Surgical management of superficial non-ampullary duodenal tumors

Signet-ring cell carcinoma of the duodenal bulb presenting with gastrointestinal hemorrhage: a case report and literature review

Background

Primary duodenal cancer (PDC) is rare, especially signet-ring cell carcinoma (SRCC) of the duodenal bulb, and it is commonly misdiagnosed as an ulceration. Here, we report a rare case of SRCC of the duodenal bulb presenting with gastrointestinal hemorrhage in an 82-year-old man.

Case presentation

An 82-year-old man was admitted for gastrointestinal hemorrhage. Physical examination revealed upper abdominal tenderness and pale appearance, but was otherwise unrevealing. Laboratory workup was significant for anemia. Imaging showed no abnormalities. Two endoscopic evaluations along with interventional embolization were attempted and, unfortunately, adequate hemostasis was not achieved, resulting in distal subtotal gastrectomy, including the duodenal bulb. SRCC of the duodenal bulb was diagnosed based on pathology after surgery. Post-operatively, the patient experienced persistent gastrointestinal bleeding. Family declined further intervention and the patient eventually died one month post-resection.

Conclusions

SRCC in the duodenal bulb is difficult to diagnose. For those with high-risk factors, endoscopic examination and biopsy are recommended. For patients who can receive radical tumor resection, pancreaticoduodenectomy (PD) is considered a first-line option. Early diagnosis and resection have been shown to improve prognosis.

ESD-aid surgery as a new treatment strategy for duodenal adenoma

OBJECTIVE

The treatment for nonampullary duodenal adenoma remains to have no consensus and established methods. Although endoscopic treatment is minimally invasive, it was reported to cause delayed perforation in more than 20% of cases. For adenomas in the duodenum, we performed endoscopic submucosal dissection (ESD)-aid surgery, which is a procedure to prophylactically suture the seromuscular structure of the duodenum after ESD. In this procedure, we did not perform Kocher mobilization prior to ESD to facilitate endoscopic resection and full-thickness resection to prevent spread of the tumor and infection to the abdominal cavity. The duodenal wall was reinforced in planes using a suture clip.

RESULTS

Of the 13 cases of duodenal adenoma that underwent ESD-aid surgery at our hospital between April 2018 and December 2020, 1 developed postoperative bleeding, but there was no late perforation. For duodenal adenomas, ESD-aid surgery was considered a safe and minimally invasive treatment.

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.

Clinical characteristics and course of sporadic non-ampullary duodenal adenomas: A multicenter retrospective study

Sporadic non-ampullary duodenal adenoma (SNADA) is a rare disease, and therefore, its clinical characteristics have not been comprehensively investigated. Furthermore, owing to the high complication rates and severity of endoscopic resection, treatment strategies vary among facilities. In the present study, we aimed to clarify the clinical characteristics and course of SNADA.We extracted clinical and histological records of SNADA cases diagnosed in 11 hospitals between September 1999 and August 2014. The patients were divided into "no-resection" and "resection" groups based on the initial treatment approach. We investigated the long-term outcome of the "no-resection" group and treatment results of the "resection" group, with particular interest in endoscopic resection.Overall, 299 patients were diagnosed with SNADA. The median age at diagnosis was 67 years (range, 31-88 years), with approximately twice as many men as women. The median tumor size was 8.0 mm (2-60 mm). In total, 161 patients were initially selected for no-resection and 138 underwent resection. Age >70 years and the presence of either severe illness or poor performance status were significantly related to opting for no-resection. In the no-resection group, 101 patients underwent endoscopic follow-up for at least 1 year. During the observational period (2.5 ± 2.2 years), 27 lesions (27%) disappeared following cold forceps biopsy, and 13 lesions (14%) presented lateral growth. Four lesions (4%) changed to mucosal carcinoma, 3 were treated endoscopically, and 1 was surgically resected. Nineteen patients died; however, no one died of duodenal carcinoma. In the endoscopic resection group, en bloc resection was achieved in 78% of patients. However, the complication rate for perforation was 7%, and endoscopic submucosal dissection was associated with a 36% perforation rate.With the low incidence of cancer development and no disease specific death, the strategy of initially not performing resection could be considered especially for the older adults, poor-prognosis patients, or small lesions.

Robotic Resection of Giant Duodenal Hamartoma After 18Fluorodeoxyglucose Positron Emission Tomography Magnetic Resonance Imaging (18FDG PET-MRI)

Brunner's gland hamartoma is a rare duodenal lesion. Resection for benign neoplasms of the duodenum should be considered in case of malignant potential or in case of symptomatic lesions. An accurate preoperative staging is mandatory in order to allow minimally invasive surgical approach, and to avoid under- or overtreatment. Endoscopic ultrasonography (EUS), Computed tomography (CT) scan, Magnetic Resonance Imaging (MRI) and PET/CT are techniques widely used for gastrointestinal tumor staging. We report a case of a 41-year-old female presenting a giant lesion of the second portion of the duodenum. Pathological examination of multiple forceps biopsies was inconclusive for histological characterization of the lesion. After a clinical staging including Esophagusgastroduodenoscopy, EUS, and CT scan, a Hybrid ¹⁸FDG PET/MRI was performed to assess the malignant potential of the lesion and the relation between polyp base and Vater's papilla. After multidisciplinary meeting, the patient underwent robotic transduodenal excision. The post-operative course was uneventful, and the patient was discharged on post-operative day 5. Final pathologic report consists in a histologically of Brunner's Glands Hamartoma. This is the first report on the role of ¹⁸FDG PET/MRI in staging and planning treatment of bulky low malignant duodenal lesion. An accurate staging with ¹⁸FDG PET/MRI could be very useful in the planning the management of duodenal lesion with uncertain malignant potential in order to avoid under- and overtreatment.

Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions

Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.

Laparoscopic resection of duodenal carcinoid: A feasible method: Single institute case series

Background

Duodenal carcinoids (neuroendocrine tumour) are rare tumour, but recently, increase in incidence has been noted. Various techniques for excision of tumour have been described in literature, but very few case reports and case series have mentioned about laparoscopic management of carcinoid tumour. We describe a case series of seven cases of duodenal non-periampullary carcinoids which was managed by laparoscopic method.

Aims

The aim of the study was to check feasibility of laparoscopic management of duodenal carcinoid and technique of surgery.

Settings and Design

This study design was a case series and prospective data were retrospectively collected.

Materials and Methods

A total of 7 patients were operated for carcinoid tumour of duodenum mainly involving first part by laparoscopic method from February 2016 to January 2017. All patients were followed up for minimum 1-year period and various pre-operative, intra-operative findings and post-operative outcome were noted.

Results

Out of seven patients, 6 patient were managed by laparoscopic duodenotomy and transduodenal excision whereas one patient required duodenectomy of first part. Mean operative time was 99 min, mean intraoperative blood loss was 55.7, mean hospital stay was 99.7 and no recurrence in a 1-year follow-up.

Conclusions

Laparoscopic excision of carcinoid tumour is safe, technically reproducible and feasible method.

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.

Duodenal tubular resection using laparoscopic-endoscopic cooperative surgery: A new technique for the treatment of duodenal lesions

INTRODUCTION

Laparoscopic-endoscopic cooperative surgery (LECS) is a minimally invasive surgical technique that combines the advantages of laparoscopic surgery and endoscopic treatment. LECS has been developed for treatment of gastric submucosal tumors and can be applied to superficial non-ampullary duodenal tumors. Here we describe the use of LECS for duodenal mucosal cancer.

MATERIALS AND SURGICAL TECHNIQUE

After the placement of five ports, an endoscopic procedure was performed to confirm the tumor location and to place marks around the tumor. The jejunum was then resected 10 cm from the ligament of Treitz, and the connective tissue between the pancreas and duodenum was dissected to close to Vater's papilla. Duodenal resection was performed with a stapling device 2 cm to the oral side of the tumor, with endoscopic confirmation of the duodenal papilla, and duodenal tubular resection was then accomplished. Duodeno-jejunostomy was carried out using the same stapling device. There were no postoperative complications.

DISCUSSION

This case shows that duodenal tubular resection using LECS enables curability through a minimally invasive procedure that offers the advantages of laparoscopic surgery and endoscopic treatment. This technique is applicable to duodenal lesions such as those due to duodenal mucosal cancers.

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.

Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis (FAP), but nonampullary sporadic duodenal adenomas (SDAs) are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polyp-free duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAP-related polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.

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

INTRODUCTION

Transduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low-grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy-assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non-ampullary duodenal epithelial tumors.

METHODS

Three patients with superficial non-ampullary duodenal epithelial tumors (mucosal adenocarcinoma, n = 1; tubular adenoma, n = 2) underwent LATDE. LATDE consists of four major procedures: (i) laparoscopic wide Kocher maneuver (mobilization of the pancreaticoduodenum); (ii) extracorporeal approach to the fully mobilized duodenum through the upper median longitudinal incision (4 cm in length); (iii) tumor excision by submucosal dissection under direct vision through longitudinal duodenotomy (4 cm in length); and (iv) hand-sewn closure of the mucosal defect and duodenotomy.

RESULTS

LATDE was successfully carried out without any intraoperative or postoperative adverse events. The mean operating time and estimated blood loss were 155 min and 17 mL, respectively. Contrast roentgenography on postoperative day 4 showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients.

CONCLUSIONS

LATDE could eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracorporeally. The meticulously hand-sewn closures of the mucosal defect and duodenotomy can minimize the possibility of postoperative hemorrhage and/or anastomotic leakage. LATDE is a feasible, safe, and minimally invasive treatment for patients with superficial non-ampullary duodenal epithelial tumors that have no risk of lymph node metastasis in the first and second portions of the duodenum.

Treatment for superficial non-ampullary duodenal epithelial tumors

Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.