Simultaneous Laparoscopic Subtotal Colectomy and Pancreaticoduodenectomy for Colonic FAP and Ampullary Cancer

Curative resection via right hemicolectomy and regional lymph node dissection for colonic adenomatous polyposis of unknown etiology with adenocarcinomas localized in the right side of the colon: a case report

BACKGROUND

APC and MUTYH are both well-known colorectal polyposis causative genes. However, 30-50% of colorectal adenomatous polyposis cases are classified as colonic adenomatous polyposis of unknown etiology and lack identifiable pathogenic variants. Although guidelines recommend total proctocolectomy for colonic adenomatous polyposis of unknown etiology with over 100 adenomas, evidence is lacking. This study presents a unique case of localized colonic adenomatous polyposis of unknown etiology with multiple adenocarcinomas, treated with hemicolectomy and regional lymph node dissection.

CASE PRESENTATION

The patient was a 72-year-old woman whose colonoscopy revealed numerous polyps and two adenocarcinomas localized in the right side of the colon, with no lesions in the left side. The patient had no family history of polyposis or colorectal cancer. No extracolonic lesions, enlarged lymph nodes, or distant metastases were found. Considering the patient's age and lesion localization, laparoscopic right hemicolectomy with regional lymph node dissection was performed. Histopathological diagnosis revealed three adenocarcinoma lesions with no lymph node metastasis. The most advanced pathological stage was T2N0M0 Stage I (UICC 8th edition). The patient was alive 5 years postoperatively, without recurrence of cancer or polyposis in the remaining colon and rectum. To diagnose hereditary colorectal cancer/polyposis, a germline multigene panel testing for APC, EPCAM, MBD4, MLH1, MLH3, MSH2, MSH3, MSH6, MUTYH, NTHL1, PMS2, POLD1, POLE, and TP53 was performed using DNA extracted from blood samples: however, no pathogenic variant was detected. Therefore, the patient was diagnosed with colonic adenomatous polyposis of unknown etiology.

CONCLUSIONS

In this rare case, colonic adenomatous polyposis of unknown etiology, with numerous adenomatous polyps and multiple adenocarcinomas localized in the right side of the colon, was successfully treated with right hemicolectomy and regional lymph node dissection. Despite genetic analysis, no causative germline variants were identified. Segmental colectomy according to the distribution of polyps might be a curative approach.

Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes

Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.

Total laparoscopic en bloc right hemicolectomy and pancreaticoduodenectomy with transvaginal specimen extraction for locally advanced right colon cancer: a case report

For locally advanced right colon cancer (LARCC) invading duodenum, multivisceral resection is a curative surgical treatment, which is technically challenging when performed in a total laparoscopic approach. Herein, we report the first case of LARCC treated by total laparoscopic en bloc right hemicolectomy and pancreaticoduodenectomy with transvaginal specimen extraction. The patient was a 37-year-old female suffering from upper abdominal pain who was diagnosed with LARCC invading the duodenum by preoperative examination. The en bloc resection and digestive tract reconstruction were completed laparoscopically without an assisted abdominal incision. Then the specimen was extracted transvaginally through a 6 cm transverse incision made in the posterior vaginal fornix and the vaginal incision was closed by a continuous suture intracorporeally. The operative time was 470 min and intraoperative blood loss was 130 mL. The postoperative pathological examination showed T4bN0M0 adenocarcinoma of the hepatic flexure of colon with infiltration of duodenal serosa, and all the margins were negative. The patient recovered uneventfully with minimal postoperative pain and was discharged from hospital on postoperative day 7. After 3 years of follow-up, the patient was alive with no recurrence. To the best of our knowledge, this is the most extensive multivisceral resection with natural orifice specimen extraction (NOSE) ever reported. We believe that NOSE surgery, with advantages of minimal invasiveness and enhanced recovery, is a feasible and promising option for LARCC.

Spigelman stage IV duodenal polyposis does not precede most duodenal cancer cases in patients with familial adenomatous polyposis

BACKGROUND AND AIMS

The greatest known risk factor for duodenal cancer in familial adenomatous polyposis (FAP) is Spigelman stage (SS) IV duodenal polyposis. Endoscopic surveillance is recommended in FAP patients with SS 0 to IV, and prophylactic duodenectomy should be considered in SS IV. Cancer occurs in patients without SS IV polyposis. We assessed the relationship of SS and other factors with duodenal cancer in FAP.

METHODS

We performed a case-control study on 18 FAP patients with duodenal cancer and 85 randomly selected FAP control subjects with similar age characteristics. Demographic, clinical, and endoscopic features were compared using univariate and logistic regression analyses to assess factors associated with duodenal cancer.

RESULTS

Fifty-three percent of cases had no SS IV history. SS components positively associated with cancer included duodenal polyp size (77% vs 47%, P = .015), and high-grade dysplasia (HGD; 29% vs 6%, P = .003) but not polyp number or histology. In the papilla, the frequency of tubulovillous or villous histology (80% vs 22%, P < .001) and HGD (30% vs 4%, P = .010) was greater in cases than control subjects.

CONCLUSIONS

SS IV polyposis was absent in half of FAP patients with duodenal cancer. Only 2 of 4 SS components (large duodenal polyp size and HGD) were positively associated with duodenal cancer. Advanced pathology of the papilla appears to be an important feature. Revision of SS to emphasize these findings should be considered to better estimate cancer risk.

Matched Case-Control Comparative Study of Laparoscopic Versus Open Pancreaticoduodenectomy for Malignant Lesions

INTRODUCTION

Advances in surgical technologies allowed safe laparoscopic pancreaticoduodenectomy (LPD). The aim of this study is to compare the oncologic outcomes of LPD to open pancreaticoduodenectomy (OPD) in terms of safety and recurrence rate.

MATERIALS AND METHODS

A cohort of 30 patients were matched for age, sex, American Society of Anaesthesiologists, tumor size, pancreatic duct diameter, and histopathologic diagnosis on a 1:1 basis (15 LPD, 15 OPD). Comparison between groups was performed on intention-to-treat basis. Survival following resection was compared using the Kaplan-Meier survival analysis.

RESULTS

The median operating time for LPD group was longer than for OPD group (470 vs. 310 min; P=0.184). However, estimated blood loss (300 vs. 620 mL; P=0.023), high dependency unit stay (2.0 vs. 6.0 d; P=0.013) and postoperative hospital stay (9.0 vs. 17.4 d; P=0.017) were significantly lower in the LPD group. There was no significant difference in postoperative rates of morbidity (40% vs. 67%; P=0.431) and mortality (0% vs. 6.7%; P=0.99). The surgical resection margins R0 status (87% vs. 73%; P=0.79) and the number of lymph nodes (18 vs. 20; P=0.99) in the resected specimens were comparable between the 2 groups. There was no significant difference in overall survival outcomes.

CONCLUSIONS

In selected patients, the laparoscopic approach to pancreaticoduodenectomy in the hands of the experienced offers advantages over open surgery without compromising the oncologic 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.