Neoadjuvant Chemotherapy Followed by Laparoscopic and Endoscopic Cooperative Surgery for Locally Advanced Duodenal Gastrointestinal Stromal Tumor: A Case Report

Abstract

INTRODUCTION: Duodenal gastrointestinal stromal tumors (D-GISTs) are rare neoplasms that pose surgical challenges, particularly when located near critical structures such as the ampulla of Vater or the pancreatic head. Although pancreaticoduodenectomy (PD) is often required in such cases, it is associated with significant morbidity. Neoadjuvant chemotherapy (NAC) with imatinib has emerged as a strategy to downsize tumors, thereby enabling organ-preserving resections. Laparoscopic and endoscopic cooperative surgery (LECS), initially developed for gastric submucosal tumors, has been adapted for duodenal lesions (D-LECS) in selected cases. Here, we present a case in which neoadjuvant imatinib therapy enabled local resection using the D-LECS approach.

CASE PRESENTATION: A 67-year-old man was diagnosed with a 55-mm D-GIST involving the duodenal bulb and descending portion, located near the ampulla of Vater and pancreatic head. NAC with imatinib (400 mg/day) was administered for 2 months, resulting in significant tumor shrinkage to 27 mm, without invasion of adjacent structures. D-LECS was performed using an endoscopic submucosal incision followed by laparoscopic full-thickness resection. After laparoscopic suturing, minor leakage at the end of the suture line was reinforced using the reopenable-clip over line method. The procedure was completed safely with negative margins and no complications. The patient was discharged on POD 14, and remained recurrence-free at 12 months.

CONCLUSIONS: Neoadjuvant imatinib effectively downsized a locally advanced D-GIST, enabling safe, minimally invasive resection via D-LECS. This case highlights the potential of NAC and D-LECS as a less invasive alternative to PD in anatomically challenging D-GISTs.