We investigated the clinicopathological features and management for superficial nonampullary duodenal tumors (SNADTs). The safety and feasibility of laparoscopic management, especially laparoscopic endoscopic cooperative surgery (LECS), were evaluated.

A total of 59 patients with SNADTs who underwent operations from January 2009 to December 2018 at all 8 institutions of the Catholic Medical Center were identified in our comprehensive multi-institutional database. Clinicopathological and surgical data on the 4 anatomical regions of the duodenum were collected and compared. Characteristics of conventional laparoscopic procedure (laparoscopy-only) and LECS procedures were also compared.

There were significantly more asymptomatic patients with tumors in the first and second vs. third and fourth duodenal regions. Gastrointestinal stromal tumors (GISTs), carcinoids, and ectopic pancreatic tumors were identified in 32, 12, and 5 cases, respectively. Forty-two patients (71.2%) underwent laparoscopy. Of patients undergoing laparoscopy, the LECS group exhibited significantly more endophytic features and smaller tumor sizes (P < 0.001 and P < 0.001, respectively). Although no significant difference in the wedge resection or postoperative complication rate was seen between the 2 groups (P = 0.096 and P = 0.227, respectively), the wedge resection rate was higher, and the complication rate lower, in the LECS group than the conventional laparoscopic surgery group.

Most of the SNADTs located in proximal duodenum were detected incidentally. GISTs were the most common diagnoses of SNADTs in all locations. In treating these tumors, laparoscopic resection is safe and feasible. Especially, LECS may be ideal for treating small endophytic tumors, minimizing over-resection and postoperative complications.

Duodenal adenomas are benign tumours of the duodenum which carry a malignant potential. They are found either sporadically or associated with familial syndromes. Majority of these cases are treated endoscopically but surgical resection is a better alternate to endoscopy in select cases. Endoscopic treatment is associated with higher chances of local recurrence and require frequent check endoscopies in the follow up period, while surgery offers a one-time treatment option. Identification of the ampulla and a duodenal resection sparing ampullary area becomes difficult in larger lesions of the 2nd part of the duodenum. Passage of a catheter from cystic duct through common bile duct to duodenum aids in identification of the ampullary area and is helpful in performing a local/wedge resection of the duodenum containing adenoma without injuring ampullary orifice.

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Duodenal adenomas carry malignant potential.

• Familial adenomatous polyposis
• Sporadic duodenal adenoma
• Tubulo-villous adenoma

Despite improvements in imaging modalities, causative lead points in adult intussusception may be difficult to diagnose. Such lead points can be malignant, causing recurrence or metastases if left unresected. We describe a case of transient adult jejunojejunal intussusception, in which intraoperative endoscopy was used to confirm the absence of a lead point. A 39-year-old woman with a history of laparoscopic oophorectomy presented with epigastric pain, nausea, and vomiting. Contrast computed tomography revealed jejunojejunal intussusception, with no visible lead point. Spontaneous reduction was confirmed during exploratory laparoscopy. After lysis of adhesions, intraoperative peroral jejunoscopy was performed with the surgeons' assistance. Endoscopy confirmed the absence of tumor, and bowel resection was avoided. No recurrence has been observed during 24 months of follow-up. Intraoperative endoscopy may provide additional reassurance for the absence of a lead point in cases where preoperative enteroscopy cannot be performed and no lead points can be identified on imaging.

Gastrointestinal subepithelial tumors (GSTs), incidentally detected during upper gastrointestinal (GI) endoscopy, may be lesions derived from the GI wall or may be caused by compression from external organs. In general, traumatic neuroma is a benign nerve tumor that results from postoperative nerve injury, occurring in the bile duct as one of the complications after cholecystectomy. This is the first case report demonstrating that neuroma of the cystic duct can be incorrectly perceived as a duodenal subepithelial tumor by compressing the duodenal wall.

We report the case of a 72-year-old man with traumatic neuroma of the cystic duct after cholecystectomy. This tumor was mistaken for a duodenal subepithelial tumor on preoperative upper GI endoscopy and endoscopic ultrasonography due to external compression of the GI wall. The patient had no symptoms, and his laboratory test results were normal. However, in a series of follow-up endoscopies, the tumor was found to have grown in size, so it was surgically resected. The lesion was completely removed by laparoscopic endoscopic cooperative surgery. The patient was discharged on postoperative day 7 without complications.

Traumatic neuroma of the cystic duct can be mistaken for GSTs in GI endoscopy.

• Case report
• Neuroma
• Tumor
• Endoscopy
• Laparoscopy
• Cholecystectomy

• Complications
• Endoscopic full-thickness resection
• Nonampullary duodenal subepithelial lesion

• Adult
• Aged
• Aged, 80 and over
• China
• Duodenal Neoplasms/mortality
• Duodenal Neoplasms/pathology
• Duodenal Neoplasms/surgery
• Endoscopy/methods
• Female
• Gastrointestinal Stromal Tumors/mortality
• Gastrointestinal Stromal Tumors/pathology
• Gastrointestinal Stromal Tumors/surgery
• Humans
• Male
• Middle Aged
• Neoplasm Recurrence, Local/mortality
• Neoplasm Recurrence, Local/pathology
• Neoplasm Recurrence, Local/surgery
• Retrospective Studies
• Suture Techniques
• Treatment Outcome

• Duodenum tumour
• endoscopic submucosal dissection
• laparoscopic endoscopic cooperative surgery

• Endoscopic submucosal dissection
• Gastric
• Gastrointestinal stromal tumors
• Laparoscopic endoscopic cooperative surgery
• Propensity score matching

• Adult
• Endoscopic Mucosal Resection/methods
• Feasibility Studies
• Female
• Gastrointestinal Stromal Tumors/surgery
• Gastroscopy/methods
• Humans
• Intraoperative Complications/epidemiology
• Laparoscopy/methods
• Male
• Middle Aged
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Period
• Propensity Score
• Reoperation
• Retrospective Studies
• Safety
• Stomach Neoplasms/surgery
• Treatment Outcome

To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors.

Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small (less than 10 mm) submucosal tumors (SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection (ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.

Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications (Clavien-Dindo classification grade III or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.

LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.

• Non-ampullary tumor
• Laparoscopic and endoscopic cooperative surgery
• Early duodenal cancer

• Adenocarcinoma/pathology
• Adenocarcinoma/surgery
• Adenoma/pathology
• Adenoma/surgery
• Aged
• Anastomotic Leak/etiology
• Blood Loss, Surgical
• Duodenal Neoplasms/pathology
• Duodenal Neoplasms/surgery
• Duodenoscopy/adverse effects
• Endoscopic Mucosal Resection/adverse effects
• Feasibility Studies
• Female
• Humans
• Japan
• Laparoscopy/adverse effects
• Magnetic Resonance Imaging, Cine
• Male
• Middle Aged
• Neuroendocrine Tumors/pathology
• Neuroendocrine Tumors/surgery
• Operative Time
• Pancreatic Fistula/etiology
• Treatment Outcome
• Tumor Burden

Duodenal endoscopic resection is the most difficult type of endoscopic treatment in the gastrointestinal tract (GI) and is technically challenging because of anatomical specificities. In addition to these technical difficulties, this procedure is associated with a significantly higher rate of complication than endoscopic treatment in other parts of the GI tract. Postoperative delayed perforation and bleeding are hazardous complications, and emergency surgical intervention is sometimes required. Therefore, it is urgently necessary to establish a management protocol for preventing serious complications. For instance, the prophylactic closure of large mucosal defects after endoscopic resection may reduce the risk of hazardous complications. However, the size of mucosal defects after endoscopic submucosal dissection (ESD) is relatively large compared with the size after endoscopic mucosal resection, making it impossible to achieve complete closure using only conventional clips. The over-the-scope clip and polyglycolic acid sheets with fibrin gel make it possible to close large mucosal defects after duodenal ESD. In addition to the combination of laparoscopic surgery and endoscopic resection, endoscopic full-thickness resection holds therapeutic potential for difficult duodenal lesions and may overcome the disadvantages of endoscopic resection in the near future. This review aims to summarize the complications and closure techniques of large mucosal defects and to highlight some directions for management after duodenal endoscopic treatment.

• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Duodenum
• Complication
• Bleeding
• Perforation
• Over-the-scope clip
• Clip
• Closure
• Endoscopic full-thickness resection

• Duodenal Neoplasms/surgery
• Duodenum/surgery
• Endoscopy, Gastrointestinal/adverse effects
• Gastrointestinal Hemorrhage/etiology
• Humans
• Intestinal Mucosa/surgery
• Intestinal Perforation/etiology
• Laparoscopy
• Suture Techniques/instrumentation

• Combination of laparoscopic and endoscopic approaches for neoplasia with a nonexposure technique
• Full-thickness resection
• Gastrointestinal stromal tumor
• Laparoscopic and endoscopic cooperative surgery
• Laparoscopic transgastric surgery
• Laparoscopy-assisted endoscopic full-thickness resection
• Laparoscopy-assisted endoscopic resection
• Nonexposed endoscopic wall-inversion surgery

• Duodenal cancer
• LECS
• laparoscopic-endoscopic cooperative surgery

• Duodenal adenoma
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Endoscopy
• Familial adenomatous polyposis

• Adenomatous Polyps/diagnosis
• Adenomatous Polyps/epidemiology
• Adenomatous Polyps/pathology
• Adenomatous Polyps/therapy
• Dissection/adverse effects
• Dissection/methods
• Duodenal Neoplasms/diagnosis
• Duodenal Neoplasms/epidemiology
• Duodenal Neoplasms/pathology
• Duodenal Neoplasms/therapy
• Duodenoscopy/adverse effects
• Humans
• Intestinal Polyps/diagnosis
• Intestinal Polyps/epidemiology
• Intestinal Polyps/pathology
• Intestinal Polyps/therapy
• Pancreaticoduodenectomy/adverse effects
• Postoperative Complications/etiology
• Predictive Value of Tests
• Treatment Outcome

As endoscopic technology has developed and matured, the endoscopic resection of gastrointestinal tract polyps has become a widely used treatment. Colorectal polyps are the most common type of polyp, which are best managed by early resection before the polyp undergoes malignant transformation. Methods for treating colorectal tumors are numerous, including argon plasma coagulation, endoscopic mucosal resection, endoscopic submucosal dissection, and laparoscopic-endoscopic cooperative surgery. In this review, we will highlight several currently used clinical endoscopic resection methods and how they are selected based on the characteristics of the targeted tumor. Specifically, we will focus on laparoscopic-endoscopic cooperative surgery.

• Colorectal tumor
• Endoscopic resection

• Duodenal tumor
• laparoscopic surgery
• transduodenal excision

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Laparoscopic and endoscopic cooperating surgery (LECS) enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing for duodenal neoplasms.

We report a case of primary adenocarcinoma in the third portion of the duodenum (D3) curatively resected by laparoscopic and endoscopic cooperating surgery (LECS).

A 65-year-old woman had a routine visit to our hospital for a follow-up of rectal cancer resected curatively 2 years ago. A routine screening gastroduodenal endoscopy revealed an elevated lesion of 20 mm in diameter in the D3. The preoperative diagnosis was adenoma with high-grade dysplasia; however, suspicion about potential adenocarcinoma was undeniable. Curative resection was performed by LECS. Pathological examination revealed intramucosal adenocarcinoma arising from normal duodenal mucosa. The tumor was stage I (T1/N0/M0) in terms of the tumor, nodes, metastasis (TNM) classification. LECS for duodenal tumor has seldom been reported previously, and this is the first report of LECS for primary adenocarcinoma in the D3. The transverse mesocolon was removed from the head of pancreas to expose the duodenum, and the accessory right colic vein was cut; this was followed by the Kocher maneuver for mobilization of the lesion site.

LECS enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing. Thorough mobilization of the mesocolon and pancreas head is essential for this procedure because it facilitates correct resection and suturing.

LECS is a feasible treatment option for duodenal neoplasms, including intramucosal adenocarcinoma, even though it exists in the D3.

• Duodenal adenocarcinoma
• Duodenum
• Laparoscopic and endoscopic cooperating surgery

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Endoscopic treatment is generally recommended for G1 NETs <10 mm in diameter and extending only to the submucosal layer in gastrointestinal tract.

We report a case of duodenal neuroendocrine tumor (NET) G1 resected by laparoscopic and endoscopic cooperative surgery (LECS) technique.

A 58-year-old woman underwent esophagastroduodenoscopy, revealing an 8-mm, gently rising tumor distal to the pylorus, on the anterior wall of the duodenal bulb. Endoscopic ultrasonography suggested the tumor might invade the submucosal layer. The tumor was pathologically diagnosed as a G1 duodenal NET, by biopsy. Endoscopic submucosal dissection was attempted, but was unsuccessful because of the difficulty of endoscopically performing an inversion operation in the narrow working space. The case was further complicated by the patient's duodenal ulcer scar. We performed a full-thickness local excision using laparoscopic and endoscopic cooperative surgery. The tumor was confirmed and endoscopically marked along the resection line. After full-thickness excision, using endoscopy and laparoscopy, interrupted full-thickness closure was performed laparoscopically.

Endoscopic treatment is generally recommended for G1 NETs <10 mm in diameter and extending only to the submucosal layer. However, some cases are difficult to resect endoscopically because the wall of duodenum is thinner than that of stomach, and endoscope maneuverability is limited within the narrow working space. LECS is appropriate for early duodenal G1 NETs because they are less invasive and resection of the lesion area is possible.

We demonstrated that LECS is a safe and feasible procedure for duodenal G1 NETs in the anterior wall of the first portion of the duodenum.

• Carcinoid
• Duodenal NET G1
• Laparoscopic and endoscopic cooperative surgery (LECS)

Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

• Duodenal neoplasms
• Duodenal cancer
• Pancreaticoduodenectomy
• Endoscopic surgery
• Esophagogastroduodenoscopy

• Adenoma/pathology
• Adenoma/surgery
• Carcinoma/secondary
• Carcinoma/surgery
• Dissection/adverse effects
• Dissection/methods
• Duodenal Neoplasms/pathology
• Duodenal Neoplasms/surgery
• Duodenoscopy
• Humans
• Lymphatic Metastasis
• Neoplasm Invasiveness
• Pancreaticoduodenectomy/adverse effects
• Treatment Outcome

• duodenal tumor
• limited resection
• local full-thickness resection
• surgical management
• transduodenal excision

• adenoma
• carcinoma
• duodenal cancer
• endoscopic diagnosis
• non-ampullary tumor

Background. Superficial duodenal neoplasms (SDNs) are a challenging target in the digestive tract. Surgical resection is invasive, and it is difficult to determine the site and extent of the lesion from outside the intestine and resect it locally. Endoscopic submucosal dissection (ESD) has scarcely been utilized in the treatment of duodenal tumors because of technical difficulties and possible delayed perforation due to the action of digestive juices. Thus, no standard treatments for SDNs have been established. To challenge this issue, we elaborated endoscopy-assisted laparoscopic full-thickness resection (EALFTR) and analyzed its feasibility and safety. Methods. Twenty-four SDNs in 22 consecutive patients treated by EALFTR between January 2011 and July 2012 were analyzed retrospectively. Results. All lesions were removed en bloc. The lateral and vertical margins of the specimens were negative for tumor cells in all cases. The mean sizes of the resected specimens and lesions were 28.9 mm (SD ± 10.5) and 13.3 mm (SD ± 11.6), respectively. The mean operation time and intraoperative estimated blood loss were 133 min (SD ± 45.2) and 16 ml (SD ± 21.1), respectively. Anastomotic leakage occurred in three patients (13.6%) postoperatively, but all were minor leakage and recovered conservatively. Anastomotic stenosis or bleeding did not occur. Conclusions. EALFTR can be a safe and minimally invasive treatment option for SDNs. However, the number of cases in this study was small, and further accumulations of cases and investigation are necessary.

• Duodenal submucosal tumor
• laparoscopic-endoscopic cooperative surgery
• single-incision laparoscopic surgery