Laparoscopy-assisted transduodenal excision of superficial non-ampullary duodenal epithelial tumors

Laparoscopic pancreas-preserving duodenectomy: Minimally invasive surgery for superficial nonampullary duodenal epithelial tumors

No consensus exists regarding the optimal treatment for superficial nonampullary duodenal epithelial tumors. Herein, we describe a laparoscopic pancreas-preserving duodenectomy for the treatment of a 30-mm adenoma located in the third portion of the duodenum. The adenoma was located on the pancreatic side, further hindering safe endoscopic resection. Via laparoscopy, the jejunum was transected first. After releasing the third portion of the duodenum from the retroperitoneal space, the jejunum was pulled to the right side of the superior mesenteric artery and separated from the pancreas. Under endoscopic guidance, the duodenum was then transected and duodenojejunostomy performed intracorporeally. Laparoscopic pancreas-preserving duodenectomy can be considered minimally invasive, achieving tumor radicality while preserving organs and causing minimal destruction to the abdominal wall. In conclusion, although technically demanding, laparoscopic pancreas-preserving duodenectomy is a valuable treatment option for superficial nonampullary duodenal epithelial tumors.

Endoscopy-assisted laparoscopic submucosal dissection for a duodenal epithelial tumor

We present the case of a 46-year-old obese woman with a 3.5-cm adenoma in the descending part of the duodenum who was treated with a totally laparoscopic approach. The preoperative examination revealed a pedunculated superficial tumor on the side of pancreas from the inferior duodenal angulus to 5 cm proximal to the papilla that was associated with massive blood flow. We chose not to perform endoscopic submucosal dissection, pancreaticoduodenectomy, or transduodenal tumor excision with laparotomy for this obese patient because of the poor exposure, risk of bleeding, and substantial invasiveness. We performed endoscopy-assisted laparoscopic submucosal dissection as a novel laparoscopic-endoscopic cooperative surgical approach in this patient. This surgery was surgically and oncologically safe.

Two cases of laparoscopic direct spiral closure of large defects in the second portion of the duodenum after laparoscopic endoscopic co-operative surgery

Curative endoscopic resection of non-ampullary duodenal lesions, although possible, is challenging. In recent years, although a novel surgical technique named laparoscopic-endoscopic cooperative surgery (LECS), which combines laparoscopic and endoscopic techniques, has made the resection of nonampullary duodenal lesions relatively easier, closure of the defect is still controversial. We report two cases of the duodenal lesion which were closed using a novel technique for primary closure utilising the free wall of the duodenum. Two cases of the duodenal lesion in the second portion of the duodenum were undergone full thickness resection using the LECS technique. The defect is designed spirally to ensure maximum use of the free wall of the duodenum. The mucosal layer is closed using a running suture, and the seromuscular layer is closed using interrupted sutures. The suture line is then reinforced with omentum. There were no intraoperative complications and had uneventful post-operative courses with no leakage, stenosis, or relapse.

Laparoscopy-assisted full-thickness resection of the duodenum for patients with gastrointestinal stromal tumor with ulceration

INTRODUCTION

Gastrointestinal stromal tumor (GIST) with ulceration may potentially disseminate into the peritoneal cavity after laparoscopic local wedge resection (full-thickness resection) when the intestinal wall is opened under the aeroperitoneum. To prevent this intraoperative tumor seeding, we developed laparoscopy-assisted full-thickness resection (LAFTR) of the duodenum for GIST with ulceration. Here, we present the preliminary results of LAFTR.

METHODS

Three patients with duodenal GIST with ulceration underwent LAFTR. LAFTR consists of four major procedures: (i) a laparoscopic Kocher maneuver (mobilization of the pancreatoduodenum); (ii) the creation of a small upper median laparotomy; (iii) the extracorporeal completion of the full-thickness resection under direct vision; and (iv) extracorporeal hand-sewn closure of the duodenal defect.

RESULTS

LAFTR was successfully performed without any intraoperative adverse events. The mean operating time and estimated blood loss were 182 min and 34 mL, respectively. Postoperative contrast roentgenography showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. None of the patients developed peritoneal recurrence.

CONCLUSIONS

LAFTR can eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracoporeally. Meticulously hand-sewn closures of the duodenal defect can minimize the possibilities of anastomotic insufficiency and deformity. LAFTR is a feasible, safe, and minimally invasive treatment for patients with GIST with ulceration in the first and second portions of the duodenum.

Laparoscopic and endoscopic cooperative surgery for gastrointestinal tumor

With technological progress of endoscopic submucosal dissection (ESD) in the last decade, several laparoscopic and endoscopic cooperative surgeries (LECS) for gastrointestinal tumor have recently been developed. LECS is definitely favorable to the minimization of surgical margin, which leads to functional and anatomical preservation of gastrointestinal tract. LECS for gastrointestinal tumor is mainly sorted by two categories: exposure procedures and non-exposure procedures between endoluminal and extraluminal spaces. Exposure procedures have the potential risk of gastric contents or tumor cells spilling out over the abdominal cavity, because the stomach wall has to be perforated intentionally during the procedure. In order to avoid the potential these risks, non-exposure procedures have been developed. Currently, the LECS concept has rapidly permeated for treatment of gastrointestinal tumor due to its certainty and safety, although there is still room for improvement to lessen its technical difficulty. This review describes the current LECS for gastrointestinal tumor based on the several articles.

Limited Resection of the Duodenum for Nonampullary Duodenal Tumors, with Review of the Literature

The surgical management of duodenal pathology is challenging because of its retroperitoneal position and shared blood supply with the pancreas. We present three types of limited resection of the duodenum for the removal of superficial or small nonampullary duodenal (NADL) lesions, and also a review of the English literature regarding management, such as endoscopic resection and limited duodenal resection. Ten cases underwent limited resections of the duodenum for superficial or small NADL lesions from 2011 to 2015. Pancreas-preserving segmental duodenectomy was performed in three cases, local full-thickness resection was performed in three and transduodenal submucosal dissection was performed in four. One patient experienced pancreatic fistula as a postoperative complication. Postoperative pathological diagnosis were adenoma (n = 2), mucosal adenocarcinomas (n = 5), and neuroendocrine tumor (n = 3). Surgical margin was negative in all cases, and no patient has experienced postoperative recurrence or metastasis. Limited resections of the duodenum were feasible and safe procedures for patients with superficial or small NADL lesions. Laparoscopic surgery may be considered in treatment for these tumors. However, the optimal surgical management for superficial or small nonampullary duodenal lesions remains controversial.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy

A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.