Duodenal villous tumors

The treatment of 36 patients with duodenal villous tumors was reviewed to determine the long-term outcome of various surgical treatment options for specific adenoma histopathology. Duodenal villous tumors were typically solitary and periampullary in location. Villous adenomas contained epithelial atypia in 30% of patients, in situ carcinoma in 14%, and invasive carcinoma in 33%. Treatment consisted of transduodenal submucosal excision in 19 patients and radical pancreaticoduodenectomy in 15. There was no perioperative mortality. Perioperative morbidity for transduodenal excision and pancreaticoduodenectomy was 16% and 47%, respectively. Benign adenomas recurred more than 5 years postoperatively in 17% of patients undergoing transduodenal excision. Five-year survival following radical resection for invasive cancers was 45%. Overall median follow-up was 5.8 years. We conclude that duodenal villous tumors without invasive cancer can be managed successfully by local submucosal excision, but invasive carcinoma requires radical resection.     

Transduodenal resection of ampullary tumors

Objective: Whether the treatment of benign ampullary tumors should be performed as transduodenal surgical excision or endoscopic ampullectomy depends on the size and spread of the tumor. In this videopaper we report technical hints on the surgical resection.Indications: Surgical resection is indicated for benign ampullary lesions if endoscopic resection is not possible. In addition, local resection can be performed in cases with high risk of malignancy or in a palliative intention.Procedure: The duodenum is mobilized by the Kocher maneuver. It is recommendable to perform a cholecystectomy to introduce a flexible catheter antegrade into the common bile duct through the cystic duct for identification of the papilla of Vater by digital palpation. An anterolateral oblique duodenotomy is made and thereby the tumor of the papilla is exposed, followed by a submucosal injection of epinephrine to elevate the tumor. Afterwards a 5-10 mm margin is scored circumferentially in the mucosa around the adenoma. The extent of the excision is based on the preoperative and intraoperative assessment; a submucosal or full thickness (for transmural lesions) excision can be performed. After submucosal excision the mucosa of the ampulla is approximated to the mucosa of the duodenum. In cases with full thickness ampullectomy the borders of the pancreatic and bile duct are approximated and then the entire complex is sutured to the full wall of the duodenum. Furthermore in some cases with extensive resection a separate reconstruction of the pancreatic and bile duct may be required. A terminal assessment of the ductal patency is imperative. The duodenectomy is closed and a paraduodenal drain is placed.Conclusion: Transduodenal resection of periampullary tumors can be technically demanding, but provides a stage-adapted treatment modality for benign and premalignant lesions of the papilla of Vater.     

Duodenal carcinoid tumors: How aggressive should we be?

Duodenal carcinoid tumors are uncommon. It is not known whether they behave more like carcinoid tumors in the appendix (indolent course) or those in the ileum (often virulent)—crucial information for determining tbe need for radical resection. A retrospective review at our tertiary referral center (from 1976 to 1999) identified 27 patients with primary duodenal carcinoid lesions, excluding functional islet cell tumors. Endoscopic biopsy provided tbe diagnosis in 78% of patients. Treatment was by endoscopic excision (n = 11), transduodenal excision (n = 8), pancreaticoduodenectomy (n = 3), segmental distal duodenectomy (n = 2), or palliative operation (n = 2). One patient did not undergo operation because of comorbidity. Eighteen of 19 patients with tumors smaller than 2 cm remained disease free after local (endoscopic or transduodenal) excision. The exception was a patient with a small periampullary carcinoid lesion. In contrast, all four patients with carcinoid tumors 2 cm or larger who were resected for cure developed a recurrence (2 to 9 years postoperatively). We conclude that duodenal carcinoid tumors smaller than 2 cm may be excised locally; to ensure complete resection we recommend open transduodenal excision for tumors between 1 and 2 cm. Endoscopic follow-up is indicated. It is unclear whether patients with larger tumors benefit from more aggressive locoregional resection. Ampullary/periampullary carcinoid tumors should be considered separately, as their behavior is unpredictable. Supported by a grant from the National Institutes of Health (NIH DK39337 [Dr. Sarr]) and the Mayo Foundation. Presented in part at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001, and published as an abstract in Gastroenterology 120:A456, 2001.     

Long-term follow-up of patients with familial adenomatous polyposis undergoing pancreaticoduodenal surgery

Adenomatous polyps and adenocarcinomas of the periampullary region are the most common upper gastrointestinal neoplasms encountered in familial adenomatous polyposis (FAP) patients. Tumors arising from the liver, biliary tract, and pancreas have also been reported. The purpose of this study was to review the clinical outcome of FAP patients after pancreaticoduodenal surgery for periampullary neoplasms. Of the 61 individuals participating in our prospective FAP registry, 8 underwent surgical resection of periampullary neoplasms between 1987 and 1998. The charts of these individuals were reviewed for clinical indications, type of pancreaticoduodenal surgery, postoperative complications, and outcome. Of the 8 patients identified, 7 had pancreaticoduodenectomy and 1 had duodenotomy with ampullectomy. The indications for surgery were periampullary cancer (3), severe dysplasia within a duodenal villous tumor (4), and solid-pseudopapillary tumor of the pancreas (1). At the time of pancreaticoduodenal surgery, patients ranged in age from 29–65 years, and all but one had undergone colorectal surgery, on average 16 years beforehand. Pancreatic ascites after a pylorus-sparing pancreaticoduodenectomy was the only surgical complication. At a median follow-up of 70.5 months (range 37–162), 2 patients had died, neither from their periampullary neoplasm. The patient treated by local excision subsequently developed gastric cancer arising from a polyp and went on to gastrectomy. Another patient developed confluent benign jejunal adenomas just beyond the gastroenteric anastomosis almost 12 years after pancreaticoduodenectomy for severe dysplasia of a duodenal villous adenoma. Pancreaticoduodenectomy is a safe and appropriate surgical option for FAP patients with duodenal villous tumors containing severe dysplasia or carcinoma. Postoperative morbidity was minimal and there was no perioperative mortality. Good long-term prognosis can be expected in completely resected patients although subsequent proliferative and/or neoplastic lesions may still be detected in the gastrointestinal tract with prolonged follow-up. Presented at the Forty-Second Annual Meeting of The Society of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation).     

Treatment Options for Villous Adenoma of the Ampulla of Vater

Introduction: Duodenal villous adenoma arising from the ampulla of Vater has a high risk of malignant development. Excluding associated malignant disease prior to resection of an adenoma of the ampulla is not always possible. Therefore, the surgical procedure of choice to treat this rare tumour is still controversial.Objective: To evaluate retrospectively results of treatment of villous adenoma arising from ampulla of Vater with dysplasia or associated carcinoma limited to the ampulla.Patients and Methods: From 1985 to 1996, eight patients have been diagnosed with ampullary villous adenoma suitable for resection. We have reviewed treatment, morbidity, mortality, follow-up and final outcome.Results: Pancreatoduodenectomy (PD) was performed in 4 patients. Transduodenal ampullectomy and endoscopic resection was performed in 2 patients each. There was no perioperative mortality. None of the patients had biliary, pancreatic or intestinal leakage but two patients who underwent PD had minor postoperative complications. The mean follow-up was 44 (range: 6–132) months. Villous adenoma was associated with adenocarcinoma in 50% of the cases (4/8 patients). During the followup both patients who underwent transduodenal ampullectomy developed recurrent disease. All patients initially treated by PD are alive without evidence of recurrent disease.Conclusions: Treatment of villous adenoma of the ampulla must be individualized within certain limits. In our series, PD achieve good results and it appears to be the procedure of choice in order to treat villous adenomas with proved presence of carcinoma, carcinoma in situ or severe dysplasia. Endoscopic or local resection may be appropriate for small benign tumours in high risk patients.     

Adenome der Ampulla Vateri und des Duodenums Darstellung von Diagnostik und Therapie durch endoskopisch interventionelle und chirurgische Methoden

Background. Adenoma of the ampulla of Vater and the duodenum are rare tumors. The leading symptoms are unspecific; sometimes they are due to the disturbances of the passage or erosion of the tumor. Early and correct diagnosis and the appropriate therapy are of decisive importance because these tumors are precancerous. Patients and methods. We report the cases of seven patients with periampullary adenoma of the duodenum, in one case with incorporation of the the distal bile duct. The diagnostic steps and the surgical treatment are reported and discussed. In achieving a definitive diagnosis, endoscopic retrograde cholangiopancreatography is of paramount importance. Three patients subsequently underwent partial pancreatoduodenectomy (Whipple's procedure); in three patients transduodenal local tumor excision was performed. Postoperative course was without complications in each case and no operative mortality occurred. One patient was treated by argon-coagulation. Results. The histopathological examination showed a tubular villous adenoma in six cases and in one case a villous adenoma (ranging from low to high grade dysplasia). Because there is evidence of an adenoma-carcinoma-sequence, radical surgical treatment is recommended, even in adenoma with low grade dysplasia, in spite of the absence of malignancy.     

Minimally invasive treatment of synchronous colorectal tumours

In patients with colorectal cancers synchronous neoplastic lesions are an increasingly frequent finding at preoperative staging; 3% of the cases are other cancers while 33-35% of the synchronous lesions are villous adenomas. The treatment of most colorectal adenomas can be performed by endoscopic poplypectomy. In 5% of cases there are synchronous colorectal lesions also requiring surgical treatment. From January 1995 to June 2007 we treated 5 patients with rectal lesions by transanal endoscopic microsurgery (TEM) together with a laparoscopic colectomy for the presence of synchronous lesions at the "Clinica Chirurgica Generale e d'Urgenza" of the University of Perugia,. Surgical timing involved performing a sequential exeresis characterised by a cancer resection, followed by resection of the voluminous adenoma: TEM for rectal cancer followed by a laparoscopic right hemicolectomy with an extracorporeal anastomosis for a voluminous villous adenoma (1 patient) and laparoscopic right hemicolectomy with an extracorporeal anastomosis for cancer followed by TEM for a voluminous villous adenoma (2 patients). One patient with left colon cancer associated with a voluminous villous rectal adenoma first underwent TEM for the rectal adenoma and then a left laparoscopic hemicolectomy with an extracorporeal anastomosis in order to ease the transit of the circular mechanical stapler. Another patient with rectal and right colon adenomas first underwent TEM for a voluminous rectal sessile adenoma and later a right hemicolectomy. The use of this minimally invasive approach allowed rectum preservation and less invasive surgery.     

Value of surgical ampullectomy in the management of benign ampullary tumors

AIM OF THE STUDY: To report the results of transduodenal excision (TDE) for tumors of the ampulla of Vater. PATIENTS AND METHODS: From 1998 to 2003, 10 patients underwent a transduodenal excision for presumed benign tumors of the ampulla of Vater. After resection, frozen sections were performed to ensure negative margins. RESULTS: There was no operative mortality. A postoperative pancreatitis occurred in one patient. For nine patients the postoperative course was uneventful. The mean duration of hospital stay was 18 +/-11 days. The final pathology showed adenoma in 8 patients, an adenocarcinoma in one patient and inflammatory lesions in other one. With a mean follow-up of 20 months, endoscopy did not show any recurrence in patients with benign lesion. Patient with an invasive cancer developed recurrence. CONCLUSION: Transduodenal excision is safe and effective treatment for benign ampullary tumors. TDE should be the operation of choice for patients with histologically-proven benign ampulloma, staged as uT1 by endoscopic ultrasound. This approach could reduce the rate of pancreaticaduodenoctomy performed for benign ampullomas.     

壶腹部癌的诊断和治疗

壶腹部癌的发病率高于胆管下端癌，但远低于胰头癌。据统计，其发病率仅为胰头癌的1／12。近年，随着消化内镜的普及，壶腹部癌的发现率逐渐增加。与胆管下端癌及胰头癌比较，壶腹部癌的预后相对较好，手术切除率高，术后5年生存率为30％-70％，诊断和治疗有其独自的特点。     

Carcinoma Arising from Villous Adenoma of the Ampullary Bile Duct: Report of a Case

Adenocarcinoma arising from the villous adenoma of the ampullary biliary epithelium is an extremely rare disorder. The preoperative diagnosis and treatment of the disease represent a major difficulty. A 67-year-old woman was admitted to the hospital with a chief complaint of jaundice. Preoperative investigations revealed obstructive type jaundice due to a 2-cm mass at the end of common bile duct. She was operated on and after undergoing a sphincterotomy, small, yellowish, grape-like particles fell down from the ampullar orifice. A frozen-section examination of these particles revealed villous adenoma. Next, a transduodenal resection of ampulla and reconstruction were performed. The frozen-section examination of the resected material also revealed a villous adenoma. The patient was discharged uneventfully. The histological examination revealed a villous adenoma arising from the biliary epithelium and some adenocarcinoma foci. The surgical margins were tumor free. Nevertheless, she developed hepatic metastases 15 months after surgery. This case shows the importance of surgeons to keep in mind the fact that frozen examinations may sometimes miss a malignancy and they therefore cannot be relied upon to rule out malignancy in villous adenoma of the ampullary bile duct. This case was presented as a poster presentation at the 12th World Congress of the International Association of Surgeons and Gastroenterologists, Istanbul, Turkey, October 31–November 4, 2002.     

Safety and long-term efficacy of transduodenal excision for tumors of the ampulla of Vater

BACKGROUND: Ampullary tumors should be resected because of the high incidence of malignancy and the unreliability of preoperative endoscopic diagnosis. Controversy exists about whether to perform a transduodenal excision (TDE) or a pancreatoduodenectomy. This study evaluated the safety and long-term efficacy of TDE. METHODS: The records of 21 patients with a pathologic diagnosis of ampullary adenoma who underwent TDE were reviewed. Demographics, symptoms, pathologic findings, and outcomes were analyzed and long-term follow-up was ascertained. RESULTS: Twenty-one patients (mean age, 61 years) underwent TDE. Final pathology showed adenoma in all patients including 1 (5%) with invasive cancer, 2 (9%) with microinvasive cancer, 6 (28%) with high-grade dysplasia, and 1 (5%) with low-grade dysplasia. The overall survival was 85% (mean follow-up of 38 months). One of 3 late deaths was likely related to disease progression. Sixteen of the 18 remaining patients (89%) had no evidence of tumor recurrence. One benign ampullary recurrence was successfully treated endoscopically. One additional patient developed an ampullary cancer and underwent pancreatoduodenectomy. CONCLUSIONS: TDE of benign ampullary tumors, even those with varying grades of dysplasia, can be performed with acceptable morbidity and low rates of recurrence. Postoperative endoscopic surveillance is mandatory to identify recurrent tumors.     

Villous tumors of the duodenum.

Records of 32 patients with 34 villous and tubulovillous adenomas of the duodenum, treated at the Cleveland Clinic over the past 21 years, were reviewed. Twenty-two patients (69%) had complete resection of the adenoma; the incidence of malignancy was 47%. Five patients underwent a Whipple procedure; 4 patients had segmental resection of the duodenum; 12 had wide local excision of the adenoma; 1 had both a segmental resection and a local excision for two separate adenomas; and 5 patients had endoscopic excision alone. The remaining five patients underwent exploratory laparotomy alone or with palliative bypass procedures. A 28% recurrence rate was observed, all of these after segmental resection, local excision, or endoscopic excision. The highest recurrence rate was associated with local excision. The 2- and 5-year survival rates for patients with adenomas containing invasive cancer were 22% and 0%, respectively, compared to 87% and 87%, respectively, for benign adenomas (including those with carcinoma in situ). Twenty-two per cent of patients had intestinal polyposis syndromes. Duodenal adenomas were diagnosed a mean of 17 years after colectomy for polyposis, indicating the need for continued surveillance in these patients.     

Safety and long-term follow-up of endoscopic snare excision of ampullary adenomas

Background Adenomas of the duodenal papilla are rare. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection techniques, transduodenal local excision, and pancreaticoduodenectomy. The aim of this retrospective study was to evaluate the safety and outcome of endoscopic snare resection of papillary adenomas in a Greek cohort of patients. Methods Fourteen patients (six women and eight men; age range, 42–76 years) were referred for endoscopic management of ampullary adenomas. A questionnaire was completed for each patient, which included preoperative and postoperative data points. Presenting symptoms were jaundice (n = 4), cholangitis (n = 1), and pain (n = 2). Seven patients were asymptomatic. If there was no common bile and main pancreatic duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy onto normal duodenal tissue was performed. The adenomas were resected via a diathermy snare, along with the major papilla, after elevation of the lesion by epinephrine plus dextrose 50% (1:10,000) solution. At the discretion of the endoscopist, a biliary or pancreatic stent was inserted as a prophylactic procedure immediately after excision. Results Histopathologically, resected tissue included 11 adenomas and three adenomas with focal malignancy, referred for pancreaticoduodenectomy. Immediate complications were moderate bleeding (n = 1) and mild pancreatitis (n = 1). No procedure-related death occurred. Follow-up was available for 11 patients (mean, 28.36 months; range, 6–72). Pancreatic and biliary stents were placed in four and nine patients, respectively. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in two patients (18%), which was resected endoscopically. Conclusion Endoscopic snare resection of adenomas of the major duodenal papilla is a safe, well-tolerated alternative to surgical therapy. In expert hands, complications are mild and may be avoided by pre-resection biductal sphincterotomy, stent placement, and elevation of the lesion by epinephrine plus dextrose 50% solution injection.     

The Role of Laparoscopy and Ultrasonography in Pancreatic Head Carcinoma

Objective: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.Summary Background Data: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.Methods: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).Results: “Occult” metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).Conclusions: Staging laparoscopy is indispensable in the detection of “occult” intraabdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.     

Treatment of ampullary villous adenomas that may harbor carcinoma

Villous adenoma of the ampulla of Vater is a rare tumor. It is a deceptive tumor because it is a premalignant lesion and biopsies of the lesion are false negative in 25% to 56% of patients. The primary focus of this report is 23 of 30 patients with villous adenoma of the ampulla of Vater who underwent Whipple operations. Paraffin blocks from 22 patients were available. In eight patients, blocks of the biopsies and the corresponding resected specimens were available. Immunohistochemical studies using antibodies to p53 and Ki-67 were performed to determine whether accumulation of these antibodies in the biopsy specimens would identify false negative biopsies. There was one operative death. The 2-, 5-, and 10-year survival rates for the 22 patients surviving a Whipple operation were 74%, 57%, and 35%, respectively. Three patients died of cancer. The mean p53 expression index was increased in adenomas to 88 (P = 0.001) and in carcinomas to 114 (P = 0.01), compared with 12.6 for normal ampullary epithelium adjacent to tumor. Significant differences in the Ki-67 proliferation index were noted between normal adjacent epithelium (13%), adenoma (34%, P = 0.0002), and carcinoma (53%, P = 0.034), as well as between adenomatous epithelium and carcinoma (34% vs. 53%, P = .012). Villous ampullary adenocarcinoma was present in 65% of patients with villous adenoma (87% if patients with carcinoma in situ in resected specimens are included). Because of the high false negative rate of ampullary biopsies, and the inability to accurately stage these lesions, we recommend pancreaticoduodenectomy in most patients. Studies with p53 and Ki-67 markers suggest that they may be helpful in the recognition of ampullary villous cancer not identified on routine biopsies.     

Villous tumors of the duodenum: Reappraisal of local vs. extended resection

Benign villous tumors of the duodenum are often managed by transduodenal local excision. Risk of local recurrence, coupled with improving safety of radical pancreaticoduodenectomy, has prompted reexamination of the roles of conservative and radical operations. The aim of this study was to determine long-term outcome after local and extended resection in order to identify factors to consider in planning operative strategy. Eighty-six patients (mean age 64 years) with villous tumors of the duodenum managed surgically from 1980 to 1997 were reviewed. Histologic findings, size, presence of polyposis syndromes, and extent of resection were correlated with outcome. Villous tumors were benign adenomas in 64 patients (74%), contained carcinoma in situ in three (4%), and invasive carcinoma in 19 (22%). The presence of cancer was not known preoperatively in 9 (47%) of the 19 with invasive carcinoma. Operative treatment included transduodenal local excision in 53 patients, pancreaticoduodenectomy in 20, pancreas-sparing duodenectomy in five, full-thickness excision in four, and other in six. Among the 50 patients with benign tumors managed by local excision, 17 had a recurrence with actuarial rates of 32% at 5 years and 43% at 10 years; four of the recurrences (24%) were adenocarcinomas. The recurrence rate was influenced by the presence of a polyposis syndrome but not by tumor size. Recurrence of benign villous tumors after local excision is common and may be malignant. Pancreaticoduodenectomy is appropriate for villous tumors containing cancer and may be considered an alternative for select patients with benign villous tumors of the duodenum. If local excision is performed, regular postoperative endoscopic surveillance is mandatory. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999, and published as an abstract in Gastroenterology 116:A1310, 1999.     

壶腹部肿瘤术前活检的诊断价值

目的探讨壶腹部肿瘤术前活检的诊断价值。方法回顾性分析2000年1月至2009年11月本院收治的53例壶腹部肿瘤患者的十二指肠镜检及活检资料。结果所有患者术前均行十二指肠镜检查并活检。术前活检病理结果 :腺癌20例(37.7%),高级别上皮内瘤变19例(35.8%),低级别上皮内瘤变13例(24.5%),炎性息肉1例(1.9%)。53例患者中47例(88.7%)行胰十二指肠切除术,6例(11.3%)行肿瘤局部切除术。术后病理结果为:腺癌46例(86.8%),类癌1例(1.9%),腺瘤恶变3例(5.7%),腺瘤伴上皮内瘤变3例(5.7%)。结论多数壶腹部癌分化程度高,肿瘤表层活检难以做出正确诊断,肿瘤定性需结合病变形态、大小,必要时行切除活检。     

Management of advanced duodenal polyposis in familial adenomatous polyposis

Patients with familial adenomatous polyposis (FAP) are at increased risk for the development of periampullary cancer. The aim of this study was to evaluate the roles of endoscopic and surgical therapy in the management of advanced duodenal polyposis in FAP. From 1990 to 1995, seventy-four FAP patients were enrolled in a prospective endoscopic surveillance protocol. Among these, 11 (14.8%) developed advanced duodenal polyposis and one had duodenal adenocarcinoma. Six patients underwent endoscopic resection of duodenal (n=5) or ampullary adenomas (n=1). The following operations were performed in the remaining six patients: ampullectomy in four, open polypectomy in one, and a Whipple procedure in one. There was one patient who died of acute pancreatitis following endoscopic ampullectomy. The patient with invasive duodenal cancer died of local recurrence. Small polyps were observed at the site of previous resection in all (9 of 9) patients undergoing repeat endoscopy during a mean follow-up of 18 months (range 4 to 34 months). An endoscopic and local surgical resectional approach to advanced duodenal polyposis in FAP is fraught with high recurrence rates, although recurrent polyps are small and may be amenable to retreatment in the future. Long-term follow-up is necessary to prove that deaths from duodenal or ampullary cancer are prevented with this strategy.     

Laparoscopic and endoscopic cooperative surgery for duodenal neuroendocrine tumor (NET) G1: Report of a case

INTRODUCTION

We report a case of duodenal neuroendocrine tumor (NET) G1 resected by laparoscopic and endoscopic cooperative surgery (LECS) technique.

PRESENTATION OF CASE

A 58-year-old woman underwent esophagastroduodenoscopy, revealing an 8-mm, gently rising tumor distal to the pylorus, on the anterior wall of the duodenal bulb. Endoscopic ultrasonography suggested the tumor might invade the submucosal layer. The tumor was pathologically diagnosed as a G1 duodenal NET, by biopsy. Endoscopic submucosal dissection was attempted, but was unsuccessful because of the difficulty of endoscopically performing an inversion operation in the narrow working space. The case was further complicated by the patient''s duodenal ulcer scar. We performed a full-thickness local excision using laparoscopic and endoscopic cooperative surgery. The tumor was confirmed and endoscopically marked along the resection line. After full-thickness excision, using endoscopy and laparoscopy, interrupted full-thickness closure was performed laparoscopically.

DISCUSSION

Endoscopic treatment is generally recommended for G1 NETs <10 mm in diameter and extending only to the submucosal layer. However, some cases are difficult to resect endoscopically because the wall of duodenum is thinner than that of stomach, and endoscope maneuverability is limited within the narrow working space. LECS is appropriate for early duodenal G1 NETs because they are less invasive and resection of the lesion area is possible.

CONCLUSION

We demonstrated that LECS is a safe and feasible procedure for duodenal G1 NETs in the anterior wall of the first portion of the duodenum.     

Transgastric endoluminal laparoscopic resection of a villous adenoma of the duodenum

Laparoscopic transgastric techniques have been introduced in the recent literature for the management of gastroduodenal lesions. The case study in this article describes a novel approach to a duodenal adenoma using endoscopically assisted laparoscopic transgastric resection.