (9%) were classified as G1 and G2, respectively. Lymphovascular invasion was observed in six lesions (18%). Intraprocedural perforation occurred in four patients (12%) who were conservatively treated with endoscopic closure. All 34 patients were followed up without additional treatment after endoscopic resection, and no recurrence or metastasis developed during the median follow-up period of 47.9 months (range: 9.0-187.1). The 5-year overall survival and recurrence-free survival rates were 87.1% and 100%, respectively.

CONCLUSIONS

Endoscopic resection provided a favorable long-term prognosis for patients with nonampullary duodenal neuroendocrine tumors without lymph node metastasis.

Feasible laparoscopic distal pancreatectomy for pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumor (PNET) cases are increasing; however, the treatment indication and procedure remain unestablished. The present study evaluated the indication, feasibility and safety of laparoscopic distal pancreatectomy (LDP) with our technique for PNET. A total of 13 patients with insulinoma and nonfunctional PNET <2 cm in diameter who underwent LDP and 13 patients with any size of PNET who underwent open distal pancreatectomy (ODP) between October 2009 and June 2019 were retrospectively reviewed and compared. The median age of patients was 45 (33-61) years, and 14 (54%) patients were male. The median follow-up periods were 70 months for the LDP group and 46 months for the ODP group. The tumor diameter of the patients who underwent LDP for PNET was 18±9 mm compared with 37±25 mm for those who underwent ODP. The operation time, estimated blood loss, and complication were 290.2±115 vs. 337±131 min (P=0.338), 122±172 vs. 649±693 ml (P=0.019) and 31 vs. 54% (P=0.234), respectively. Pancreatic fistula developed in 8% of patients who underwent LDP compared with 31% who underwent ODP (P=0.131). Notably, the postoperative hospitalization period was significantly shorter in the LDP group (11±7 vs. 21±13 days; P=0.022). Tumor grade of 2017 World Health Organization classification (G1/G2/G3/NEC/unknown) was 9/2/0/0/2 for the LDP group compared with 5/5/0/3/0 for the ODP group. Furthermore, lymph node metastasis was detected in only 1 patient who underwent ODP, for whom the maximum tumor diameter was 70 mm and was classified as G2. In addition, 2 patients in the ODP group developed postoperative lung and liver metastases. LDP for PNETs of <2 cm in selected patients can be safely performed; however, the extent of lymph node dissection needs to be clarified.

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 Resection of Giant Duodenal Hamartoma After 18Fluorodeoxyglucose Positron Emission Tomography Magnetic Resonance Imaging (18FDG PET-MRI)

Brunner's gland hamartoma is a rare duodenal lesion. Resection for benign neoplasms of the duodenum should be considered in case of malignant potential or in case of symptomatic lesions. An accurate preoperative staging is mandatory in order to allow minimally invasive surgical approach, and to avoid under- or overtreatment. Endoscopic ultrasonography (EUS), Computed tomography (CT) scan, Magnetic Resonance Imaging (MRI) and PET/CT are techniques widely used for gastrointestinal tumor staging. We report a case of a 41-year-old female presenting a giant lesion of the second portion of the duodenum. Pathological examination of multiple forceps biopsies was inconclusive for histological characterization of the lesion. After a clinical staging including Esophagusgastroduodenoscopy, EUS, and CT scan, a Hybrid ¹⁸FDG PET/MRI was performed to assess the malignant potential of the lesion and the relation between polyp base and Vater's papilla. After multidisciplinary meeting, the patient underwent robotic transduodenal excision. The post-operative course was uneventful, and the patient was discharged on post-operative day 5. Final pathologic report consists in a histologically of Brunner's Glands Hamartoma. This is the first report on the role of ¹⁸FDG PET/MRI in staging and planning treatment of bulky low malignant duodenal lesion. An accurate staging with ¹⁸FDG PET/MRI could be very useful in the planning the management of duodenal lesion with uncertain malignant potential in order to avoid under- and overtreatment.

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.

Protruded duodenal tumor arising from Santorini's duct of the pancreas: a rare case of intraductal papillary mucinous neoplasm mimicking a duodenal polypoid tumor

Background

We experienced a rare case of intraductal papillary mucinous neoplasm arising from Santorini’s duct (SD) forming a tumor protruding into the duodenum .

Case presentation

A 71-year-old woman was incidentally diagnosed with a 3 cm type Isp polypoid tumor in the second portion of the duodenum at another hospital. Enhanced CT and endoscopic ultrasound revealed that the origin of this protruding tumor was arising from SD and that the tumor mimicked a pedunculated duodenal tumor. Our preoperative diagnosis was a malignant pancreatic tumor arising from SD with invasion into the duodenum. She underwent a subtotal stomach-preserving pancreaticoduodenectomy, and the resected specimen showed a 25 mm tumor protruding into the duodenum with a villous surface. The pathological findings revealed that the tumor was intraductal papillary mucinous adenoma (IPMA) arising from SD.

Conclusions

To the best of our knowledge, this is the first case of IPMA protruding into the duodenal lumen from SD, although most of the tumors arising from SD have been reported to be malignant.

Robotic Treatment for Large Duodenal Gastrointestinal Stromal Tumor

BACKGROUND

Duodenal gastrointestinal stromal tumors (D-GISTs) represent a rare entity.1 Surgery is the primary treatment choice for localized or potentially resectable D-GISTs. The main principle is the complete excision of the lesion with microscopically negative margins, without performing lymph node dissection.2 Nevertheless, the best surgical choice is still controversial since the strategy depends not only on the tumor size but also on its anatomic location.3^,4 As a result, surgical management ranges from a major resection such as pancreaticoduodenectomy to more conservative procedures.5-8 This video presents a duodenal sparing robotic resection of a large GIST of the second-third duodenal portion.

METHODS

A 49-year-old healthy female complained episodes of melena. Endoscopy with endoscopic ultrasound identified a 6-cm lesion of the second-third portion of the duodenum with recent bleeding, arising from muscolaris propria. A computed tomography scan confirmed a large mass suspected to be a GIST without metastases or involvement of the ampulla of Vater. On the basis of these findings, after a multidisciplinary consultation, she was offered robotic surgery with a radical intent.

RESULTS

A duodenal-sparing da Vinci^®Si™ resection with robot-sewn primary duodenal closure was performed. After an uneventful postoperative course, the patient was discharged on post-operative day 7. Final pathology revealed a high-grade risk D-GIST with free margins: adjuvant Imatinib was recommended.9 At 4 years follow-up, no recurrence has been detected.

CONCLUSIONS

A robotic approach might be considered in cases of large D-GISTs amenable to a conservative R0 surgery. This system provides several technical advantages that facilitate otherwise complex resection and reconstruction.10.

Novel surgical approach without bowel resection for multiple gastrointestinal lipomatosis: A case report

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We experienced GI lipomatosis existing from the duodenum to the small intestine.

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In case of multiple lipomas, resection procedure and range cannot be determined.

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Intestinal lipomas were resected with local excision without any bowel resection.

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And duodenal lipoma was resected with ESD.

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Local excision + ESD seemed to be one of the methods in resecting lipomatosis.

Introduction

Asymptomatic lipoma only requires observation, whereas symptomatic lipoma requires treatment such as endoscopic or surgical resection. However, in case of multiple lipomas, with evident diffusion and malignancy, resection procedure and range cannot be determined.

We experienced GI lipomatosis (multiple lipomas) diffusely existing from the duodenum to the small intestine and involved recurrent intussusception.

Presentation of case

47 year-old female was a history of open bowel resection for intestinal obstruction caused by intussusceptions of multiple small intestinal lipoma 11 years ago. EGD showed duodenal lipoma, and CT showed diffuse multiple lipomas from the proximal jejunum to the distal ileum. Another CT also showed intussusception of small intestine, but no signs of intestinal obstruction. Surgical procedures performed included diagnostic laparoscopy. All intestinal lipomas were resected with local excision, and duodenal lipoma was resected with ESD without any bowel resection.

Discussion

Multiple local excision  ESD for multiple GI lipomatosis have not been reported. The most problematic thing is that if extensive resection is performed to cut off all multiple lipoma, short bowel syndrome may occur. Determining the range to be cut remains unclear.

Conclusions

Multiple local excision ± ESD seemed to be one of the methods in resecting multiple GI lipomatosis. In the future, cases and indications of surgery and resection method for GI lipoma should be accumulated and considered, respectively.

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.

Duodenal neuroendocrine neoplasms: a still poorly recognized clinical entity

BACKGROUND

Duodenal neuroendocrine neoplasms (dNENs) are rare tumors, which usually show good prognosis. The optimal management of these tumors is still far from being clearly understood because of their rarity and the poor level of knowledge about their natural history. Herein, we have reviewed the literature on dNENs to collect and analyze the current data on epidemiology, diagnosis and management of these rare tumors.

METHODS

Bibliographical searches were performed in PubMed, using the following keywords: duodenal neuroendocrine neoplasm; duodenum; gastrinoma; diagnosis; therapy; guidelines. We searched for all relevant articles published over the last 15 years. Non-English language papers were excluded.

RESULTS

We reviewed the pertinent articles about dNENs. Upper gastrointestinal endoscopy with biopsy is the cornerstone of the dNENs diagnostic process. Endoscopic ultrasound with fine-needle aspiration/biopsy should be performed in order to locally stage the disease and in all cases of non-diagnostic endoscopy. Endoscopic or complete surgical removal of the primary lesion is the recommended treatment and is generally achievable for the majority of the patients. A less aggressive approach may be suggested for well-differentiated low-stage tumors. After NEN removal, patients should be closely followed-up especially during the first 3 years by endoscopic examination, imaging tests and CgA measurements.

CONCLUSIONS

The multi-disciplinary approach and the preservation of the quality of life of the patients play a key role in the therapeutic process for dNENs. Further studies are needed to better define standardized guidelines specific to dNENs, including optimal management approaches and follow-up intervals.

Surgical treatment of gastrointestinal stromal tumors of the duodenum: a literature review

Background

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4-5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment.

Methods

An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST.

Results

Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections).

Conclusions

dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1-2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided.

The Risk Factors for Metastasis in Non-Ampullary Duodenal Neuroendocrine Tumors Measuring 20 mm or Less in Diameter

BACKGROUND/AIMS

The treatment strategy for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤20 mm in diameter has not been established. In this study, we aimed to evaluate the detailed characteristics of NAD-NETs ≤20 mm in diameter to clarify the risk factors of subsequent metastasis.

METHODS

The patients with NAD-NETs ≤20 mm in diameter who had been treated at 12 institutions between 1992 and 2013 were enrolled. Clinical records were retrieved, and histopathological findings of all cases were centrally reviewed by 2 pathologists.

RESULTS

We studied 49 patients with a mean follow-up period of 66.5 months. Thirty-five patients were initially treated with endoscopic resection (ER), and 14 with surgery. A univariate analysis revealed the ORs and 95% CIs of the risk factors for metastasis were lymphovascular invasion (12.5 [2.01-77.9]), multiple tumors (9.75 [1.46-65.4]), a tumor size of 11-20 mm (6.67 [1.21-36.6]), and World Health Organization grade G2 (7.13 [1.16-43.9]). Five-year overall and disease-specific survival rates were 86.1 and 97.2%, respectively.

CONCLUSION

This is the first study to demonstrate the risk factors of metastasis in NAD-NETs ≤20 mm in diameter. These findings may be helpful for determining the appropriate therapeutic approach and the clinical strategy of treatment following ER.

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.

Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report

INTRODUCTION

Duodenal lipoma is very rare with limited case reports present in literature. Owing to recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, no systematic study of duodenal lipomas has been reported.

AIM

To study the diagnosis and treatment of duodenal lipoma in a female patient and review the relative literatures to enhance the knowledge of it.

MATERIALS AND METHODS

A literature search for 'duodenal lipoma' was performed on PubMed. Papers published from 1948 to 2016 in the English language were identified. Each article was then read in detail and analysed for clinical data, imaging features, diagnosis and therapy. Also, we hereby present a case of upper gastrointestinal obstruction secondary to multiple duodenal lipomas in a 67-year-old woman. The patient underwent a limited bowel resection with an uneventful recovery.

RESULTS

Literature review demonstrated 59 cases of duodenal lipoma, which indicate that duodenal lipomas are rare to occur but commonly found in the second part. The peak of incidence seems to be around the fifth and seventh decade of life. Duodenal lipomas may present as gastrointestinal bleeding, abdominal pain, obstruction or upper abdominal fullness. CT, MRI, Endoscopic Ultrasound (EUS), endoscopy are highly accurate diagnostic tools. The disease could be managed by endoscopy or surgery.

CONCLUSION

Our review of literature indicated duodenal lipoma is extremely rare. The symptoms are nonspecific and CT is the first choice for diagnosis. The treatment depends on the patient's condition as well as the size and position of the tumour.

A Novel Technique for Duodenal Resection and Primary Anastomosis With Robotic Assistance and OrVil

Background and Objectives:

Benign duodenal neoplasm is a rare occurrence. Minimally invasive tumor resection and anastomosis formation with an OrVil catheter is a novel approach to treating this disease. In this article, we present a new technique for duodenojejunal anastomosis. This technique was applied in 4 patients with benign distal duodenal tumors who were treated with minimally invasive surgery with robotic assistance.

Methods:

In 4 patients, after the removal of distal duodenal masses with a robotic technique, an orifice in the duodenum was opened to allow for the passage of a guidewire. The guidewire was removed from the orifice by holding it with forceps during an upper endoscopy. An OrVil catheter was sutured to the guidewire outside to allow 2 catheters to proceed consecutively. After the removal of the anvil, an end-lateral duodenojejunostomy was performed with a circular stapler.

Results:

The patients included 3 men and 1 woman (average age, 56). The durations of the operations were 215, 175, 180, and 185 minutes. No complications were observed in any of the patients during the postoperative period. The patients began oral intake on the fifth day of the postoperative period, and they were discharged on the sixth postoperative day. Histopathologic analyses indicated that the removed tumors were adenomas in 2 patients and gastrointestinal stromal tumors (GISTs) in 2 patients. Clear surgical margins were observed in all of the patients.

Conclusion:

The placement of an OrVil catheter for anastomosis in benign neoplasms with distal duodenum localization and the subsequent achievement of duodenojejunal anastomosis with a circular stapler constitute a novel treatment approach.

Safety in Numbers: Progressive Implementation of a Robotics Program in an Academic Surgical Oncology Practice

Background Robotic-assisted surgery has potential benefits over laparoscopy yet little has been published on the integration of this platform into complex surgical oncology. We describe the outcomes associated with integration of robotics into a large surgical oncology program, focusing on metrics of safety and efficiency. Methods A retrospective review of a prospectively maintained database of robotic procedures from July 2009 to October 2014 identifying trends in volume, operative time, complications, conversion to open, and 90-day mortality. Results Fourteen surgeons performed 1236 cases during the study period: thyroid (246), pancreas/duodenum (458), liver (157), stomach (56), colorectal (129), adrenal (38), cholecystectomy (102), and other (48). There were 38 conversions to open (3.1%), 230 complications (18.6%), and 13 mortalities (1.1%). From 2009 to 2014, operative volume increased (7 cases/month vs 24 cases/month; P < .001) and procedure time decreased (471 ± 166 vs 211 ± 140 minutes; P < .001) with statistically significant decreases for all years except 2014 when volume and time plateaued. Conversion to open decreased (12.1% vs 1.7%; P = .009) and complications decreased (48.5% vs 12.3%; P < .001) despite increasing complexity of cases performed. There were 13 deaths within 90 days (5/13 30-day mortality) and 2 (15.4%) were from palliative surgeries. Conclusions Implementation of a diverse robotic surgical oncology program utilizing multiple surgeons is safe and feasible. As operative volume increased, operative time, complications, and conversions to open decreased and plateaued at approximately 3 years. No unanticipated adverse events attributable to the introduction of this platform were observed.

Duodenal gastrointestinal stromal tumors: clinicopathological characteristics, surgery, and long-term outcome

Background

Duodenal gastrointestinal stromal tumors (DGIST) are rare, and data on their management is limited. We here report the clinicopathological characteristics, different surgical treatments, and long-term prognosis of DGIST.

Methods

Data of 74 consecutive patients with DGIST in a single institution from June 2000 to June 2014 were retrospectively analyzed. The overall survival (OS) and recurrence/metastasis-free survival rates of 74 cases were calculated using Kaplan–Meier method.

Results

Out of 74 cases, 42 cases were female (56.76 %) and 32 cases (43.24 %) were male. Approximately 22.97, 47.30, 16.22, and 13.51 % of the tumors originated in the first to fourth portion of the duodenum, respectively, with a tumor size of 5.08 ± 2.90 cm. Patients presented with gastrointestinal bleeding (n = 37, 50.00 %), abdominal pain (n = 25, 33.78 %), mass (n = 5, 6.76 %), and others (n = 7, 9.76 %). A total of 18 patients (24.3 %) underwent wedge resection (WR); 39 patients (52.7 %) underwent segmental resection (SR); and 17 cases (23 %) underwent pancreaticoduodenectomy (PD). The median follow-up was 56 months (1–159 months); 19 patients (25.68 %) experienced tumor recurrence or metastasis, and 14 cases (18.92 %) died. The 1-, 3-, and 5-year recurrence/metastasis-free survival rates were 93.9, 73.7, and 69 %, respectively. The 1-, 3- and 5-year OS were 100, 92.5, and 86 %, respectively. The recurrence/metastasis-free survival rate in the PD group within 5 years was lower than that in the WR group (P = 0.047), but was not different from that in the SR group (P = 0.060). No statistically significant difference was found among the three operation types (P = 0.294).

Conclusions

DGIST patients have favorable prognosis after complete tumor removal, and surgical procedures should be determined by the DGIST tumor location and size.

Duodenal gastrointestinal stromal tumor: From clinicopathological features to surgical outcomes

Duodenal gastrointestinal tumors represent an extremely rare subset of stromal tumors arising from interstitial cells of Cajal. In the last 30 years the comprehension of the pathophysiology and natural history of this previously misunderstood clinical entity, in association with developments in endoscopy, imaging technology, and immunohistochemistry has resulted in novel diagnostic and treatment approaches. This is a comprehensive review of the current data of the literature on the various aspects of the diagnosis and treatment of these tumors. The duodenum is the less commonly involved site for these tumors in the digestive tract. Endoscopy and computed tomography can usually establish the diagnosis, confirmed by immunohistochemical staining and occasionally molecular genetic analysis. Endoscopic ultrasound with fine needle aspiration has been recently found to be the gold diagnostic standard with high sensitivity and specificity rates, diagnosing GIST in up to 80% of patients. Due to the complex anatomy of the pancreatico-duodenal region optimal therapeutic strategy of duodenal GISTs are challenging. Nevertheless surgical resection with microscopically clear resection margins seems to be the only potentially curative treatment for non-metastatic primary GISTs of the duodenum. Imatinib mesylate plays a key role in the management of GISTs both as neoadjuvant therapy and in patients with recurrent and metastatic disease. Meanwhile, the advances in the comprehension of the pathophysiology and natural history of this previously misunderstood clinical entity as well as the treatment of these tumors may render feasible, in the near future, the advent of newer and more effective treatment options.