<p>Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy?</p>

Abstract

Background: Gastrointestinal stromal tumors (GIST) of the duodenum are rarely reported and optimal minimally invasive management has not been well proposed. Pancreaticoduodenectomy and different types of pancreas-sparing duodenectomy can be chosen; however, which to choose and its corresponding clinical outcomes and oncological concerns remain controversial. Patients and Methods: Patients diagnosed with GIST of duodenum underwent laparoscopic pancreaticoduodenectomy (L-PD) or pancreas-sparing duodenectomy (L-PSD) in Zhejiang Provincial People's Hospital were enrolled. All prospectively maintained data were analyzed retrospectively. Patients were grouped into the L-PD group or the L-PSD group, and the clinical outcomes and oncological outcomes were analyzed. Results: Between June 2013 and March 2019, a total of 22 patients (11 males/11 females) underwent surgical management, including 13 L-PDs and 9 L-PSDs. The average age was 58.2 ±9.5 year-old (median 60.5 year-old). The most common presentations were GI bleeding (54.5%) and abdominal discomfort (27.2%), and the dominant lesion located in the second portion of duodenum (59.1%). Compared with L-PD group, L-PSD group showed much shorter operation time (364.2±58.7min vs. 230.0±12.3min, P<0.001), less blood loss (176.9±85.7mL vs. 61.1±18.2min, P<0.001), faster recovery to off-bed (2.6±1.3d vs. 1.1±0.3d, P=0.003), anus flatus (4.5±1.0d vs. 2.4±0.5d, P<0.001) and liquid intake (4.9±1.3d vs. 2.3±0.5d, P<0.001). Lymph node retrieval was much less in L-PSD, but no lymph node metastasis was observed in any patients. L-PSD had much Lower morbidity of both minor (Grade I/II) and major (III/IV/V) complications than that of L-PD (11.1% vs. 61.6%, P=0.02), resulting in shorter hospital stays (10.9±3.8d vs. 20.6±11.1d, P=0.021) and less total cost (76,972.4±11,614.8yuan vs 125,628.7 ±46,356.8yuan, P=0.006). The median follow-up was 42 months (range from 12 to 82months) without loss. Only 1 L-PD patient suffered hepatic metastasis 36months after surgery, and given sunitinib to stabilize the disease, none of the rest observed recurrence or metastasis. Conclusion: For GIST located opposite the major papilla, L-PSD showed comparable safety and oncological benefits when compared to L-PD, with shorter operation time, less blood loss and much faster recovery time, resulting in much less total cost. L-PSD should be applied in selected patients with experienced hands.

Laparoscopic pancreas-preserving near total duodenectomy for large villous adenoma in patients with total colectomy for familial adenomatous polyposis

“…tomy is shown to be comparable safe and favorable short-term oncologic outcome comparing with laparoscopic PD in terms with less blood loss, much faster recovery time, and much less total cost [4].…”

“…In line with this concept, we previously reported the technical feasibility and safety of laparoscopic partial sleeve duodenectomy for an infraampullary gastrointestinal stromal tumor of the duodenum [ 3 ], and laparoscopic pancreas-sparing duodenectomy is shown to be comparable safe and favorable short-term oncologic outcome comparing with laparoscopic PD in terms with less blood loss, much faster recovery time, and much less total cost [ 4 ].…”

Current surgical management of duodenal gastrointestinal stromal tumors

“…A recent study of 22 patients with D-GISTs located opposite the ampulla of Vater, both laparoscopic PD and laparoscopic pancreas-sparing duodenectomy have been shown to confer comparable safety and oncological benefits[ 57 ]. It is important to take note that the laparoscopic pancreas-sparing duodenectomy group had shorter operative duration (364.2 ± 58.7 vs 230.0 ± 12.3 min, P < 0.001), less blood loss (176.9 ± 85.7 vs 61.1 ± 18.2 mL, P < 0.001) and much shorter recovery time (10.9 ± 3.8 vs 20.6 ± 11.1 d, P = 0.021), resulting in lower total cost (76972.4 ± 11614.8 yuan vs 125628.7 ± 46356.8 yuan, P = 0.006).…”

A narrative review of surgical management of gastrointestinal stromal tumors

“…The patients in the LR group had fewer late complications than in the PD group and no postoperative newly developed diabetes mellitus. The MI-LR group had a shorter duration of surgery and a shorter length of postoperative hospital stay (28).…”