Two cases of laparoscopic direct spiral closure of large defects in the second portion of the duodenum after laparoscopic endoscopic co-operative surgery.

Curative endoscopic resection of non-ampullary duodenal lesions, although possible, is challenging. In recent years, although a novel surgical technique named laparoscopic-endoscopic cooperative surgery (LECS), which combines laparoscopic and endoscopic techniques, has made the resection of nonampullary duodenal lesions relatively easier, closure of the defect is still controversial. We report two cases of the duodenal lesion which were closed using a novel technique for primary closure utilising the free wall of the duodenum. Two cases of the duodenal lesion in the second portion of the duodenum were undergone full thickness resection using the LECS technique. The defect is designed spirally to ensure maximum use of the free wall of the duodenum. The mucosal layer is closed using a running suture, and the seromuscular layer is closed using interrupted sutures. The suture line is then reinforced with omentum. There were no intraoperative complications and had uneventful post-operative courses with no leakage, stenosis, or relapse.

INTRODUCTION

Management of non-ampullary duodenal adenomas and early duodenal cancer present surgeons with unique challenges. While endoscopic curative resection of these lesions is possible, limited space inside the duodenum and the thin duodenal wall make endoscopic submucosal dissection (ESD) a challenging procedure even for experienced surgeons.[12] Perforation rates, including delayed perforation following this procedure, reportedly range from 10% to 35.7%.[345] Delayed bleeding is another major complication.[6] These limit the performance of endoscopic resection of non-ampullary duodenal lesions to high volume centres with highly experienced endoscopists.[2]

Hiki et al.[7] described a novel surgical technique named laparoscopic-endoscopic cooperative surgery (LECS), which combines laparoscopic and endoscopic techniques to surgically remove the gastric gastrointestinal stromal tumours. In recent years, this technique has also been used for the resection of non-ampullary duodenal lesions.[89] While the technique has eased the resection of duodenal tumours, the procedure, especially the closure of the defect is still technically difficult. Medially, the duodenum is attached to the pancreatic head, limiting the duodenal wall area that can be used for closure. This is particularly pronounced in the second portion of the duodenum. While this does not pose a significant challenge during resection of small lesions, closure of the defect after resection of larger lesions, which require the resection of more than half the circumference of the duodenal wall, is quite challenging. Conventionally, large defects in the duodenal wall are closed using a jejunal serosal patch or Roux-en-Y duodenojejunostomy.[10] These procedures require division, mobilisation and anastomosis of the digestive tract, which makes the procedure technically difficult. We developed a novel technique for primary closure of the duodenal wall defect utilising the free wall of the duodenum as much as possible. Our novel technique is a relatively easier option for the repair of large duodenal defects. The aim of this paper is to report our technique and the short-term results of its use.

CASE REPORTS

Case 1

The patient was 70-year-old male. Duodenal lesion located in the second portion of the duodenum was identified during screening upper gastrointestinal endoscopy. Biopsy showed the lesion to be suspected case of duodenal carcinoma. Endoscopic ultrasound showed that tumour invasion limited to mucosa level. Computed tomography (CT) showed no lymph node or distant metastasis.

Case 2

ThePatient was 61-year-old female who as being followed up after curative resection of breast cancer. Her follow-up blood test revealed elevated serum carcinoembryonic antigen. Duodenal lesion located in the second portion of the duodenum was identified during the upper gastrointestinal endoscopy. Biopsy of the lesion showed suspected case of duodenal cancer. The depth of the tumour was found to be within mucosa layer, and CT revealed no lymph node or distant metastasis.

LECS procedure was planned for both the patients after explaining the need for further treatment, including pancreaticoduodenectomy with lymph node dissection, if the depth of the tumour was deeper than the mucosa, or if the resection was incomplete. Written, informed consent was obtained from both the patients.

Surgical technique

Under general anaesthesia, the patients are placed in the supine, reverse trendelenburg position with their legs apart. A 12 mm trocar (Excel; Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA) is inserted through an incision in the umbilicus. After a carbon dioxide pneumoperitoneum is created at a pressure of 10 mmHg, an electrolaparoscope (WA50013; Olympus Medical Systems, Tokyo, Japan) is introduced through the port, and four other trocars are positioned as shown in Figure 1. We use laparoscopic coagulation shears (SonoSurg-X; Olympus Medical Systems, Tokyo, Japan or Harmonic Ace; Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA) for vessel coagulation. The surgeon stands between the legs of the patient, the first assistant on the left side of the patient and the endoscopist on the right side of the patient. The Kocher manoeuvre is performed to free the duodenal wall. The location of the tumour is then confirmed both endoscopically and laparoscopically. We then perform full-thickness resection of the tumour using the LECS technique as described by Sakon et al.[8] During the procedure, 3-0 prolene sutures are used to lift the cut ends of the duodenal wall to avoid spillage of the duodenal contents into the abdominal cavity. The resected tumour is immediately placed in a plastic bag and removed through the umbilical incision. The specimen is checked to ensure that it has an adequate margin.

Figure 1

Trocar placement. The circles represent 12 mm trocars and triangles represent 5 mm trocars. The 12 mm trocar in the umbilicus was used for the camera. Two 12 mm trocars on either side of the camera port were used by the operator, the 5 mm trocar on the left side was for the assistant, and that in the epigastrium was for retraction of the liver

Closure technique

We laparoscopically perform the spiral closure technique utilising the free wall of the duodenum. Spiral closure is attempted when the size of the defect is less than half the circumference of the duodenal lumen. The surgeon first approximates the edges of the defect. The anterior free wall of the duodenum above the defect is twisted and slid posteriorly and the posterior free wall below the defect is twisted and slid anteriorly to mobilize the free wall from the lateral and posterior surfaces and design the defect spirally [Figure 2]. This is done to ensure maximum use of the free wall of the duodenum. Stay sutures are placed at both edges of the defect using 3-0 prolene (Ethicon, Somerville, NJ, USA) sutures. The mucus layer is closed using a running suture with 3-0 vicryl (Ethicon, Somerville, NJ, USA). The seromuscular layer is then closed using interrupted sutures with 3-0 prolene. During the procedure, the assistant employs frequent use of suction to limit the spillage of duodenal contents into the abdominal cavity and avoid contamination. After the closure, the operative field is thoroughly lavaged using a saline solution. Intraoperative endoscopy is performed to check for stenosis and leakage [Figure 3a]. The suture line is then reinforced by covering it with omentum, which is fixed in place with 3-0 prolene sutures. There were no intraoperative complications, and none of the cases were converted to open surgery. Both patients had uneventful postoperative courses. The details of both cases are summarised in Table 1. A solid diet was started on the postoperative day 3 in both cases, and they were discharged on postoperative days 13 and 14, respectively. Gastroduodenography performed after few months in the outpatient department showed no stenosis or leakage [Figure 3b]. The pathological diagnosis in both cases was adenocarcinoma, with the final pathological staging of Case 1 being pT1a (m) cN0 ly (-) v (-) cM0 Stage Ia and that of Case 2 being Tis cN0 ly (-) v (-) cM0 Stage 0 according to the TNM Classification 7th Edition. Both the cases are being followed up 36 and 31 months later, respectively, without recurrence.

Figure 2

Spiral closure of the defect. (a) The defect in the second portion of the duodenum. The coloured dots represent the edge of the defect. (b) The duodenal wall on the oral and anal sides of the defect are twisted as shown by the arrows and the free wall of the duodenum is slid to close the defect by mobilising and utilising the free wall of the duodenum as much as possible. The colored dots show the locations of the edges of the defect after arranging the defect for the spiral closure

Figure 3

(a) Postoperative endoscopy showing the suture line. The lumen shows no signs of stenosis, bleeding or leakage. (b) Postoperative gastroduodenograpy showing the absence of stenosis or leakage from the repaired duodenum (the arrow shows the approximate repaired portion of the duodenum)

Table 1

Details of the two cases

DISCUSSION

We described two cases of novel technique for laparoscopic closure of the duodenal wall after full thickness resection of large lesions in the second portion of the duodenum using LECS. Our technique maximises the use of the free wall of the duodenum, allowing primary closure of larger defects without stenosis or leakage.

In general, endoscopic resection or full thickness resection is considered as curative resection for duodenal lesions such as adenomas and early stage duodenal carcinoma whose depth is limited to the mucosa. Various authors have evaluated the minimally invasive approach for the curative resection of these lesions. Since endoscopic resection of duodenal lesions is technically challenging, this treatment option is limited to high-volume centres with highly experienced endoscopists. Irino et al.[9] described the LECS procedure for duodenal tumours, where the endoscopist resects the tumour endoscopically and the laparoscopic surgeon reinforces the duodenal wall with sutures laparoscopically. This procedure, however, still requires a highly skilled endoscopist who can perform ESD in the limited space available in the duodenum without perforating its thin walls. There have been reports of totally laparoscopic pancreas-sparing duodenectomy and laparoscopic partial sleeve duodenectomy.[1112] These procedures are also technically challenging and need to be performed by highly experienced laparoscopic surgeons with experience in laparoscopic pancreatobiliary surgery. All the above-mentioned techniques are technically challenging, limiting the adoption of these techniques outside of high volume centres. The LECS technique reported by Sakon et al.,[8] endoscopy-assisted laparoscopic full thickness resection reported by Ohata et al.,[13] and laparoscopy-assisted transduodenal excision technique reported by Abe et al.[14] are technically more suitable for the resection of non-ampullary duodenal lesions. Closure of the residual defect in the case of large tumours is, however, still challenging.

Report of use of a Roux-en-Y anastomosis of the duodenum and jejunum, jejunal serosal patching, gastroduodenoplasty, and diverticulisation for the management of large duodenal defects have been reported.[15161718] Several animal studies using jejunal serosal patches, expanded polytetrafluoroethylene patches, pedicled gastric seromuscular flaps, jejunal pedicled flaps, gallbladder serosal patches and Roux-en-Y anastomosis have also been reported.[10192021] An animal study comparing various techniques showed that jejunal serosal patches, Roux-en-Y repairs, and expanded polytetrafluoroethylene patch repair techniques are superior to primary repair in the management of large duodenal defects covering almost 50% or more of the duodenal circumference.[10] However, this study looked at a peritonitis model with a delay of 8 h between the creation of the defect and repair. It should also be noted that all of these techniques are technically challenging to perform laparoscopically at most centres. Ohata et al.[13] in their case series used a laparoscopic hand sewn technique for the primary closure of defects without major complications. Other authors have also successfully used laparoscopic primary closure to close the duodenal defect after resection of duodenal tumours without major complications.[81422] These studies show that laparoscopic primary closure is a feasible and safe option for the closure of duodenal defects.

However, in most previous cases in which primary closure was attempted, the size of the tumour was small, requiring resection of less than half the circumference of the duodenal lumen. Conventionally, the gastrointestinal lumen is closed horizontally to avoid stenosis. This can be easily performed in most parts of the gastrointestinal tract; however, for the second portion of the duodenum, its unique anatomy and fixation of the medial surface to the pancreas causes restriction of movement of the medial wall of the duodenum. This might result in stenosis while closing large defects in the second part of the duodenum using horizontal primary closure. By twisting the duodenum spirally, the suture line is extended without constricting the lumen, utilising the free surface of the duodenum to the maximum [Figure 2].

The study is limited by several factors. This is just an initial technical case report of two cases. We will need more cases with a longer follow-up period to definitively determine the safety of this procedure. The maximum limit of the circumference of the duodenal wall that can be safely closed using this technique also needs to be determined. However, our early results have been excellent, suggesting that this technique has the potential to broaden the scope of the duodenal lesions that can be treated laparoscopically.

CONCLUSION

Our novel spiral closure technique is safe and feasible for the closure of duodenal defects after laparoscopic resection of duodenal lesions. Evaluation of a larger number of cases and longer follow-up are needed to assess the long-term safety of this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.