Abstract:Introduction: Gastrointestinal stromal tumors (GISTs), with a primary occurrence in the duodenum and proximal jejunum, are rare and treatment is poorly understood. This study aimed to evaluate the main factors influencing the prognosis of GIST resection in this complex anatomical structure. Materials and methods: This retrospective study included 47 patients who underwent surgery for primary GIST of the duodenum (20) and proximal jejunum (27) between 2012 and 2017. Perioperative clinical data as well as relaps… Show more
“…Las neoplasias duodenales primarias son raras y corresponden más frecuentemente a GIST. Por lo mismo, la evidencia se limita a series de casos que describen como único tratamiento curativo la resección 8 . Los adenocarcinomas de duodeno (excluyendo los ampulomas) son aún más raros, con un mal pronóstico debido a su diagnóstico tardío 5,9,10 .…”
Section: Discussionunclassified
“…El abordaje fue abierto en la mayoría de los casos, dado que se requería una resección en bloque (colon, riñón) o correspondían a casos de urgencia. La técnica laparoscópica fue una buena alternativa para el manejo de GIST limitados al duodeno 8 . Nuestra serie describe la experiencia con una técnica quirúrgica que, debido a lo infrecuente de su indicación, nos parece relevante dar a conocer.…”
Introducción: La resección duodenal distal (RDD) es una técnica quirúrgica compleja e infrecuente usada para el tratamiento de patologías duodenales o extraduodenales, que no comprometen la papila duodenal mayor, siendo su indicación más frecuente la patología neoplásica. Material y Métodos: Serie de pacientes sometidos a RDD entre 2009-2020 en el Hospital Clínico UC. Resultados: Total 12 pacientes, mediana de edad 56 años. Diagnóstico preoperatorio: tumores primarios duodenales (4), tumores con compromiso duodenal por contigüidad (5) y patologías de urgencia (3). El abordaje fue abierto en 9 pacientes y laparoscópico en 3 (1 caso convertido). En 9 pacientes se resecó D3-D4, en 1 paciente incluyó parte de D2 y en 2, sólo D4. La anastomosis duodenoyeyunal fue manual en 10 casos, todas con ascenso transmesocólico del asa yeyunal. Hubo 33% (n: 4) de morbilidad, todos Clavien Dindo II y 8% de mortalidad (n: 1). No hubo filtración de la anastomosis duodenoyeyunal. En el seguimiento ninguno presentó complicaciones y 4 pacientes fallecieron por progresión oncológica. Conclusión: La principal indicación quirúrgica fue patología neoplásica y en nuestra serie no hubo morbilidad mayor ni filtración anastomótica.
“…Las neoplasias duodenales primarias son raras y corresponden más frecuentemente a GIST. Por lo mismo, la evidencia se limita a series de casos que describen como único tratamiento curativo la resección 8 . Los adenocarcinomas de duodeno (excluyendo los ampulomas) son aún más raros, con un mal pronóstico debido a su diagnóstico tardío 5,9,10 .…”
Section: Discussionunclassified
“…El abordaje fue abierto en la mayoría de los casos, dado que se requería una resección en bloque (colon, riñón) o correspondían a casos de urgencia. La técnica laparoscópica fue una buena alternativa para el manejo de GIST limitados al duodeno 8 . Nuestra serie describe la experiencia con una técnica quirúrgica que, debido a lo infrecuente de su indicación, nos parece relevante dar a conocer.…”
Introducción: La resección duodenal distal (RDD) es una técnica quirúrgica compleja e infrecuente usada para el tratamiento de patologías duodenales o extraduodenales, que no comprometen la papila duodenal mayor, siendo su indicación más frecuente la patología neoplásica. Material y Métodos: Serie de pacientes sometidos a RDD entre 2009-2020 en el Hospital Clínico UC. Resultados: Total 12 pacientes, mediana de edad 56 años. Diagnóstico preoperatorio: tumores primarios duodenales (4), tumores con compromiso duodenal por contigüidad (5) y patologías de urgencia (3). El abordaje fue abierto en 9 pacientes y laparoscópico en 3 (1 caso convertido). En 9 pacientes se resecó D3-D4, en 1 paciente incluyó parte de D2 y en 2, sólo D4. La anastomosis duodenoyeyunal fue manual en 10 casos, todas con ascenso transmesocólico del asa yeyunal. Hubo 33% (n: 4) de morbilidad, todos Clavien Dindo II y 8% de mortalidad (n: 1). No hubo filtración de la anastomosis duodenoyeyunal. En el seguimiento ninguno presentó complicaciones y 4 pacientes fallecieron por progresión oncológica. Conclusión: La principal indicación quirúrgica fue patología neoplásica y en nuestra serie no hubo morbilidad mayor ni filtración anastomótica.
“…While a stapled side-to-side anastomosis would have been the ideal and preferred approach to create the anastomosis, it was not possible in this case due to the short length of the proximal jejunal limb, which prevented the use of a stapler to connect the ends of small bowel. In other circumstances where the jejunojejunostomy cannot be safely created due to the proximity to the ligament of Treitz, other surgical options such as a gastrojejunostomy, duodenojejunostomy or more complex bowel reconstruction must be considered, although they may result in higher rates of complications and worse outcomes [ 12 ]. Fig.…”
Section: Discussionmentioning
confidence: 99%
“…Our decision regarding the type of anastomosis to be created was based on the availability of only 5cm of proximal jejunum. Previous studies have shown no significant difference in anastomotic leak rates, morbidity or mortality between sutured versus stapled bowel anastomoses [ [12] , [13] , [14] ]. Today, while it is more common to perform a stapled anastomosis, the proximity of the proximal jejunal limb to the ligament of Treitz did not allow us to perform an adequately sized stapled side-to-side jejunojejunostomy.…”
Introduction
Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that occur along the alimentary tract, and are most commonly found in the stomach. Rarely, these tumors can occur in the small bowel, and when located in the duodenum or proximal jejunum, they may require challenging reconstruction of the alimentary tract. Patients with GISTs often present with non-specific abdominal pain or symptoms of obstruction, hemorrhage, and less commonly perforation.
Presentation of case
A 46-year-old male presented to the hospital with a one-day history of left upper quadrant pain with fevers and chills. Physical examination was significant for signs of peritonitis, and laboratory results revealed leukocytosis and lactic acidosis. CT abdomen showed a large soft tissue mass in the proximal jejunum. In the operating theater he was found to have a perforated jejunal tumor. Pathology report revealed a 13cm GIST, pT4N0M0, Stage IIIa. He had an uneventful recovery and was discharged nine days after surgery.
Discussion
Proximal jejunal GISTs are a rare entity and when present, perforation is unlikely. Pathological diagnosis of GISTs are relies on immunohistochemistry demonstrating c-KIT or CD34 positivity. The prognosis of GISTs are dependent on the size and the mitotic index. Definitive treatment of non-metastatic GISTs is R0 resection. When located in the duodenum or proximal jejunum, resection can be very challenging and may require clinical expertise in order to safely perform complex alimentary tract reconstruction.
Conclusion
Further investigation is required in order to determine best practice management for patients who present with proximal GISTs.
“…However, given that duodenal GIST are rare, the characteristics, prognosis, and optimal management have not been well clarified. More studies in the literature addressing the topic of duodenal GIST are limited by case reports [ 1 , 10 , 11 , 12 , 13 , 14 , 15 ] and small study populations [ 7 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. More rarely, there are larger single-/multi-institutional experiences [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].…”
Background: Duodenal gastrointestinal stromal tumors (GIST) are a rare subset of GIST. Their surgical management in this anatomically complex region consists of varied approaches, and the administration of imatinib mesylate (IM) has not been clarified. Methods: We retrospectively reviewed patients with duodenal GIST treated during a 10-year-period. We analysed the clinicopathological characteristics and survival factors and evaluated the perioperative and long-term outcomes based on the extent of resection ((ocal-resection (LR) versus pancreaticoduodenectomy (PD)) and the IM-administration. The median follow-up period was 60 months (range, 12–140). Results: A total of thirteen patients (M:F = 7:6) with median age of 64 years (range, 42–77) underwent resection of duodenal GIST. Median tumor size was 5.2 cm (range, 1.5–13.3). Eight patients (61.5%) underwent LR and five patients (38.5%) PD. R0-resection was achieved in 92.5%. Neoadjuvant IM-therapy was administered in five patients leading to tumor downsizing and in 40% to less-extended resection. The PD group consisted of larger tumors with higher mitotic count, mostly located in D2 (p = 0.031). The PD group had longer operative time (p = 0.026), longer hospital stay (p = 0.016), and higher rate of postoperative complications (p = 0.128). The actuarial 1-, 3-, and 5-year overall survival were 92.5%, 84%, and 73.5%, respectively, whereas the disease-free survival rates at 1, 3, and 5 years were 91.5%, 83%, and 72%, respectively. A tendency towards increased risk of disease recurrence was demonstrated for patients with tumor >5 cm and high-risk potential. There was not statistic survival benefit for one or the other surgical approach. Conclusion: The type of resection depends on duodenal site of origin and tumor size. LR can be the treatment of choice for duodenal GIST whenever technically feasible. Recurrence of duodenal GIST is dependent on tumor biology rather than surgical approach. Administration of IM in neaodjuvant setting should be considered in cases with high-risk GIST scheduled for PD since it might facilitate less-extended resection.
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