Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy?

Feasibility and efficacy of minimally invasive limited resection for primary duodenal gastrointestinal stromal tumors: a retrospective cohort study

BACKGROUND

The primary duodenal gastrointestinal stromal tumor (GIST) is a rare type of gastrointestinal tract tumor. Limited resection (LR) has been increasingly performed for duodenal GIST. However, only a few studies reported minimally invasive limited resection (MI-LR) for primary duodenal GIST.

METHODS

The clinical data of 33 patients with primary duodenal GIST from December 2014 to February 2024 were retrospectively analyzed including 23 who received MI-LR and 10 who received laparoscopic or robotic pancreaticoduodenectomy (LPD/RPD).

RESULTS

A total of 33 patients with primary duodenal GIST were enrolled and retrospectively reviewed. Patients received MI-LR exhibited less OT (280 vs. 388.5min, P=0.004), EBL (100 vs. 450ml, P<0.001), and lower morbidity of postoperative complications (52.2% vs. 100%, P=0.013) than LPD/RPD. Patients received LPD/RPD burdened more aggressive tumors with larger size (P=0.047), higher classification (P<0.001), and more mitotic count/50 HPF(P=0.005) compared with patients received MI-LR. The oncological outcomes were similar in MI-LR group and LPD/RPD group. All the patients underwent MI-LR with no conversion, including 12 cases of LLR and 11 cases of RLR. All of the clinicopathological data of the patients were similar in both groups. The median OT was 280(210-480) min and 257(180-450) min, and the median EBL was 100(20-1000) mL and 100(20-200) mL in the LLR and the RLR group separately. The postoperative complications mainly included DGE (LLR 4 cases, 33.4% and RLR 4 cases, 36.4%), intestinal fistula (LLR 2 cases, 16.7%, and RLR 0 case), gastrointestinal hemorrhage (LLR 0 case and RLR 1 case, 9.1%), and intra-abdominal infection (LLR 3 cases, 25.0% and RLR 1 case, 9.1%). The median postoperative length of hospitalization was 19.5(7-46) days in the LLR group and 19(9-38) days in the RLR group. No anastomotic stenosis, local recurrence or distant metastasis was observed during the follow-up period in the two groups.

CONCLUSIONS

Minimally invasive limited resection is an optional treatment for primary duodenal GIST with satisfactory short-term and long-term oncological outcomes.

Laparoscopic pancreas-preserving near total duodenectomy for large villous adenoma in patients with total colectomy for familial adenomatous polyposis

Most familial adenomatous polyposis (FAP) patients undergo total colectomy, but duodenal polyposis develops in up to 90% of patients with FAP and a 4% to 18% risk of duodenal and ampullary cancer remains. Laparoscopic pancreas-preserving near total duodenectomy is thought to be a potential option and can be an effective approach to preserve the pancreas. A 48-year-old male patient, who underwent laparoscopic total colectomy with end ileostomy because of FAP with colorectal cancer, was diagnosed with a 20 mm-sized duodenal adenoma in the second to the third portion. The operation was performed on December 27, 2021. Near total duodenectomy was done and type II Billroth gastrojejunostomy was done. Laparoscopic pancreas-sparing duodenectomy is shown to be safe, with favorable short-term oncologic outcome compared to laparoscopic pancreatoduodenectomy in terms of less blood loss, faster recovery time, and much less total cost.

Laparoscopic duodenum-preserving pancreatic head resection with real-time indocyanine green guidance of different dosage and timing: enhanced safety with visualized biliary duct and its long-term metabolic morbidity

PURPOSE

Laparoscopic duodenum-preserving pancreatic head resection (L-DPPHR) is technically demanding with extreme difficulty in biliary preservation. Only a few reports of L-DPPHR are available with alarming bile leakage, and none of them revealed the long-term metabolic outcomes. For the first time, our study explored the different dosage and timing of indocyanine green (ICG) for guiding L-DPPHR and described the long-term metabolic results.

METHODS

Between October 2015 and January 2021, different dosage and timing of ICG were administrated preoperatively and evaluated intra-operatively using Image J software to calculate the relative fluorescence intensity ratio of signal-to-noise contrast between bile duct and pancreas. Short-term complications and long-term metabolic disorder were collected in a prospectively maintained database and analyzed retrospectively.

RESULTS

Twenty-five patients were enrolled without conversion to laparotomy or pancreaticoduodenectomy. Administrating a dosage of 0.5 mg/kg 24 h before the operation had the highest relative fluorescence intensity ratio of 19.3, and it proved to guide the biliary tract the best. Fifty-six percent of patients suffered from postoperative complications with 48% experiencing pancreatic fistula and 4% having bile leakage. No one suffered from the duodenal necrosis, and there was no mortality. When compared with the non-ICG group, the ICG group had a comparable diameter of tumor and similar safety distance from lesions to common bile duct; however, it decreased the incidence of bile leakage from 10% to none. The median length of hospital stay was 16 days. After a median follow-up of 26.6 months, no one had tumor recurrence or refractory cholangitis. No postoperative new onset of diabetes mellitus (pNODM) was observed, while pancreatic exocrine insufficiency (pPEI) and non-alcoholic fatty liver disease (NAFLD) were seen in 4% of patients 12 months after the L-DPPHR.

CONCLUSION

L-DPPHR is feasible and safe in selected patients, and real-time ICG imaging with proper dosage and timing may greatly facilitate the identification and the prevention of biliary injury. And it seemed to be oncological equivalent to PD with preservation of metabolic function without refractory cholangitis.

Safety and efficacy of surgical and endoscopic resection in the treatment of duodenal subepithelial lesions

BACKGROUND

Duodenal subepithelial lesions (D-SELs) are rare and their resection is challenging. Unfortunately, data on surgical and endoscopic resection of D-SELs are scarce. This study aimed to assess the safety and efficacy of surgical resection and endoscopic resection (ER) for D-SELs.

METHODS

We retrospectively analyzed clinical data of patients with non-ampullary D-SELs who underwent ER or surgery and compared the outcomes between ER and surgery with no/low-risk SELs over 15 mm from March 2010 to August 2020. Clinicopathologic findings, procedure-related parameters, and follow-up data were analyzed.

RESULTS

A total of 107 patients (108 lesions) were enrolled; 52 patients (53 lesions) received ER and 55 patients (55 lesions) received surgery. In ER group, en bloc resection rate and R0 resection rate were 94 and 89%, respectively. Major adverse events rate was 6%. One (2%) patient experienced local recurrence. In surgery group, R0 resection was achieved in all cases. Major adverse events rate was 20%. Recurrence rate and distant metastases rate were 4 and 8%, respectively. One (2%) patient died from septicemia during follow-up. Thirty-three patients in each group were enrolled in the comparison. There were no significant differences in age, sex, lesion size and location (P > 0.05). More histologically GISTs and muscularis propria-originated lesions were treated by surgery (P < 0.05). ER was significantly associated with a shorter operation time, shorter hospital stay, lower cost, less estimated blood loss, and lower major adverse events rate compared to the surgery group (P < 0.05). However, R0 resection rate, mortality, recurrence rate, and metastases rate were not significant different (P > 0.05).

CONCLUSIONS

ER is an effective and safe treatment modality for selected patients with non-ampullary D-SELs by expert endoscopists. Surgery is a radical method for D-SELs that should be reserved for D-SELs not amenable to ER.

Current surgical management of duodenal gastrointestinal stromal tumors

Duodenal gastrointestinal stromal tumors (D-GISTs) are uncommon mesenchymal tumors and are managed differently to common duodenal epithelial tumors. They may pose surgical challenges due to their unique but complex pancreaticoduodenal location of the gastrointestinal tract near the ampulla of Vater, pancreas, mesenteric blood vessels, biliary and pancreatic ducts. The surgical management of D-GISTs can be performed safely with good oncological outcomes provided an adequate resection margin can be achieved. The current surgical options of resectable primary D-GISTs varies with increasing complexity depending on the location, size and involvement of surrounding structures such as wedge resection with primary closure, segmental resection with small bowel anastomosis or radical pancreaticoduodenectomy. Laparoscopic approaches have been shown to be feasible and safe with good oncological outcomes in experienced hands. The minimally invasive techniques including robotic-assisted approach will likely increase in the future. D-GISTs have a prognosis comparable to gastric and other small bowel GISTs. However, the heterogeneity of different studies and the limited use of systemic tyrosine kinase inhibitor in the neoadjuvant and adjuvant settings may influence the overall survival of resected D-GISTs. The use of limited resection when condition allows is recommended due to lower surgical morbidity, less postoperative complications and better oncologic outcomes.