Endoscopy 2020; 52(02): E68-E70
DOI: 10.1055/a-0999-5172
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Laparoscopy and endoscopy cooperative surgery is a safe and effective novel treatment for duodenal neuroendocrine tumor G1

Nobukazu Yorimitsu
1  Department of Gastroenterology, Tokyo Metropolitan Cancer Detection Center, Tokyo, Japan
2  Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
,
Tsuneo Oyama
2  Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
,
Akiko Takahashi
2  Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
,
Takuo Takehana
3  Department of Surgery, Saku Central Hospital Advanced Care Center, Saku, Japan
,
Satoshi Shiozawa
4  Department of Pathology, Saku Central Hospital Advanced Care Center, Saku, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
17 September 2019 (online)

The European Neuroendocrine Tumor Society guidelines recommend endoscopic resection for nonampullary duodenal neuroendocrine tumors (NETs) < 10 mm in size without any metastasis [1]; however, endoscopic resection for duodenal NETs is challenging [2]. Gincul et al. reported 32 duodenal NETs treated by endoscopic mucosal resection [3]. The R0 resection rate was 50 %, the overall complication rate was 38 %, and one procedure-related death occurred. Suzuki et al. reported the outcome of endoscopic submucosal dissection (ESD) for 37 rectal, 2 gastric, and 3 duodenal NET cases [4]. The R0 resection rate was 98 % but the perforation rate of duodenal ESDs was 66 %. Laparoscopy and endoscopy cooperative surgery (LECS) [5] is one of the options to resect duodenal NETs safely.

A 77-year-old man was referred to our hospital for treatment of duodenal NET G1 diagnosed by biopsy. Esophagogastroduodenoscopy revealed a 5-mm submucosal tumor at the duodenal bulb ([Fig. 1]). Endoscopic ultrasonography revealed a hypoechoic lesion in the submucosal layer just above the muscularis propria ([Fig. 2]). It was considered that an R0 resection would be too difficult to achieve and the risk of perforation would be too great with endoscopic resection. Hence, we selected LECS ([Video 1]).

Zoom Image
Fig. 1 Esophagogastroduodenoscopy revealed a 5-mm submucosal tumor at the duodenal bulb.
Zoom Image
Fig. 2 Endoscopic ultrasonography revealed a hypoechoic lesion in the submucosal layer just above the muscularis propria.

Video 1 Laparoscopy and endoscopy cooperative surgery for duodenal neuroendocrine tumor G1. Selection of the appropriate resection area and initial mucosal incision (endoscopically) were followed by complete resection (endoscopically and laparoscopically) and suturing (laparoscopically).


Quality:

First, surgeons exposed the duodenal bulb and the second portion laparoscopically. Then, endoscopists and surgeons marked around the lesion, and mucosal circumferential incision was performed endoscopically ([Fig. 3]). After that, we performed a quarter of the full-thickness incision endoscopically, with the remaining three-quarters being performed laparoscopically. Finally, surgeons performed laparoscopic suturing, and endoscopists confirmed duodenal lumen patency and no leakage. The overall operative time was 3 hours 41 minutes, and the hemorrhage volume was 10 mL.

Zoom Image
Fig. 3 Mucosal circumferential incision was performed endoscopically.

The pathological diagnosis was duodenal NET G1, T1b-SM2, ly0, v0, HM0, VM0, and 5 mm in size ([Fig. 4]). The NET invasion extended to just above the muscularis propria ([Fig. 5]). Notably, endoscopic resection seemed impossible. At 3 years after LECS, local recurrence and metastasis have not been observed. Our findings suggest that LECS is an effective treatment for duodenal T1b NET G1.

Zoom Image
Fig. 4 The pathological diagnosis was duodenal NET G1, T1b-SM2, ly0, v0, HM0, VM0, and 5 mm in size.
Zoom Image
Fig. 5 The neuroendocrine tumor invasion extended to just above the muscularis propria.

Endoscopy_UCTN_Code_TTT_1AO_2AN

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos