Laparoscopicendoscopic cooperative surgery is ... - Wiley Online Library

bs_bs_banner

Asian J Endosc Surg ISSN 1758-5902

C A S E R E P O RT

Laparoscopic-endoscopic cooperative surgery is a safe and effective treatment for superficial nonampullary duodenal tumors Daisuke Kyuno,1 Keisuke Ohno,1 Shinichi Katsuki,2 Tomoki Fujita,2 Ai Konno,1 Takeshi Murakami,1 Eriko Waga,2 Kunihiro Takanashi,2 Keisuke Kitaoka,2 Yuya Komatsu,2 Kazuaki Sasaki1 & Koichi Hirata3 1 Department of Surgery, Otaru Ekisaikai Hospital, Otaru, Japan 2 Department of Gastroenterology, Otaru Ekisaikai Hospital, Otaru, Japan 3 Departments of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan

Keywords Duodenal tumor; endoscopic submucosal dissection (ESD); laparoscopic- endoscopic cooperative surgery (LECS) Correspondence Daisuke Kyuno, Department of Surgery, Otaru Ekisaikai Hospital, 10-17 Ironai 1-chome, Otaru 047-0031, Japan. Tel: +81 134 24 0325 Fax: +81 134 25 3408 Email: [email protected] Received 23 March 2015; revised 30 May 2015; accepted 24 June 2015 DOI:10.1111/ases.12211

Abstract The use of endoscopic submucosal dissection (ESD) for duodenal neoplasms has increased in recent years, but delayed perforation and bleeding are also known to frequently occur. We present two cases in which duodenal adenoma was successfully treated with laparoscopic-endoscopic cooperative surgery. ESD was combined with laparoscopic seromuscular sutures. The lesions in both cases were located in the second portion of the duodenum. The patients requested resection of the lesion, and we performed laparoscopic-endoscopic cooperative surgery. After the laparoscopic surgeon mobilized the duodenum, the endoscopic surgeon performed ESD for the duodenal tumor without perforation. The laparoscopic surgeon sutured the duodenal wall in the seromuscular layer to strengthen the ulcer bed after ESD. Histopathological studies confirmed that the surgical margins were tumor-free in both cases. The patients were discharged with no complications. This unique laparoscopic-endoscopic cooperative procedure is a safe and effective method for resecting superficial nonampullary duodenal tumors.

Introduction Recently, endoscopic submucosal dissection (ESD) has been used for the treatment of epithelial neoplasms in the digestive tract, and it has been applied to superficial nonampullary tumors in the duodenum (1,2). However, delayed perforation and bleeding are known to frequently occur after duodenal ESD (2,3). The most appropriate prophylactic approach has not been fully established. In this report, we present two cases in which the duodenal adenoma was successfully treated by laparoscopicendoscopic cooperative surgery (LECS). We combined the ESD technique with laparoscopic seromuscular sutures. This unique surgical procedure appears to be safe and feasible for resection of superficial nonampullary duodenal tumors.

Case Presentation Detailed procedure of LECS In each case, laparoscopic surgery was performed with the patient in the supine position under general anesthesia. The laparoscopic surgeon stood on the patient’s left side. Initially, the first trocar was placed with a standard umbilical cut-down technique. Carbon dioxide was insufflated through this port with a pressure setting of 8 mmHg. A laparoscope was introduced through the umbilical port, two additional trocars were inserted into the left upper quadrant, and one trocar was inserted into the right upper quadrant under laparoscopic guidance. After examination of the abdominal cavity, the laparoscopic surgeon dissected the omentum from the front of duodenum to the right lateral side and removed the mesocolon from the epigastric tissue. The procedure con-

Asian J Endosc Surg 8 (2015) 461–464 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

461

LECS for superficial duodenal tumors

D Kyuno et al.

tinued with dissection of the right hepatocolic ligament to mobilize the right colic flexure. The duodenum was mobilized from the retropertoneum using the laparoscopic Kocher maneuver. The jejunum near the ligament of Treitz was clamped with a pair of bulldog clamp forceps. Next, we performed intraoperative gastroduodenal endoscopy and ESD for the tumor in the duodenum. Under the laparoscopic view, we identified the ulcer bed of the duodenum after ESD using the transmitted light of the endoscope. The laparoscopic surgeon added dye marks to the ulcer bed and sutured the duodenal wall using a laparoscopic hand-sewn technique in the seromuscular layer around the resected area using the endoscope (Figures 1,2). We confirmed that there was no bleeding, leakage, or stenosis in the duodenum by intraluminal endoscopy after suturing. We did not place a drainage tube. Case 1 A 77-year-old male patient was diagnosed with a duodenal tumor on regular medical examination. He had previously undergone a laparoscopic cholecystectomy because of cholelithiasis. Endoscopic screening examination identified a 10-mm 0-IIc lesion in the second portion of the duodenum. The lesion was located on the opposite and the anal side of Vater’s ampulla (Figure 1). The patient requested resection of the lesion, and we performed LECS. The operation time was 146 min, and there was little

intraoperative blood loss. Histopathological examination of the tumor revealed a low-grade tubular adenoma with moderate atypia. The surgical margins were tumor-free. Upper gastrointestinal endoscopy revealed that stenosis or bleeding had not occurred in the duodenum on postoperative day 7. The patient was discharged with no complications. Case 2 A 70-year-old male patient was diagnosed with a duodenal tumor on regular medical examination. His medical history included hypertension and a gastric ulcer. Endoscopic examination screening showed an approximately 15-mm elevated lesion in the second portion of the duodenum. The lesion was located on the opposite and the anal side of Vater’s ampulla, as in case 1 (Figure 2). The patient requested resection of the lesion, and we performed LECS. The operation time was 116 min, and there was little intraoperative blood loss. Histopathological studies confirmed that the lesion was a low-grade tubular adenoma with moderate atypia and that the surgical margins were tumor-free. Upper gastrointestinal endoscopy on postoperative day 5 showed that there was no stenosis or bleeding. The patient was discharged with no complications.

Discussion Although duodenal ESD is a less invasive treatment than surgical resection, a high rate of complications, such as

Figure 1 Laparoscopic-endoscopic cooperative surgery procedure in case 1. (a) Endoscopic view of a duodenal tumor. (b) Endoscopic view of the ulcer bed after endoscopic submucosal dissection. (c) Laparoscopic view of the resected area identified with the transmitted light of the endoscope. (d) Laparoscopic view after the seromuscular sutures.

462



D Kyuno et al.

Figure 2 Laparoscopic-endoscopic cooperative surgery procedure in case 2. (a) Endoscopic view of a duodenal tumor. (b). Endoscopic view of the ulcer bed after endoscopic submucosal dissection. (c) Laparoscopic view of the resected area identified with the transmitted light of the endoscope. (d) Laparoscopic view after the seromuscular sutures.

perforation and bleeding, has been reported for the ESD procedure (1,4,5). In particular, the incidence of perforation induced by duodenal ESD can range between 21% and 35.7% (4,5). Even if complete ESD has been performed, delayed perforation is sometimes reported (4). Perforation of the duodenum almost always causes potentially fatal peritonitis, requiring emergency open surgery. Thus, preventive measures against delayed perforation after ESD are important. We combined the ESD technique with laparoscopic seromuscular sutures to strengthen the ulcer bed. This procedure can certainly close mucosal defects and has some other advantages (6). The laparoscopic surgeon can help with the ESD procedure by shifting or fixing the duodenum if the endoscopic surgeon has difficulty during surgery. Furthermore, even if perforation occurs during the endoscopic procedure, this perforation can be closed immediately with laparoscopic sutures. Unlike with duodenal ESD alone, LECS has complication risks associated with laparoscopic surgery and general anesthesia. However, we believe the advantage of this effective procedure, which can prevent delayed perforation, outweighs those complications. To prevent delayed perforation, closure methods with multiple endoclips (7), an over-the-scope clip (8), or the shielding method with polyglycolic acid sheets for mucosal defects have been previously reported (9). The most appropriate prophylactic intervention has not been established for

delayed perforation of the duodenal ESD. Further accumulation of cases and investigation will be necessary to determine the procedure’s feasibility and effectiveness for preventing the complications. One of the limitations of LECS was tumor location. This procedure is not applicable to periampullary tumors because seromuscular suturing on the duodenal wall cannot be performed near the pancreas. In addition, the indication for LECS is the same as that for ESD in duodenal tumors such as the adenoma and intramucosal cancer. However, periampullary tumors, submucosal cancer, and gastrointestinal stromal tumors of the duodenum are not indicated. In conclusion, the LECS procedure for duodenal neoplasms, which combines ESD and laparoscopic seromuscular sutures, enables successful resection without intraoperative and postoperative complications. Although our experience was limited to only two patients, we believe that this surgical procedure is an effective method for minimizing the risk of developing complications and can become an attractive option in the treatment for superficial nonampullary duodenal tumors.

Acknowledgement The authors have no conflicts of interest or financial ties to disclose.


463


D Kyuno et al.

References 1. Honda T, Yamamoto H, Osawa H et al. Endoscopic submucosal dissection for superficial duodenal neoplasms. Dig Endosc 2009; 21: 270–274. 2. Inoue T, Uedo N, Yamashina T et al. Delayed perforation: A hazardous complication of endoscopic resection for nonampullary duodenal neoplasm. Dig Endosc 2014; 26: 220–227. 3. Hoteya S, Kaise M, Iizuka T et al. Delayed bleeding after endoscopic submucosal dissection for non-ampullary superficial duodenal neoplasias might be prevented by prophylactic endoscopic closure: Analysis of risk factors. Dig Endosc 2015; 27: 323–330. 4. Jung JH, Choi KD, Ahn JY et al. Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas. Endoscopy 2013; 45: 133–135. 5. Matsumoto S, Miyatani H, Yoshida Y. Endoscopic submucosal dissection for duodenal tumors: A single-center experience. Endoscopy 2013; 45: 136–137.

464

6. Irino T, Nunobe S, Hiki N et al. Laparoscopic-endoscopic cooperative surgery for duodenal tumors: A unique procedure that helps ensure the safety of endoscopic submucosal dissection. Endoscopy 2014; 47: 103–112. 7. Otake Y, Saito Y, Sakamoto T et al. New closure technique for large mucosal defects after endoscopic submucosal dissection of colorectal tumors (with video). Gastrointest Endosc 2012; 75: 663–667. 8. Mori H, Shintaro F, Kobara H et al. Successful closing of duodenal ulcer after endoscopic submucosal dissection with over-the-scope clip to prevent delayed perforation. Dig Endosc 2013; 25: 459–461. 9. Takimoto K, Imai Y, Matsuyama K. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection. Dig Endosc 2014; 26 (Suppl. 2): 46–49.
