Mesenteric approach in pancreas-preserving partial duodenectomy for a gastrointestinal stromal tumor located in the third portion of the duodenum: A ‍case report

Abstract

Owing to the anatomical specificity of duodenal gastrointestinal stromal tumors, various surgical techniques are for removal, ranging from local resection to pancreaticoduodenectomy, depending on the location, size, and nature of the tumor. Considering the invasiveness of the procedure and postoperative quality of life, local resection is the preferred choice if complete tumor resection is feasible. However, resection of the third portion of the duodenum is difficult because it lies between the superior mesenteric artery and the abdominal aorta. The patient was a 65-year-old male. Contrast-enhanced abdominal computed tomography revealed a 10-mm mass in the third portion of the duodenum, which was diagnosed as a duodenal gastrointestinal stromal tumor. The patient underwent pancreas-preserving partial duodenectomy via the mesenteric approach, a technique typically used in pancreaticoduodenectomy for pancreatic cancer. Following this approach, the superior mesenteric artery and vein were separated and the mesentery located anterior to the duodenum was removed. Using this method, bleeding could be controlled and the uncinate processes of the pancreas and duodenum could be accurately divided. Pancreas-preserving partial duodenectomy using the mesenteric approach is beneficial for treating gastrointestinal stromal tumors involving the third portion of the duodenum.

INTRODUCTION

Pancreaticoduodenectomy (PD) is a general procedure used to treat periampullary tumors, including pancreatic cancer, intraductal papillary mucinous neoplasms, and neuroendocrine neoplasms. Notably, PD is a complex procedure associated with high morbidity, including postoperative pancreatic fistula (POPF), delayed gastric emptying, and abdominal abscesses^5,9). For low-malignancy tumors, including gastrointestinal stromal tumors (GISTs), pancreas-preserving partial duodenectomy is a surgical option for preserving the entire pancreas¹⁾. However, dissection of the third portion of the duodenum is difficult because it lies between the superior mesenteric artery (SMA) and the abdominal aorta. The mesenteric approach, first reported by Nakao and Takagi⁶⁾ in 1993, is the preferred arterial approach for PD in pancreatic cancer. In this approach, the connective tissue around the superior mesenteric vein (SMV) and SMA is first removed. Pancreas-preserving partial duodenectomy via the mesenteric approach may be useful for resecting low-malignancy tumors in the third portion of the duodenum. Herein, we present the case of a patient with a GIST located in the third portion of the duodenum who was treated with partial pancreas-preserving duodenectomy via the mesenteric approach.

CASE REPORT

A 65-year-old man presented with abdominal discomfort. Abdominal computed tomography (CT) indicated a small mass near the pancreatic head. The patient was referred to our hospital for further examination and treatment. His medical history included hyperlipidemia, tachyarrhythmia, asthma, acute pancreatitis, postoperative inguinal hernia, and postoperative appendicitis. Carcinoembryonic antigen and carbohydrate antigen 19-9 levels were not elevated. Contrast-enhanced CT of the abdomen revealed a small nodule (10 mm) in the third portion of the duodenum on the opposite side of the pancreatic parenchyma with early staining (Fig. 1a, b). No radiological lymph node or distant metastases were detected. Esophagogastroduodenoscopy revealed a small tumor in the third portion of the duodenum, and endoscopic ultrasonography revealed a well-defined, round, hypoechoic mass, 10 mm in size, without invasion of the pancreatic uncinate process (Fig. 2a, b). Color Doppler imaging revealed internal blood flow. A biopsy was performed and histopathological examination confirmed the GIST diagnosis. Based on these results, we diagnosed the patient with a GIST located in the third portion of the duodenum and performed a pancreas-preserving partial duodenectomy.

Figure 1

a, b: Contrast-enhanced computed tomography scan of the abdomen showing a small nodule (10 mm; arrowhead) in the third portion of the duodenum with early staining. CT, computed tomography.

Figure 2

a: Esophagogastroduodenoscopy showed a small tumor in the third portion of the duodenum. b: Endoscopic ultrasonography revealed that it was well-defined, round, hypoechoic mass, having internal blood flow,and 10 mm in size bordering the uncinate process of the pancreas. A biopsy was performed.

Intraoperative ultrasonography revealed a hypoechoic mass on the left side of the SMA. After cranial lifting of the transverse colon, the mesentery was incised from the ligament of Treitz to the lower border of the second duodenal portion. The SMV and SMA were exposed after the connective tissues in the mesentery were dissected (Fig. 3a). The ligament of Treitz was then dissected, the third portion of the duodenum was widely mobilized, and the border between the uncinate process of the pancreas and duodenum was clearly observed and dissected (Fig. 3b). A mass protruding from the duodenum was identified at the border of the uncinate process in the pancreas. Partial resection of the duodenum was then conducted (Fig. 3c, d).

Figure 3

a: The superior mesenteric vein and superior mesenteric artery exposed after the connective tissues in the mesentery were dissected. b: The clearly observable border between the uncinate process of the pancreas and duodenum. c: The clearly identifiable mass protruding from the duodenum at the border with the uncinate process of the pancreas (arrowhead). d: Partial resection of the duodenum.

Figure 4

a, b: Hematoxylin-Eosin Stain. Spindle-shaped cells arising from the muscularis propria and subserosal layer.

Histopathological examination revealed that the tumor had a maximum diameter of 15 mm and was located in the muscularis propria and the subserosal layer of the duodenum (Fig. 3a, b). The tumor cells were spindle-shaped and eosinophilic with oval nuclei; however, mitotic figures were not observed (Fig. 4a, b). Immunohistochemistry revealed that the tumor cells were strongly positive for CD117 (c-KIT) and DOG-1. Based on these findings, the tumor was diagnosed as a very-low-risk GIST. The patient had an uncomplicated postoperative course, and was discharged 15 days postoperatively. The patient did not require adjuvant chemotherapy and remained alive six months after surgery without recurrence.

DISCUSSION

GISTs are relatively rare tumors with an incidence of 1–2 per 100,000 individuals. Duodenal primary tumors account for 4.5% of all GISTs⁸⁾. A proportion of 18.3% of duodenal GISTs have been reported to occur in the third portion⁸⁾. Although surgical resection is the first choice of treatment for low-malignancy GISTs, safe resection margins must be secured without damaging the false capsule²⁾. Owing to the anatomical specificity of duodenal GISTs, various surgical techniques are used depending on the size and location of the tumor and the degree of invasion. In general, partial resection of the duodenum, segmental duodenectomy with duodenojejunal anastomosis, pancreas-preserving duodenectomy, and PD are often performed, and there is no significant difference in survival or local recurrence rates between these surgical options^2,4). PD was selected when the resection area included Vater’s papilla or the pancreatic head. It is more invasive than partial resection, and there are concerns regarding reduced postoperative quality of life. Therefore, partial resection should be performed if a margin-negative resection is possible. When performing partial resection of a primary GIST in the third portion of the duodenum, the approach is relatively difficult. The most common approach is to remove and open the ligament of Treitz and transfer the proximal jejunum to the right using the Kocher maneuver⁴⁾. The third portion of the duodenum is attached to the inferior border of the pancreas, making complete transfer difficult. The uncinate process of the pancreas to the beginning of the jejunum remains in the deepest part of the abdominal cavity, making it difficult to obtain a clear view due to obstruction by the mesentery of the transverse colon. The short branches of the SMV and SMA are easily damaged during surgery, resulting in massive bleeding, prolonged operative time, and increased blood loss. Therefore, a mesenteric approach was selected for this case.

The mesenteric approach is the preferred arterial approach for PD in pancreatic cancer⁶⁾. The effectiveness of this technique has been reported in terms of its good bleeding control, radical resection, and oncological benefits for pancreatic cancer³⁾. In the present case, the SMV and SMA were first separated and the mesentery, located anterior to the duodenum, was removed using a mesenteric approach. This approach allowed wide visualization of the area around the SMV and SMA, enabling easy separation and transection of the third portion of the duodenum. Therefore, bleeding can be controlled, and the uncinate processes of the pancreas and duodenum can be accurately divided.

Reports of pancreas-preserving partial duodenectomy using the mesenteric approach are extremely rare. Nakao et al.⁷⁾ reported a case of aortic graft–duodenal fistula treated with partial pancreas-preserving duodenectomy using this approach, which decreased the difficulty of graft replacement and pancreas-sparing partial duodenectomy and reduced the risk of serious postoperative complications, such as POPF and abdominal abscess. The authors concluded that this approach reduced the difficulty of graft replacement and pancreas-preserving partial pancreatectomy and prevented serious postoperative complications, such as POPF and abdominal abscesses.

In the present case, the mesenteric approach was useful in pancreas-preserving partial duodenectomy for GISTs located in the third portion of the duodenum and had the potential to decrease intraoperative blood loss, surgery time, and surgical invasiveness.

CONFLICTS OF INTEREST DISCLOSURE

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices mentioned in this article.

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