Laparoscopic resection of duodenal gastrointestinal stromal tumour.

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.

INTRODUCTION

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.[2345]

Only a few studies revealed using laparoscopic technique with limited resection of GISTs; emphasising that there is very little experience with duodenal GIST.[67]

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

PRESENTATION OF CASE

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

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

Figure 3

Tumour resected over the gastroscope

Figure 4

Tumour specimen

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

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,[1112] 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,[23] 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 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

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.

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Conflicts of interest

There are no conflicts of interest.