Case series
349
Authors
Tomoyuki Irino1, Souya Nunobe1, Naoki Hiki1, Yorimasa Yamamoto2, Toshiaki Hirasawa2, Manabu Ohashi1, Junko Fujisaki2, Takeshi Sano1, Toshiharu Yamaguchi1
Institutions
1 2
submitted 9. August 2014 accepted after revision 30. September 2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1390909 Published online: 5.12.2014 Endoscopy 2015; 47: 349–351 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Naoki Hiki, MD, PhD Department of Gastroenterological Surgery Cancer Institute Hospital 3-8-31, Ariake Koto-ku Tokyo, 135-8550 Japan Fax: +81-3-35200141 [email protected]
Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
A new rendezvous-style surgical technique has been developed to ensure the safety of endoscopic submucosal dissection (ESD) for duodenal tumors. The new technique, called “laparoscopicendoscopic cooperative surgery (LECS),” combines ESD with laparoscopic, reinforcing, seromuscular suturing. This case series report describes how three patients with a duodenal tumor were safely treated by LECS. ESD was performed by endoscopy, followed by closure of the mucosal
defect using seromuscular suturing by laparoscopy. ESD was successfully completed in all patients. Endoscopic findings after suturing revealed that the mucosal defect was closed appropriately and tightly. None of the three patients experienced delayed perforation or stricture after LECS. LECS for extraction of duodenal tumors seems to be feasible and helps to ensure the safety of ESD in the duodenum.
Introduction
ble 1). The indication for D-LECS is primarily the same as that for ESD in duodenal tumors; however, tumors located near the ampulla of Vater are not indicated. D-LECS was completed under general anesthesia and epidural anesthesia. Pneumoperitoneum was induced after the first trocar was placed at the level of the umbilicus. Four other trocars were inserted through the abdominal wall: one 12-mm trocar was inserted at the left upper quadrant, and three 5-mm trocars were inserted at the left lower, the right upper, and the right lower quadrants. After examination of the peritoneal cavity, the operative field was prepared according to the tumor location. For example, if the lesion was located in the second part of the duodenum, the right side of the transverse colon was adequately mobilized. Next, an endoscope was inserted into the duodenum to confirm the precise location of the lesion " Fig. 1 a). ESD was performed using an insula(● tion-tipped electrosurgical knife, the detailed procedure of which has been described elsewhere " Fig. 1 b). The specimen was retrieved intra[2] (● luminally and removed, with the endoscope, through the mouth. After ESD was completed, the mucosal defect was reinforced with seromuscular sutures to prevent complications after surgery. The endoscopist illuminated the mucosal defect with transmitted light so that the laparoscopist could clearly locate
!
Endoscopic submucosal dissection (ESD) for early duodenal cancer is associated with a high risk of perforation during and after surgery, occurring at rates up to 35.7 % [1, 2]. Furthermore, delayed perforation in the duodenum in particular may cause potentially fatal peritonitis, requiring emergency open surgery to perform adequate peritoneal lavage to counter leakage of bile and pancreatic juices [3]. Along with advancing the ESD technique, we have developed “laparoscopic-endoscopic cooperative surgery (LECS),” which combines laparoscopic surgery with endoscopic therapy for gastrointestinal tumors [4]. A number of novel procedures based on the LECS concept have arisen in its wake, such as inverted LECS [5], full-layer resection for gastric cancer with nonexposure technique (CLEAN-NET) [6], and nonexposed endoscopic wall-inversion surgery (NEWS) [7]. This report describes the LECS procedure for duodenal neoplasm (D-LECS), which could lead to successful endoscopic treatment for duodenal neoplasm.
Case report !
Three patients with duodenal carcinoma under" Tawent D-LECS with seromuscular sutures (●
Irino Tomoyuki et al. Laparoscopic-endoscopic surgery for duodenal tumors … Endoscopy 2015; 47: 349–351
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection
Case series
Table 1
Patient demographics and surgical results.
Patient 1
Patient 2
Patient 3
Age, years
60
68
71
Sex
Male
Male
Male
Tumor Biopsy
Adenoma with severe atypia
Adenoma with severe atypia
Adenoma with moderate atypia
Location
2nd part Perineal side Opposite to papilla
2nd part Perineal side 2 cm distal from papilla
2nd part Perineal side Opposite to papilla
Diameter, mm
25 × 17
12 × 6
14 × 10
Total duration, minutes
262
265
176
ESD, minutes
103
95
40
Suturing, minutes
74
22
38
Blood loss, mL
20
0
15
Hospital stay, days
8
7
Complications
None
None
Postoperative bleeding
Re-admission
No
No
No
Pathological result
Very well differentiated adenocarcinoma, mucosal invasion
Very well differentiated adenocarcinoma, mucosal invasion
Well differentiated adenocarcinoma, mucosal invasion
D-LECS
12
D-LECS, laparoscopy – endoscopy cooperative surgery for duodenal neoplasm; ESD, endoscopic submucosal dissection.
Fig. 1 Clinical manifestations of Patient 1. a Duodenoscopy of the tumor. b Duodenoscopy after endoscopic submucosal dissection. c Silhouette of the mucosal defect visualized by transluminal lighting. d Laparoscopy after seromuscular suturing. e Duodenoscopy after seromuscular suturing by laparoscopy.
Irino Tomoyuki et al. Laparoscopic-endoscopic surgery for duodenal tumors … Endoscopy 2015; 47: 349–351
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
350
" Fig. 1 c, ● " Video 1). The laand recognize the mucosal defect (● paroscopist added dye marks around the silhouette of the defect, and then placed seromuscular sutures in order to reinforce the " Fig. 1 d). Following suturing, locally thinned duodenal wall (● endoscopy was performed to confirm that the defect was appropriately closed and that neither stricture nor bleeding was pres" Fig. 1e; ● " Video 1). ent (● Demographic and surgical details of the three patients who un" Table 1. D-LECS was sucderwent D-LECS are summarized in ● cessfully performed in all patients. The duration of surgery was 176 – 265 minutes, and the volume of blood loss was 0 – 20 mL. Five days later, one patient experienced bleeding of which he was unaware. Endoscopy was performed and a small bleeding vessel was found in the submucosal layer. Endoscopic clips were immediately applied to the vessel. No patient experienced delayed perforation or required re-admission.
Discussion !
D-LECS offers easy closure for mucosal defects through the placement of several seromuscular sutures. Single-layer seromuscular sutures with the knots tied on the serosa have been demonstrated to result in less inflammation, less adherence, better tissue approximation, and better tissue regeneration in intestinal anastomosis. However, the mechanisms causing delayed perforation remain unclear. Hanaoka et al. proposed a hypothesis based on histological examination around perforations, in which necrotic change was more distinct on the inner side of the muscular layer than on the outside layer [9]. These observations can be crucial for the prevention of delayed perforation and to strengthen the rationale for seromuscular sutures in the duodenum. D-LECS has other advantages. First, D-LECS can be completed in a closed manner, thus preventing tumor dissemination and infection from spillage of duodenal contents. Pneumoperitoneum from laparoscopic surgery could be a risk factor for intra-abdominal dissemination of tumor cells, enhancing tumor cell implantation when viable tumor cells spread into the abdominal cavity from the lumen [10]. Second, laparoscopic surgery is of great use because laparoscopic surgeons can reposition the duodenum if endoscopists have difficulty performing ESD as a result of tumor location. Third, even if perforation during the endoscopic procedure occurs, the perforation can be closed immediately, both endoscopically and laparoscopically. Fourth, laparoscopic surgery allows direct exploration of the abdominal cavity, which can minimize the possibility of tumor dissemination and lymph node involvement. D-LECS does possess some disadvantages: it requires laparoscopic surgery and general anesthesia, which are not only more expensive, but require a longer operating time, thus increasing
Video 1
Laparoscopic– endoscopic cooperative surgery for duodenal neoplasm.
Online content including video sequences viewable at: www.thieme-connect.de
the risk of complications. However, this risk may be minimal, as laparoscopic surgery in D-LECS is not a technically difficult procedure, and general anesthesia is associated with few risks nowadays. The cumulative additional cost of D-LECS would be less than that of emergency surgery and intensive care in patients who experience perforation. Taken together with the high rate of perforation in the duodenum, we believe that the advantages of DLECS outweigh the disadvantages, although the benefits of the minimal invasiveness of this technique require further confirmation by collecting data from a greater number of patients. Two issues arose in this series: postoperative bleeding and prolonged hospitalization. Postoperative bleeding occurred in one patient and was caused by a small bleeding vessel in the submucosal layer. This was believed to be a surgery-independent event. The prolonged hospitalization can be partially explained by the intentionally heightened postoperative monitoring of the three patients, which was deemed essential because they were the first patients to undergo D-LECS. Patients can usually be discharged 3 or 4 days after surgery because severe complications, if they do develop, often do so within 1 or 2 days of surgery. In conclusion, our experience of using D-LECS shows that it is a safe treatment option for duodenal adenoma and mucosal cancer. As the procedure requires no special instruments, devices, or techniques, nonspecialists and specialists alike can perform the procedure, both radically and safely. We believe that D-LECS can minimize the risk of developing complications related to endoscopic surgery and offers the best outcome in patients with duodenal tumors. Competing interests: None
References 1 Jung JH, Choi KD, Ahn JY et al. Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas. Endoscopy 2013; 45: 133 – 135 2 Yamamoto Y, Yoshizawa N, Tomida H et al. Therapeutic outcomes of endoscopic resection for superficial non-ampullary duodenal tumor. Dig Endosc 2014; 26: 0250 – 56 3 Inoue T, Uedo N, Yamashina T et al. Delayed perforation: a hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig Endosc 2014; 26: 220 – 227 4 Hiki N, Yamamoto Y, Fukunaga T et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008; 22: 1729 – 1735 5 Nunobe S, Hiki N, Gotoda T et al. Successful application of laparoscopic and endoscopic cooperative surgery (LECS) for a lateral-spreading mucosal gastric cancer. Gastric Cancer 2012; 15: 338 – 342 6 Inoue H, Ikeda H, Hosoya T et al. Endoscopic mucosal resection, endoscopic submucosal dissection, and beyond: full-layer resection for gastric cancer with nonexposure technique (CLEAN-NET). Surg Oncol Clin N Am 2012; 21: 129 – 140 7 Mitsui T, Goto O, Shimizu N et al. Novel technique for full-thickness resection of gastric malignancy: feasibility of nonexposed endoscopic wall-inversion surgery (NEWS) in porcine models. Surg Laparosc Endosc Percutan Tech 2013; 23: e217 – 221 8 Azevedo JL, Hypolito O, Azevedo OC et al. Comparative study of hand sewn single layer anastomosis of dog’s bowel. Arq Gastroenterol 2008; 45: 319 – 322 9 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112 – 1115 10 Shen MY, Huang IP, Chen WS et al. Influence of pneumoperitoneum on tumor growth and pattern of intra-abdominal tumor spreading: in vivo study of a murine model. Hepatogastroenterology 2008; 55: 947 – 951
Irino Tomoyuki et al. Laparoscopic-endoscopic surgery for duodenal tumors … Endoscopy 2015; 47: 349–351
351
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Case series
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
349
Authors
Tomoyuki Irino1, Souya Nunobe1, Naoki Hiki1, Yorimasa Yamamoto2, Toshiaki Hirasawa2, Manabu Ohashi1, Junko Fujisaki2, Takeshi Sano1, Toshiharu Yamaguchi1
Institutions
1 2
submitted 9. August 2014 accepted after revision 30. September 2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1390909 Published online: 5.12.2014 Endoscopy 2015; 47: 349–351 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Naoki Hiki, MD, PhD Department of Gastroenterological Surgery Cancer Institute Hospital 3-8-31, Ariake Koto-ku Tokyo, 135-8550 Japan Fax: +81-3-35200141 [email protected]
Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
A new rendezvous-style surgical technique has been developed to ensure the safety of endoscopic submucosal dissection (ESD) for duodenal tumors. The new technique, called “laparoscopicendoscopic cooperative surgery (LECS),” combines ESD with laparoscopic, reinforcing, seromuscular suturing. This case series report describes how three patients with a duodenal tumor were safely treated by LECS. ESD was performed by endoscopy, followed by closure of the mucosal
defect using seromuscular suturing by laparoscopy. ESD was successfully completed in all patients. Endoscopic findings after suturing revealed that the mucosal defect was closed appropriately and tightly. None of the three patients experienced delayed perforation or stricture after LECS. LECS for extraction of duodenal tumors seems to be feasible and helps to ensure the safety of ESD in the duodenum.
Introduction
ble 1). The indication for D-LECS is primarily the same as that for ESD in duodenal tumors; however, tumors located near the ampulla of Vater are not indicated. D-LECS was completed under general anesthesia and epidural anesthesia. Pneumoperitoneum was induced after the first trocar was placed at the level of the umbilicus. Four other trocars were inserted through the abdominal wall: one 12-mm trocar was inserted at the left upper quadrant, and three 5-mm trocars were inserted at the left lower, the right upper, and the right lower quadrants. After examination of the peritoneal cavity, the operative field was prepared according to the tumor location. For example, if the lesion was located in the second part of the duodenum, the right side of the transverse colon was adequately mobilized. Next, an endoscope was inserted into the duodenum to confirm the precise location of the lesion " Fig. 1 a). ESD was performed using an insula(● tion-tipped electrosurgical knife, the detailed procedure of which has been described elsewhere " Fig. 1 b). The specimen was retrieved intra[2] (● luminally and removed, with the endoscope, through the mouth. After ESD was completed, the mucosal defect was reinforced with seromuscular sutures to prevent complications after surgery. The endoscopist illuminated the mucosal defect with transmitted light so that the laparoscopist could clearly locate
!
Endoscopic submucosal dissection (ESD) for early duodenal cancer is associated with a high risk of perforation during and after surgery, occurring at rates up to 35.7 % [1, 2]. Furthermore, delayed perforation in the duodenum in particular may cause potentially fatal peritonitis, requiring emergency open surgery to perform adequate peritoneal lavage to counter leakage of bile and pancreatic juices [3]. Along with advancing the ESD technique, we have developed “laparoscopic-endoscopic cooperative surgery (LECS),” which combines laparoscopic surgery with endoscopic therapy for gastrointestinal tumors [4]. A number of novel procedures based on the LECS concept have arisen in its wake, such as inverted LECS [5], full-layer resection for gastric cancer with nonexposure technique (CLEAN-NET) [6], and nonexposed endoscopic wall-inversion surgery (NEWS) [7]. This report describes the LECS procedure for duodenal neoplasm (D-LECS), which could lead to successful endoscopic treatment for duodenal neoplasm.
Case report !
Three patients with duodenal carcinoma under" Tawent D-LECS with seromuscular sutures (●
Irino Tomoyuki et al. Laparoscopic-endoscopic surgery for duodenal tumors … Endoscopy 2015; 47: 349–351
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection
Case series
Table 1
Patient demographics and surgical results.
Patient 1
Patient 2
Patient 3
Age, years
60
68
71
Sex
Male
Male
Male
Tumor Biopsy
Adenoma with severe atypia
Adenoma with severe atypia
Adenoma with moderate atypia
Location
2nd part Perineal side Opposite to papilla
2nd part Perineal side 2 cm distal from papilla
2nd part Perineal side Opposite to papilla
Diameter, mm
25 × 17
12 × 6
14 × 10
Total duration, minutes
262
265
176
ESD, minutes
103
95
40
Suturing, minutes
74
22
38
Blood loss, mL
20
0
15
Hospital stay, days
8
7
Complications
None
None
Postoperative bleeding
Re-admission
No
No
No
Pathological result
Very well differentiated adenocarcinoma, mucosal invasion
Very well differentiated adenocarcinoma, mucosal invasion
Well differentiated adenocarcinoma, mucosal invasion
D-LECS
12
D-LECS, laparoscopy – endoscopy cooperative surgery for duodenal neoplasm; ESD, endoscopic submucosal dissection.
Fig. 1 Clinical manifestations of Patient 1. a Duodenoscopy of the tumor. b Duodenoscopy after endoscopic submucosal dissection. c Silhouette of the mucosal defect visualized by transluminal lighting. d Laparoscopy after seromuscular suturing. e Duodenoscopy after seromuscular suturing by laparoscopy.
Irino Tomoyuki et al. Laparoscopic-endoscopic surgery for duodenal tumors … Endoscopy 2015; 47: 349–351
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
350
" Fig. 1 c, ● " Video 1). The laand recognize the mucosal defect (● paroscopist added dye marks around the silhouette of the defect, and then placed seromuscular sutures in order to reinforce the " Fig. 1 d). Following suturing, locally thinned duodenal wall (● endoscopy was performed to confirm that the defect was appropriately closed and that neither stricture nor bleeding was pres" Fig. 1e; ● " Video 1). ent (● Demographic and surgical details of the three patients who un" Table 1. D-LECS was sucderwent D-LECS are summarized in ● cessfully performed in all patients. The duration of surgery was 176 – 265 minutes, and the volume of blood loss was 0 – 20 mL. Five days later, one patient experienced bleeding of which he was unaware. Endoscopy was performed and a small bleeding vessel was found in the submucosal layer. Endoscopic clips were immediately applied to the vessel. No patient experienced delayed perforation or required re-admission.
Discussion !
D-LECS offers easy closure for mucosal defects through the placement of several seromuscular sutures. Single-layer seromuscular sutures with the knots tied on the serosa have been demonstrated to result in less inflammation, less adherence, better tissue approximation, and better tissue regeneration in intestinal anastomosis. However, the mechanisms causing delayed perforation remain unclear. Hanaoka et al. proposed a hypothesis based on histological examination around perforations, in which necrotic change was more distinct on the inner side of the muscular layer than on the outside layer [9]. These observations can be crucial for the prevention of delayed perforation and to strengthen the rationale for seromuscular sutures in the duodenum. D-LECS has other advantages. First, D-LECS can be completed in a closed manner, thus preventing tumor dissemination and infection from spillage of duodenal contents. Pneumoperitoneum from laparoscopic surgery could be a risk factor for intra-abdominal dissemination of tumor cells, enhancing tumor cell implantation when viable tumor cells spread into the abdominal cavity from the lumen [10]. Second, laparoscopic surgery is of great use because laparoscopic surgeons can reposition the duodenum if endoscopists have difficulty performing ESD as a result of tumor location. Third, even if perforation during the endoscopic procedure occurs, the perforation can be closed immediately, both endoscopically and laparoscopically. Fourth, laparoscopic surgery allows direct exploration of the abdominal cavity, which can minimize the possibility of tumor dissemination and lymph node involvement. D-LECS does possess some disadvantages: it requires laparoscopic surgery and general anesthesia, which are not only more expensive, but require a longer operating time, thus increasing
Video 1
Laparoscopic– endoscopic cooperative surgery for duodenal neoplasm.
Online content including video sequences viewable at: www.thieme-connect.de
the risk of complications. However, this risk may be minimal, as laparoscopic surgery in D-LECS is not a technically difficult procedure, and general anesthesia is associated with few risks nowadays. The cumulative additional cost of D-LECS would be less than that of emergency surgery and intensive care in patients who experience perforation. Taken together with the high rate of perforation in the duodenum, we believe that the advantages of DLECS outweigh the disadvantages, although the benefits of the minimal invasiveness of this technique require further confirmation by collecting data from a greater number of patients. Two issues arose in this series: postoperative bleeding and prolonged hospitalization. Postoperative bleeding occurred in one patient and was caused by a small bleeding vessel in the submucosal layer. This was believed to be a surgery-independent event. The prolonged hospitalization can be partially explained by the intentionally heightened postoperative monitoring of the three patients, which was deemed essential because they were the first patients to undergo D-LECS. Patients can usually be discharged 3 or 4 days after surgery because severe complications, if they do develop, often do so within 1 or 2 days of surgery. In conclusion, our experience of using D-LECS shows that it is a safe treatment option for duodenal adenoma and mucosal cancer. As the procedure requires no special instruments, devices, or techniques, nonspecialists and specialists alike can perform the procedure, both radically and safely. We believe that D-LECS can minimize the risk of developing complications related to endoscopic surgery and offers the best outcome in patients with duodenal tumors. Competing interests: None
References 1 Jung JH, Choi KD, Ahn JY et al. Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas. Endoscopy 2013; 45: 133 – 135 2 Yamamoto Y, Yoshizawa N, Tomida H et al. Therapeutic outcomes of endoscopic resection for superficial non-ampullary duodenal tumor. Dig Endosc 2014; 26: 0250 – 56 3 Inoue T, Uedo N, Yamashina T et al. Delayed perforation: a hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig Endosc 2014; 26: 220 – 227 4 Hiki N, Yamamoto Y, Fukunaga T et al. Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 2008; 22: 1729 – 1735 5 Nunobe S, Hiki N, Gotoda T et al. Successful application of laparoscopic and endoscopic cooperative surgery (LECS) for a lateral-spreading mucosal gastric cancer. Gastric Cancer 2012; 15: 338 – 342 6 Inoue H, Ikeda H, Hosoya T et al. Endoscopic mucosal resection, endoscopic submucosal dissection, and beyond: full-layer resection for gastric cancer with nonexposure technique (CLEAN-NET). Surg Oncol Clin N Am 2012; 21: 129 – 140 7 Mitsui T, Goto O, Shimizu N et al. Novel technique for full-thickness resection of gastric malignancy: feasibility of nonexposed endoscopic wall-inversion surgery (NEWS) in porcine models. Surg Laparosc Endosc Percutan Tech 2013; 23: e217 – 221 8 Azevedo JL, Hypolito O, Azevedo OC et al. Comparative study of hand sewn single layer anastomosis of dog’s bowel. Arq Gastroenterol 2008; 45: 319 – 322 9 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112 – 1115 10 Shen MY, Huang IP, Chen WS et al. Influence of pneumoperitoneum on tumor growth and pattern of intra-abdominal tumor spreading: in vivo study of a murine model. Hepatogastroenterology 2008; 55: 947 – 951
Irino Tomoyuki et al. Laparoscopic-endoscopic surgery for duodenal tumors … Endoscopy 2015; 47: 349–351
351
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Case series
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
