Pancreas-preserving limited duodenal resection: Minimizing morbidity without compromising oncological adequacy.

Duodenal pathologies in children: a single‐center experience

Duodenal pathologies in children: a single-center experience

MS07.04 Stage I (Resectable) NSCLC: Surgery

Duodenal resections are sometimes necessary for radical surgery. We analyzed technical aspects and post-operative outcomes in patients with RPS and GIST involving duodenum. We identified patients who underwent duodenal resection for RPS and GIST at our Institute between 2000 and 2016. Clinical, pathological and treatment variables were analyzed. Thirty patients were treated: 15 for GIST, 15 for RPS. Sixteen duodenal wedge resections (WR) and 14 segmental resections (SR) were performed. Multi-organ resection was frequently performed (63.4%). Median time to flatus was 3days (range 1-6), to oral refeeding 4.5 (range 2-15). Overall postoperative morbidity rate was 53% (16/30): Clavien Dindo grade≤ II: 10; duodenum-related complication rate was 33% (10/30), Clavien Dindo grade≤ II: 9. Morbidity rates were higher in SR than WR. Duodenal resections for RPS and GIST have significant morbidity rate and whenever it is possible, WR is preferable to SR because of the lower morbidity rate.

The surgical management of duodenal gastrointestinal stromal tumors (DGIST) is poorly characterized. Limited resection may be technically feasible and oncologically safe, but anatomic considerations may compromise the resection margins due to the proximity of critical structures, thereby necessitating more extensive resections such as pancreaticoduodenectomy. Patients undergoing surgery for DGIST at two institutions from 1994 to 2014 were identified. Clinicopathologic and survival data were analyzed to compare outcomes in patients treated with limited or radical resection. Sixty patients underwent surgery for DGIST. Pancreaticoduodenectomy was performed in 38% while the rest underwent limited resections. The most common type of limited resection was wedge resection and primary closure (49%) followed by segmental resection with an end-to-end or side-to-side duodenojejunostomy (27%). The pancreaticoduodenectomy group tended to have larger tumors with the majority located in D2/3 (87%) and at the mesenteric border (91%). The pancreaticoduodenectomy group also had significantly greater intraoperative blood loss, longer operative time, longer hospital stay, and higher 90-day morbidity and readmission rates. The 5-year relapse-free survival, recurrence-free survival, and overall survival for the pancreaticoduodenectomy versus limited resection were 81 versus 56% (p=0.05), 64 versus 53% (p=0.5), and 76 versus 72 % (p=0.6), respectively. A surgical algorithm based on the location and size of the tumor is proposed. Limited resection of DGIST is safe, but may be associated with lower 5-year relapse-free survival. Pancreaticoduodenectomy is recommended for selected patients with DGIST when an R0 resection cannot be performed without removing the ampulla or part of the pancreas.

Myoglobin levels at 12 hours identify patients at low risk for 30-day mortality after thrombolysis in acute myocardial infarction: A Thrombolysis in Myocardial Infarction 10B substudy

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: is limited pulmonary resection equivalent to lobectomy in terms of morbidity, long-term survival and locoregional recurrence in patients with stage I non-small-cell lung cancer (NSCLC)? A total of 166 papers were found using the reported search; of which, 16 papers, including one meta-analysis and one randomized control trial (RCT), represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. With regards to 5-year survival rates, the evidence is conflicting: a 2005 meta-analysis and six other retrospective or prospective nonrandomized analyses did not find any statistically significant difference when comparing lobectomy with limited resection. However, three studies found evidence of a decreased overall survival with limited resection, including the only randomized control trial, which showed a 50% increase in the cancer-related death rate (P = 0.09), and a 30% increase in the overall death rate in patients undergoing limited resection (P = 0.08). Age, tumour size and specific type of limited resection were also factors influencing the survival rates. Four studies, including the RCT, found increased locoregional recurrence rates with limited resection. There is also evidence that wedge resections, compared with segmentectomies, lead to lower survival and higher recurrence rates. In conclusion, lobectomy is still recommended for younger patients with adequate cardiopulmonary function. Although limited resection carries a decreased rate of complications and shorter hospital stays, it may also carry a higher rate of loco-regional recurrences. However, limited resection may be comparable for patients >71 years of age, and those with small peripheral tumours.

Feasibility and Oncological Outcomes of Limited Duodenal Resection in Patients with Primary Nonmetastatic Duodenal GIST

To analyze our experience in patients with duodenal gastrointestinal stromal tumors (GIST) and review the appropriate surgical approach. We retrospectively reviewed the medical records of all patients with duodenal GIST surgically treated at our medical institution between 2002 and 2011. Patient files, operative reports, radiological charts and pathology were analyzed. For surgical therapy open and laparoscopic wedge resections and segmental resections were performed for limited resection (LR). For extended resection pancreatoduodenectomy was performed. Age, gender, clinical symptoms of the tumor, anatomical localization, tumor size, mitotic count, type of resection resectional status, neoadjuvant therapy, adjuvant therapy, risk classification and follow-up details were investigated in this retrospective study. Nine patients (5 males/4 females) with a median age of 58 years were surgically treated. The median follow-up period was 45 mo (range 6-111 mo). The initial symptom in 6 of 9 patients was gastrointestinal bleeding (67%). Tumors were found in all four parts of the duodenum, but were predominantly located in the first and second part of the duodenum with each 3 of 9 patients (33%). Two patients received neoadjuvant medical treatment with 400 mg imatinib per day for 12 wk before resection. In one patient, the GIST resection was done by pancreatoduodenectomy. The 8 LRs included a segmental resection of pars 4 of the duodenum, 5 wedge resections with primary closure and a wedge resection with luminal closure by Roux-Y duodeno-jejunostomy. One of these LRs was done minimally invasive; seven were done in open fashion. The median diameter of the tumors was 54 mm (14-110 mm). Using the Fletcher classification scheme, 3/9 (33%) tumors had high risk, 1/9 (11%) had intermediate risk, 4/9 (44%) had low risk, and 1/9 (11%) had very low risk for aggressive behaviour. Seven resections showed microscopically negative transsection margins (R0), two showed positive margins (R1). No patient developed local recurrence during follow-up. The one patient who underwent pancreatoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local recurrence. Another patient died in complete remission due to cardiac disease. Seven of the nine patients are alive disease-free. In patients with duodenal GIST, limited surgical resection with microscopically negative margins, but also with microscopically positive margins, lead to very good local and systemic disease-free survival.

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010-2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3-21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.

Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer

The “Goldilocks” Principle

Wedge Resection Offers Similar Survival to Segmentectomy for Typical Carcinoid Tumors

What is the Impact of External Beam Radiation Therapy (EBRT) Following Limited Resection of T1 or T2 Non-small Cell Lung Cancer (NSCLC)? A SEER Analysis

Limited Resection of Bronchogenic Carcinoma in the Patient with Marked Impairment of Pulmonary Function