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Hayashi H, Miyamoto H, Nakagawa S, Matsuno K, Miyata T, Tsukamoto M, Mima K, Nitta H, Tanaka Y, Baba H. Distinct approaches (antecolic and retrocolic) according to tumor location in laparoscopic and endoscopic cooperative surgery for non-ampullary duodenum tumors. Surg Endosc 2023; 37:6718-6726. [PMID: 37217687 DOI: 10.1007/s00464-023-10114-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 05/24/2023]
Abstract
AIM Laparoscopic and endoscopic cooperative surgery for early non-ampullary duodenum tumors (D-LECS) is now noted because of its safety and lower invasiveness. Here, we introduce two distinct approaches (antecolic and retrocolic) according to the tumor location during D-LECS. METHODS From October 2018 to March 2022, 24 patients (25 lesions) underwent D-LECS. Two (8%), two (8%), 16 (64%), and five (20%) lesions were located in the first portion, in the second portion to Vater's papilla, around the inferior duodenum flexure, and in the third portion of the duodenum, respectively. The median preoperative tumor diameter was 22.5 mm. RESULTS Antecolic and retrocolic approaches were employed in 16 (67%) and 8 (33%) cases, respectively. LECS procedures, such as two-layer suturing after full-thickness dissection and laparoscopic reinforcement by seromuscular suturing after endoscopic submucosal dissection (ESD), were performed in five and 19 cases, respectively. Median operative time and blood loss were 303 min and 5 g, respectively. Intraoperative duodenal perforations occurred in three of 19 cases during ESD; however, they were successfully laparoscopically repaired. Median times until start diet and postoperative hospital stay were 4.5 and 8 days, respectively. Histological examination of the tumors revealed nine adenomas, 12 adenocarcinomas, and four GISTs. Curative resection (R0) was achieved in 21 cases (87.5%). In a comparison of the surgical short outcomes between antecolic and retrocolic approaches, there was no significant difference. CONCLUSION D-LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors, and two distinct approaches according to the tumor location are feasible.
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Affiliation(s)
- Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan.
| | - Hideaki Miyamoto
- Department of Gastroenterology, Kumamoto University, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Kenshi Matsuno
- Department of Gastroenterology, Kumamoto University, Kumamoto, Japan
| | - Tatsunori Miyata
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Masayo Tsukamoto
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Kosuke Mima
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Hidetoshi Nitta
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Yasuhito Tanaka
- Department of Gastroenterology, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
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Libânio D, Pimentel-Nunes P, Bastiaansen B, Bisschops R, Bourke MJ, Deprez PH, Esposito G, Lemmers A, Leclercq P, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, Fuccio L, Bhandari P, Dinis-Ribeiro M. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55:361-389. [PMID: 36882090 DOI: 10.1055/a-2031-0874] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.
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Affiliation(s)
- Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute - Porto, Portugal.,MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Pedro Pimentel-Nunes
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, FMUP, Porto, Portugal.,Gastroenterology, Unilabs, Portugal
| | - Barbara Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia.,Western Clinical School, University of Sydney, Sydney, Australia
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gianluca Esposito
- Department of Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philippe Leclercq
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy. Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brueder Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.,University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, Gastroenterology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute - Porto, Portugal.,MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Porto, Portugal
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Feasibility and Safety of a Novel Laparoscopic and Endoscopic Cooperative Surgery Technique for Superficial Duodenal Tumor Resection: How I Do It. J Gastrointest Surg 2019; 23:2068-2074. [PMID: 30859426 DOI: 10.1007/s11605-019-04176-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatoduodenectomy is considered to be a very invasive treatment for early superficial duodenal tumors (SDTs), which have a lower risk of lymph node metastasis. Partial resection of the duodenum with endoscopic submucosal dissection for SDT resection is an attractive technique but it is associated with a high risk of complications. We describe our technique for SDT resection. METHOD It includes the following elements: freeing the transverse mesocolon, exposing and mobilizing the second part of the duodenum and the head of the pancreas (Kocher maneuver), confirming the location of the ulcer bed for endoscopic submucosal dissection, and laparoscopic suturing by hand in the seromuscular layer of the duodenum. We performed this technique in 10 patients between March 2015 and March 2017. RESULTS The median tumor diameter and resected tissue diameter were 36 (20-54) and 41 (25-60) mm, respectively. Curative resection (R0) with negative margins was achieved for all patients. There were no conversions to open surgery in this series. No postoperative complications were above grade 2 in the Clavien-Dindo classification system. No recurrences were observed during the medium-term follow-up period. CONCLUSION This technique is safe and feasible and can be an option for surgical SDT resection.
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Hirashita T, Ohta M, Tada K, Saga K, Takayama H, Endo Y, Uchida H, Iwashita Y, Inomata M. Prognostic factors of non-ampullary duodenal adenocarcinoma. Jpn J Clin Oncol 2018; 48:743-747. [PMID: 29931295 DOI: 10.1093/jjco/hyy086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background Non-ampullary duodenal adenocarcinoma, excluding carcinoma in the ampulla of Vater, is a rare disease. Although several prognostic factors have been reported, they remain controversial due to the rarity of non-ampullary duodenal adenocarcinoma. The aims of this study were to investigate prognostic factors in patients with non-ampullary duodenal adenocarcinoma and to assess chemotherapy in patients with recurrence. Patients and methods Records of 25 patients who underwent surgical treatment for non-ampullary duodenal adenocarcinoma from 2004 to 2016 were retrospectively reviewed. The relationship between the clinicopathological factors and outcomes was investigated. Results Serum level of CA19-9, gross appearance, tumor size, tumor invasion, lymph node metastases, TNM stage and lymphatic and vascular invasion were significant risk factors of recurrence. Patients with recurrence who received chemotherapy according to regimens used to treat colorectal cancer had a better prognosis than those without chemotherapy (P = 0.016). Conclusion Advanced non-ampullary duodenal adenocarcinoma has a poor prognosis, but chemotherapy possibly improves the prognosis in the patients with recurrent non-ampullary duodenal adenocarcinoma.
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Affiliation(s)
- Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Kazuhiro Tada
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Kunihiro Saga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Hiroomi Takayama
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Hiroki Uchida
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
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Indications and benefits of intraoperative esophagogastroduodenoscopy. Wideochir Inne Tech Maloinwazyjne 2018; 13:164-175. [PMID: 30002748 PMCID: PMC6041574 DOI: 10.5114/wiitm.2018.72740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy. Aim To evaluate the indications, benefits and risks of IOG. Material and methods A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed. Results The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG. Conclusions The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.
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Matsuda Y, Sakamoto K, Kataoka N, Yamaguchi T, Tomita M, Makimoto S. Perforation associated with endoscopic submucosal dissection for duodenal neoplasm without a papillary portion. World J Gastrointest Surg 2017; 9:161-166. [PMID: 28824748 PMCID: PMC5545134 DOI: 10.4240/wjgs.v9.i7.161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/03/2017] [Accepted: 06/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate predictors of perforation after endoscopic resection (ER) for duodenal neoplasms without a papillary portion.
METHODS This was a single-center, retrospective, cohort study conducted between April 2003 and September 2014. A total of 54 patients (59 lesions) underwent endoscopic mucosal resection (EMR) (n = 36) and endoscopic submucosal dissection (ESD) (n = 23). Clinical features, outcomes, and predictors of perforation were investigated.
RESULTS Cases of perforation occurred in eight (13%) patients (95%CI: 4.7%-22.6%). Three ESD cases required surgical management because they could not be repaired by clipping. Delayed perforation occurred in two ESD cases, which required surgical management, although both patients underwent prophylactic clipping. All patients with perforation who required surgery had no postoperative complications and were discharged at an average of 13.2 d after ER. Perforation after ER showed a significant association with a tumor size greater than 20 mm (P = 0.014) and ESD (P = 0.047).
CONCLUSION ESD for duodenal neoplasms exceeding 20 mm may be associated with perforation. ESD alone is not recommended for tumor treatment, and LECS should be considered as an alternative.
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Ichikawa D, Komatsu S, Dohi O, Naito Y, Kosuga T, Kamada K, Okamoto K, Itoh Y, Otsuji E. Laparoscopic and endoscopic co-operative surgery for non-ampullary duodenal tumors. World J Gastroenterol 2016; 22:10424-10431. [PMID: 28058023 PMCID: PMC5175255 DOI: 10.3748/wjg.v22.i47.10424] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/10/2016] [Accepted: 11/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors.
METHODS Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small (less than 10 mm) submucosal tumors (SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection (ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.
RESULTS Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications (Clavien-Dindo classification grade III or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.
CONCLUSION LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.
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