Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy?

Abstract

Background: Gastrointestinal stromal tumors (GIST) of the duodenum are rarely reported and optimal minimally invasive management has not been well proposed. Pancreaticoduodenectomy and different types of pancreas-sparing duodenectomy can be chosen; however, which to choose and its corresponding clinical outcomes and oncological concerns remain controversial.

Patients and methods: Patients diagnosed with GIST of duodenum underwent laparoscopic pancreaticoduodenectomy (L-PD) or pancreas-sparing duodenectomy (L-PSD) in Zhejiang Provincial People's Hospital were enrolled. All prospectively maintained data were analyzed retrospectively. Patients were grouped into the L-PD group or the L-PSD group, and the clinical outcomes and oncological outcomes were analyzed.

Results: Between June 2013 and March 2019, a total of 22 patients (11 males/11 females) underwent surgical management, including 13 L-PDs and 9 L-PSDs. The average age was 58.2±9.5 year-old (median 60.5 year-old). The most common presentations were GI bleeding (54.5%) and abdominal discomfort (27.2%), and the dominant lesion located in the second portion of duodenum (59.1%). Compared with L-PD group, L-PSD group showed much shorter operation time (364.2±58.7min vs. 230.0±12.3min, P<0.001), less blood loss (176.9±85.7mL vs. 61.1±18.2min, P<0.001), faster recovery to off-bed (2.6±1.3d vs. 1.1±0.3d, P=0.003), anus flatus (4.5±1.0d vs. 2.4±0.5d, P<0.001) and liquid intake (4.9±1.3d vs. 2.3±0.5d, P<0.001). Lymph node retrieval was much less in L-PSD, but no lymph node metastasis was observed in any patients. L-PSD had much Lower morbidity of both minor (Grade I/II) and major (III/IV/V) complications than that of L-PD (11.1% vs. 61.6%, P=0.02), resulting in shorter hospital stays (10.9±3.8d vs. 20.6±11.1d, P=0.021) and less total cost (76,972.4±11,614.8yuan vs 125,628.7±46,356.8yuan, P=0.006). The median follow-up was 42 months (range from 12 to 82months) without loss. Only 1 L-PD patient suffered hepatic metastasis 36months after surgery, and given sunitinib to stabilize the disease, none of the rest observed recurrence or metastasis.

Conclusion: For GIST located opposite the major papilla, L-PSD showed comparable safety and oncological benefits when compared to L-PD, with shorter operation time, less blood loss and much faster recovery time, resulting in much less total cost. L-PSD should be applied in selected patients with experienced hands.

Keywords: GIST; duodenum; pancreas-sparing duodenectomy; pancreaticoduodenectomy.

Figure 1

Flow diagram and indication for laparoscopic pancreaticoduodenectomy (L-PD) or laparoscopic pancreas-sparing duodenectomy (L-PSD) for duodenal GISTs.

Figure 2

For lesions adjacent to papilla, laparoscopic pancreaticoduodenectomy was indicated and performed (A). The blue spot represented the duodenal GISTs. (B) Shows the resected specimen with ulcerative lesions in the same side of papilla.

Figure 3

Laparoscopic pancreas-sparing duodenectomy (L-PSD) for supra-ampulla lesions. Diagnostic endoscopy was used to exclude possibility of endoscopic resections (A) and marking the tumor location to papilla (B). Supra-ampulla duodenum was gradually separated from the pancreas (C), and the distal margin was transected without stapler for preserving the ampulla intact (D). With the guidance of catheter along the common bile duct (E), intraoperative cholangiogram (IOC, 3F) was also performed to locate the papilla. With the help of catheter, the opening was closed without injury the papilla (G). (H) Shows the trocar distribution and the specimen.

Figure 4

Laparoscopic pancreas-sparing duodenectomy (L-PSD) for infra-ampulla lesions. Lesions located in the 3rd part of duodenum (A). After clamping the pre-set margin (B), before transection by stapler, IOC was performed to confirm the papilla intact. (C and D) Show the trocar distribution and the resected specimen, respectively.

Figure 5

Overall survival (A) and disease-free survival (B) of patients underwent L-PD and L-PSD.