Laparoscopic Duodenectomy for Benign Nonampullary Duodenal Neoplasms

Endoscopic management of non-ampullary duodenal adenomas

Duodenal polyps are found in 0.1 % to 0.8 % of all upper endoscopies. Duodenal adenomas account for 10 % to 20 % of these lesions. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis. Endoscopy is the cornerstone of management of duodenal adenomas, allowing for diagnosis and treatment, primarily by endoscopic mucosal resection. The endoscopic treatment of duodenal adenomas has a high morbidity, reaching 15 % in a prospective study, consisting of bleeding and perforations, and should therefore be performed in expert centers. The local recurrence rate ranges from 9 % to 37 %, and is maximal for piecemeal resections of lesions > 20 mm. Surgical resection of the duodenum is flawed with major morbidity and considered a rescue procedure in cases of endoscopic treatment failures or severe endoscopic complications such as duodenal perforations. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of non-ampullary duodenal adenomas.

Laparoscopic Partial Sleeve Duodenectomy for the Infra-Ampullary Gastrointestinal Stromal Tumors of the Duodenum

BACKGROUND

Although organ-preserving operations are regarded as effective strategies for duodenal gastrointestinal stromal tumors (GISTs), laparoscopic partial sleeve duodenectomy (lap PSD) has not been fully evaluated. The aims of this study were to evaluate the effectiveness and technical feasibility of lap PSD.

STUDY DESIGN

Between January 2011 and March 2016, we reviewed 13 patients who underwent laparoscopic approach among 22 patients who underwent PSD. PSD for the infra-ampullary lesions was defined as infra-ampullary duodenal resection including the first portion of the jejunum. After resection, all patients underwent reconstruction via side-to-side duodenojejunostomy.

RESULTS

The total mean operation time was 273 min (range 160-346 min), and estimated mean blood loss was 80 ml (range scanty-200 ml). One patient was converted to open laparotomy because of mesocolonic tumor involvement. The median postoperative hospital stay was 10.5 days (range 4-36 days). There were no postoperative mortalities. Postoperative complications included 2 instances of delayed gastric emptying (DGE), 1 duodenojejunostomy stricture, and 2 intestinal obstructions. No patient was treated with adjuvant therapy. One patient experienced hepatic metastasis 28 months after surgery during a mean follow-up period of 48.6 months.

CONCLUSION

Lap PSD might be an oncologically effective strategy for duodenal GIST, and the laparoscopic approach is a technically feasible and appealing surgical modality in terms of safety and perioperative results. However, DGE and anastomosis strictures are concerns for postoperative complications, which need to be further investigated.

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.

[Primary Non-ampullary Duodenal Adenocarcinoma: A Single-center Experience for 15 Years]

BACKGROUND/AIMS

Primary non-ampullary duodenal adenocarcinomas (PNADAs) comprise <œ0.3% of gastrointestinal malignancies. The rarity of PNADA and poorly defined natural history often leads to a delayed correct diagnosis. This study was conducted to evaluate the clinical characteristics of PNADA and to identify its prognostic factors.

METHODS

Data were collected by retrospectively reviewing the medical records of patients with PNADA managed at Gyeongsang National University Hospital from January 2000 to December 2014. Demographic, clinical, endoscopic, and pathological variables were investigated, and factors related to survival were analyzed.

RESULTS

Twenty-seven patients with PNADA were identified, and their median age was 64.9±13.6 years with 16 (59.3%) being male. The majority of patients (25/27, 92.6%) were initially diagnosed during upper endoscopy with biopsies. The tumor was located on the 1st or 2nd portion of duodenum in 92.6% (25/27) of patients. At the time of diagnosis, 85.2% (23/27) had advanced diseases (stage III or IV); 48.2% (13/27) had distant metastasis. Median survival time was 12 months (1-93 months). One and 3-year survival rates were 48.1% and 33.3%, respectively. On multivariable analysis, total bilirubin ≥2 mg/dL (OR, 85.28; 95% CI, 3.77-1,938.79; p=0.005) and distant metastasis (OR, 26.74; 95% CI, 3.13-2,328.14; p=0.003) at the time of diagnosis were independent poor prognostic factors.

CONCLUSIONS

The majority of patients were diagnosed at an advanced stage. Presence of distant metastasis was independent prognostic factor of PNADA together with elevated total bilirubin.