Laparoscopic and endoscopic co-operative surgery for non-ampullary duodenal tumors

Abstract

AIMTo assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors.METHODSTwelve 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.RESULTSTwo 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.CONCLUSIONLECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.

Current Status of Endoscopic Resection for Superficial Nonampullary Duodenal Epithelial Tumors

“…LECS is an effective backup technique that avoids the risk of delayed perforation after duodenal ESD, but it must be performed in a surgical theatre with the patient under general anesthesia. The recurrence rate after LECS was reportedly 0% [19-21], but only small case series are reported for LECS. Thus, large-scale multicenter studies are needed to clarify the usefulness of the LECS.…”

“…LECS, in which the mucosal defect after ESD is closed from the outside of the lumen using laparoscopic suture, was recently implemented for treatment of large SNADETs (≥20 mm) [19-21]. LECS is an effective backup technique that avoids the risk of delayed perforation after duodenal ESD, but it must be performed in a surgical theatre with the patient under general anesthesia.…”

“…Conversely, endoscopic submucosal dissection (ESD) can achieve complete resection regardless of lesion size, but it was also accompanied by high adverse event rates [13-18]. To prevent adverse events after ESD, laparoscopic-endoscopic cooperative surgery (LECS), in which the mucosal defect after ESD is closed by laparoscopic suture from the outside of the duodenal lumen, was recently implemented to treat patients with SNADETs [19-21]. Although LECS requires complicated equipment and procedures, it is an effective backup technique.…”

Laparoscopic and endoscopic cooperative surgery for non-ampullary duodenal epithelial neoplasms

“…Duodenal stenosis occurred in the case of open conversion but was treated by repeated endoscopic balloon dilatation. ESD: endoscopic submucosal dissection In the literature [10][11][12][13][14][15] , a total seven authors reported a series of LECS for NADENs where the lesions were treated by either ESD and subsequent laparoscopic repair or endoscopy-assisted laparoscopic full-thickness resection and repair without any serious intra-and postoperative complications, corresponding to our results [ Table 3]. In those reports, surgery was occasionally performed for adenocarcinomas confined in the mucosa, but no tumor recurrence was noted in the postoperative course, revealing the feasibility of the indication of LECS for NADENs.…”

“…Similarly, recent reports demonstrated that LECS offers a promising procedure of choice to facilitate less invasive surgery in the treatment of NADENs [10][11][12][13][14][15] , but the clinical evidence verifying its efficacy remains limited. In this report, we sought to investigate our initial experience of LECS for NADENs and further reveal its clinical significance.…”