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 ¤  Abstract
 ¤ Introduction
 ¤ Presentation of Case
 ¤ Discussion
 ¤ Conclusion
 ¤  References
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 Table of Contents     
HOW I DO IT DIFFERENTLY
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 157-160
 

Laparoscopic resection of duodenal gastrointestinal stromal tumour


1 Department of Surgery “A”, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
2 Department of Gastroenterology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel

Date of Submission05-May-2016
Date of Acceptance15-Aug-2016
Date of Web Publication9-Mar-2017

Correspondence Address:
Boris Kirshtein
Department of Surgery “A”, Soroka University Medical Center, POB 151, Beersheba 84101
Israel
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.195576

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 ¤ Abstract 

Only a few studies have revealed using laparoscopic technique with limited resection of gastrointestinal stromal tumour (GIST) of the duodenum. A 68-year-old man was admitted to the hospital due to upper gastrointestinal (GI) bleeding. Evaluation revealed an ulcerated, bleeding GI tumour in the second part of the duodenum. After control of bleeding during gastroduodenoscopy, he underwent a laparoscopic wedge resection of the area. During 1.5 years of follow-up, the patient is disease free, eats drinks well, and has regained weight. Surgical resection of duodenal GIST with free margins is the main treatment of this tumour. Various surgical treatment options have been reported. Laparoscopic resection of duodenal GIST is an advanced and challenging procedure requiring experience and good surgical technique. The laparoscopic limited resection of duodenal GIST is feasible and safe, reducing postoperative morbidity without compromising oncologic results.


Keywords: Duodenum, gastrointestinal stromal tumour, laparoscopy


How to cite this article:
Zioni T, Dizengof V, Kirshtein B. Laparoscopic resection of duodenal gastrointestinal stromal tumour. J Min Access Surg 2017;13:157-60

How to cite this URL:
Zioni T, Dizengof V, Kirshtein B. Laparoscopic resection of duodenal gastrointestinal stromal tumour. J Min Access Surg [serial online] 2017 [cited 2017 Apr 27];13:157-60. Available from: http://www.journalofmas.com/text.asp?2017/13/2/157/195576



 ¤ Introduction Top


Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the digestive tract. The stomach and small bowel are the most common primary locations of GIST. Three to 5% of GISTs are located in the duodenum and are associated with an increased risk of gastrointestinal (GI) bleeding as a primary manifestation.[1]

Complete surgical resection with clear margins is thought to be the treatment of choice for GISTs. Due to technical complexity in obtaining wide surgical margins with duodenal GIST, present surgical options are not clear. Some authors support the selective use of limited resection, and others prefer pancreaticoduodenectomy. Surgical techniques depend on tumour location in the duodenum, size, and relation to surrounding structures.[2],[3],[4],[5]

Only a few studies revealed using laparoscopic technique with limited resection of GISTs; emphasising that there is very little experience with duodenal GIST.[6],[7]

Herein, we present a case of a man who presented with a bleeding duodenal GIST and underwent a successful laparoscopic resection.


 ¤ Presentation of Case Top


A 68-year-old man with a medical history of BPH and glaucoma was admitted to the hospital with upper GI bleeding, presenting as general weakness and melena. He underwent resection of sessile polyp in the gastroesophageal junction and treated with PPI 3 years before admission. On admission his blood pressure was 118/72 mmHg, pulse 81 beats/min, haemoglobin level was 8.5 g/dL. After transfusion of 2 units of packed cells, his haemoglobin level was unchanged. Gastroduodenoscopy showed a bleeding submucosal 5 cm tumour, with ulceration in the centre and a large clot, in the second part of the duodenum. Clot washing resulted in bleeding worsening. Bleeding was controlled by adrenalin injection, clips and argon plasma coagulation.

The following gastroscopy, he was admitted to the surgical department. On admission he was hemodynamically stable, physical examination revealed paleness and some epigastric sensitivity. There was no blood in the nasogastric tube. The next day abdominal computer tomography showed a round exophytic space-occupying lesion that looked to be an integral part of the duodenum, located between the second and third parts of the duodenum, measuring 55 mm × 56 mm, with air bubbles inside, suspected to be a GIST [Figure 1]. A few enlarged retroperitoneal lymph nodes were demonstrated, the largest 7 mm in diameter. The patient was considered for laparoscopic tumour resection.
Figure 1: Abdominal computed tomography scan showing duodenal gastrointestinal stromal tumour with air bubbles inside

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Diagnostic laparoscopy found a mass arising between the second and third parts of the duodenum adjacent to the transverse mesocolon and covered by a small amount of fibrin [Figure 2]. Laparoscopic dissection of tumour from surrounding tissue was performed. Insertion of 36F Boogie was unsuccessful due to distal tumour location. A gastroscope was inserted and passed beyond the tumour. Laparoscopic wedge resection of the duodenum wall including the tumour with 2 fires of Eshelon Flex Endopath ® Stapler 60 mm Golden Cartridge (Ethicon Endo-surgery, J and J) over the gastroscope was done [Figure 3]. The specimen [Figure 4] was extracted from the peritoneal cavity in a bag, and the abdominal wall was closed with Vicryl 2/0.
Figure 2: Tumour with fibrin on laparoscopy

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Figure 3: Tumour resected over the gastroscope

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Figure 4: Tumour specimen

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Pathological examination revealed a unifocal, low grade (mitotic count less than 1 per 50 HPF) GIST, of spindle cell subtype, stained positive for c-kit. The tumour was 5 cm in the largest diameter (including the area of necrosis – 80%). Surgical margins were clear.

On a post-operative day (POD) 4 the patient suffered from vomiting. Contrast X-ray of the duodenum showed a filiform passage of contrast agent, probably due to oedema in the operated site. In the next few days, he gradually started drinking and eating and was discharged on POD 8. Gastroscopy was performed 2 months later due to the difficulty of food passage. The gastroscope was passed freely through the second and third parts of the duodenum, and there was no stricture found. After 1.5 years follow-up, the patient eats drinks well and has regained weight.


 ¤ Discussion Top


GISTs of the duodenum are relatively rare tumours, accounting for nearly 30% of all primary tumours of the duodenum.[8] The clinical presentations of duodenal GISTs are highly variable in size and the existence of mucosal ulceration. The most common clinical presentation of duodenal GISTs has been reported to be GI bleeding or abdominal pain. For GISTs of the foregut, GI endoscopy may be diagnostic whenever the tumour is located in the stomach or the upper duodenum. On the other hand, GISTs of the distal duodenum may remain undetected at GI endoscopy. Alternative diagnostic means include computed tomography, magnetic resonance imaging, barium study or ultrasonography.[9]

Surgery is the mainstay of treatment for localised, resectable GISTs. The tumour should be removed en bloc with its pseudocapsule to yield an adequate resection margin. The optimal width of the tumour-free margin has not been defined, and it is unclear if re-resection is beneficial for positive microscopic surgical margins (R1), especially as the free radial margin is the one that is positive in most instances and there is no additional tissue to be removed.[8]

A GIST arising from the duodenum is more problematic because of adjacent anatomy. Although large GISTs more frequently dictate resection of adjacent structures, a small GIST may arise at organ interfaces or potentiate a desmoplastic reaction, which dictates resection of adjacent structures.[10] Surgical removal of duodenal GISTs may be accomplished by several options, ranging from minimal to major procedures. Limited resection should be considered a viable treatment option for duodenal GISTs when technically feasible. Various techniques of limited resection for duodenal GISTs have been advocated depending on the site and the size of the tumours. Wedge resection with primary closure can be performed for small lesions if the resulting lumen is adequate and the ampulla of Vater can be preserved. Segmental duodenectomy with side-to-end or end-to-end duodenojejunostomy can be performed for larger tumours located at the third and fourth portions of the duodenum. Partial duodenectomy with Roux-en-Y duodenojejunostomy can be performed for larger tumours involving the antimesenteric border of the second and third portions of the duodenum. An aggressive surgical approach may be required for complete removal. Major resection via a pancreaticoduodenectomy or a pancreas-sparing duodenectomy is indicated when the tumours are located at the second portion of the duodenum.[9]

A 5 cm GIST was resected laparoscopically from the second part of duodenal wall. The patient went through laparoscopic limited resection, a procedure with relatively low postoperative morbidity and short hospital stay.

Kim et al.[6] reported a series of 125 laparoscopic resections of gastroduodenal GISTs. However, in two cases of duodenal bulb, they performed preventive laparoscopic gastrojejunostomy due to structural deformity following wedge resection. Actually, a case included in area of tumour location with gastric outlet obstruction. In this case, the lesion was located at the antrum, lesser curvature side. Possibly, longitudinal stapling creates structural deformity and gastric outlet obstruction.

Laparoscopic wedge resection of the duodenal wall lowers operative morbidity and complications,[11],[12] but offers a few challenges.

The first concern is resection of the tumour with clear margins, a goal that is achieved by meticulous dissection of the surrounding tissues. Due to the fact that GISTs, unlike carcinoma, rarely metastasize to regional lymph nodes or infiltrate to surrounding tissue microscopically,[2],[3] that dissection was satisfactory. A rupture of the tumour has to be strictly avoided during surgery to prevent intraperitoneal seeding and haemorrhage. A gentle touch technique should be applied, as GISTs tend to have a friable consistency.

The second concern was resecting the wall, and leaving a wide enough lumen for the passage of digested food. Horizontal tumour resection and suturing, and reconstruction of duodenal wall such as  Heineke-Mikulicz pyloroplasty More Details can prevent bowel lumen narrowing. Intraoperative insertion of wide NG tube or Boogie (more than 36F diameter) is another possibility. In our case, the use of gastroscopy intraoperatively, simultaneously with the resection, ensured that goal. Two months later, expansion of the operative area endoscopically improved results. This technique limited the amount of resection, and we were able to avoid the extensive resection of adjacent nontumourous organs and the need for bowel anastomosis.


 ¤ Conclusion Top


To the best of our knowledge, only a few cases of laparoscopic wedge resection of duodenal GISTs have been reported. The laparoscopic limited resection in this challenging area is feasible and safe, reducing postoperative morbidity without compromising oncologic results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Hecker A, Hecker B, Bassaly B, Hirschburger M, Schwandner T, Janssen H, et al. Dramatic regression and bleeding of a duodenal GIST during preoperative imatinib therapy: Case report and review. World J Surg Oncol 2010;8:47.  Back to cited text no. 1
    
2.
Goh BK, Chow PK, Kesavan S, Yap WM, Wong WK. Outcome after surgical treatment of suspected gastrointestinal stromal tumors involving the duodenum: Is limited resection appropriate? J Surg Oncol 2008;97:388-91.  Back to cited text no. 2
    
3.
Machado NO, Chopra PJ, Al-Haddabi IH, Al-Qadhi H. Large duodenal gastrointestinal stromal tumor presenting with acute bleeding managed by a Whipple resection. A review of surgical options and the prognostic indicators of outcome. JOP 2011;12:194-9.  Back to cited text no. 3
    
4.
Chung JC, Chu CW, Cho GS, Shin EJ, Lim CW, Kim HC, et al. Management and outcome of gastrointestinal stromal tumors of the duodenum. J Gastrointest Surg 2010;14:880-3.  Back to cited text no. 4
    
5.
Mennigen R, Wolters HH, Schulte B, Pelster FW. Segmental resection of the duodenum for gastrointestinal stromal tumor (GIST). World J Surg Oncol 2008;6:105.  Back to cited text no. 5
    
6.
Kim DJ, Lee JH, Kim W. Laparoscopic resection for 125 gastroduodenal submucosal tumors. Ann Surg Treat Res 2014;86:199-205.  Back to cited text no. 6
    
7.
Chen YH, Liu KH, Yeh CN, Hsu JT, Liu YY, Tsai CY, et al. Laparoscopic resection of gastrointestinal stromal tumors: Safe, efficient, and comparable oncologic outcomes. J Laparoendosc Adv Surg Tech A 2012;22:758-63.  Back to cited text no. 7
    
8.
Liang X, Yu H, Zhu LH, Wang XF, Cai XJ. Gastrointestinal stromal tumors of the duodenum: Surgical management and survival results. World J Gastroenterol 2013;19:6000-10.  Back to cited text no. 8
    
9.
Chung JC, Kim HC, Chu CW. Segmental duodenectomy with duodenojejunostomy of gastrointestinal stromal tumor involving the duodenum. J Korean Surg Soc 2011;80 Suppl 1:S12-6.  Back to cited text no. 9
    
10.
Kamath AS, Sarr MG, Nagorney DM, Que FG, Farnell MB, Kendrick ML, et al. Gastrointestinal stromal tumour of the duodenum: Single institution experience. HPB (Oxford) 2012;14:772-6.  Back to cited text no. 10
    
11.
Van de Walle P, Dillemans B, Vandelanotte M, Proot L. The laparoscopic resection of a benign stromal tumour of the duodenum. Acta Chir Belg 1997;97:127-9.  Back to cited text no. 11
    
12.
Kato M, Nakajima K, Nishida T, Yamasaki M, Nishida T, Tsutsui S, et al. Local resection by combined laparoendoscopic surgery for duodenal gastrointestinal stromal tumor. Diagn Ther Endosc 2011;2011:645609.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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