- Email: [email protected]
Small bowel neuroendocrine tumors surgery: Technical point – with video
+Model
ARTICLE IN PRESS
JVS-664; No. of Pages 2
Journal of Visceral Surgery (2017) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
VISCERAL SURGERY VIDEOS
Small bowel neuroendocrine tumors surgery: Technical point — with video A. Pasquer a,b,∗, G. Poncet a,b a
Department of digestive and oncologic surgery, Edouard-Herriot university hospital, 69003 Lyon, France b Claude-Bernard Lyon 1 university, Lyon, France
KEYWORDS Neuroendocrine; Small bowel; Carcinoid; Node resection
∗
Small bowel neuroendocrine tumors (SBNETs) account for 25% of gastroenteropancreatic NETs. Current recommendations propose to resect the primitive tumor(s) even when metastatic in order to prevent local morbidity (ischaemia, digestive perforation and occlusion). Nodes dissections are not standardized and rely on lymph node extension. The resection of at least 7 lymph nodes is correlated with an improvement of overall survival [1]. This video shows a standardized procedure based on European NeuroEndocrine Tumors Society recommendations [2]. It shows a frequent situation corresponding to multiple ileal tumors located in a small bowel segment at the right part of superior mesenteric vessels. This surgical approach was performed through a median laparotomy. Exploration of the whole peritoneal cavity must be exhaustive to detect all tumoral nodes (digestive tube and lymph nodes) that should be resected [2]. This exploration is combined with an intraoperative hepatic ultrasonography to detect potential undiagnosed metastasis. This liver mapping is essential for further management. Finally, a careful small bowel examination must be done starting from Treitz angle by inspection, palpation and compression as up to 60% of tumors are missed on preoperative workup [2]. Before bowel resection, the first step is to confirm the vascular resecability of lymph nodes. A dissection over the Treitz angle and a Kocher maneuver is performed to expose the origin of the superior mesenteric vein and artery. Generally, lymph nodes resection is performed more proximal than the ileocolic artery root nearby the pancreatic uncus. Consequently, these nodes resection usually imply a right colectomy. However, ileocolic artery has sometimes a very proximal origin on mesenteric axis, as observed in this video, allowing to preserve the ileocolic artery and the right colon. Then, dissection is extended toward the left side of superior mesenteric vessels and 3 jejunal arteries are needed to avoid postoperative short bowel syndrome [3]. Preoperative abdominal computed tomography with vascular reconstruction is important to anticipate nodal mass resecability [3]. After vascular clamping, areas for digestive tube sections are delimitated and nodal resection is performed. Then, digestive anastomosis is performed as well as cholecystectomy because of the risk for cholecystitis, necrosis after embolization, and biliary lithiasis with somatostatine analogs (Figs. 1—3).
Corresponding author. Department of digestive and oncologic surgery, Edouard-Herriot university hospital, 69003 Lyon, France. E-mail address: [email protected] (A. Pasquer).
http://dx.doi.org/10.1016/j.jviscsurg.2016.11.002 1878-7886/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Pasquer A, Poncet G. Small bowel neuroendocrine tumors surgery: Technical point — with video. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2016.11.002
+Model JVS-664; No. of Pages 2
ARTICLE IN PRESS
2
A. Pasquer, G. Poncet
Authors’ contribution Manuscript content warranty: A.P., G.P.; study design: A.P., G.P.; manuscript revision: A.P., G.P.; references research: A.P., G.P.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.jviscsurg.2016.11.002. Figure 1.
Disclosure of interest The authors declare that they have no competing interest.
References
Figure 2.
[1] Landry CS, Lin HY, Phan A, et al. Resection of at-risk mesenteric lymph nodes is associated with improved survival in patients with small bowel neuroendocrine tumors. World J Surg 2013;37(7):1695—700. [2] Pasquer A, Walter T, Hervieu V, et al. Surgical management of small bowel neuroendocrine tumors: specific requirements and their impact on staging and prognosis. Ann Surg Oncol 2015;22(Suppl. 3):742—9. [3] Lardière-Deguelte S, de Mestier L, Appéré F, et al. Toward a preoperative classification of lymph node metastases in patients with small intestinal neuroendocrine tumors in the era of intestinal-sparing surgery. Neuroendocrinology 2016;103(5):552—9.
Figure 3.
Please cite this article in press as: Pasquer A, Poncet G. Small bowel neuroendocrine tumors surgery: Technical point — with video. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2016.11.002
ARTICLE IN PRESS
JVS-664; No. of Pages 2
Journal of Visceral Surgery (2017) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
VISCERAL SURGERY VIDEOS
Small bowel neuroendocrine tumors surgery: Technical point — with video A. Pasquer a,b,∗, G. Poncet a,b a
Department of digestive and oncologic surgery, Edouard-Herriot university hospital, 69003 Lyon, France b Claude-Bernard Lyon 1 university, Lyon, France
KEYWORDS Neuroendocrine; Small bowel; Carcinoid; Node resection
∗
Small bowel neuroendocrine tumors (SBNETs) account for 25% of gastroenteropancreatic NETs. Current recommendations propose to resect the primitive tumor(s) even when metastatic in order to prevent local morbidity (ischaemia, digestive perforation and occlusion). Nodes dissections are not standardized and rely on lymph node extension. The resection of at least 7 lymph nodes is correlated with an improvement of overall survival [1]. This video shows a standardized procedure based on European NeuroEndocrine Tumors Society recommendations [2]. It shows a frequent situation corresponding to multiple ileal tumors located in a small bowel segment at the right part of superior mesenteric vessels. This surgical approach was performed through a median laparotomy. Exploration of the whole peritoneal cavity must be exhaustive to detect all tumoral nodes (digestive tube and lymph nodes) that should be resected [2]. This exploration is combined with an intraoperative hepatic ultrasonography to detect potential undiagnosed metastasis. This liver mapping is essential for further management. Finally, a careful small bowel examination must be done starting from Treitz angle by inspection, palpation and compression as up to 60% of tumors are missed on preoperative workup [2]. Before bowel resection, the first step is to confirm the vascular resecability of lymph nodes. A dissection over the Treitz angle and a Kocher maneuver is performed to expose the origin of the superior mesenteric vein and artery. Generally, lymph nodes resection is performed more proximal than the ileocolic artery root nearby the pancreatic uncus. Consequently, these nodes resection usually imply a right colectomy. However, ileocolic artery has sometimes a very proximal origin on mesenteric axis, as observed in this video, allowing to preserve the ileocolic artery and the right colon. Then, dissection is extended toward the left side of superior mesenteric vessels and 3 jejunal arteries are needed to avoid postoperative short bowel syndrome [3]. Preoperative abdominal computed tomography with vascular reconstruction is important to anticipate nodal mass resecability [3]. After vascular clamping, areas for digestive tube sections are delimitated and nodal resection is performed. Then, digestive anastomosis is performed as well as cholecystectomy because of the risk for cholecystitis, necrosis after embolization, and biliary lithiasis with somatostatine analogs (Figs. 1—3).
Corresponding author. Department of digestive and oncologic surgery, Edouard-Herriot university hospital, 69003 Lyon, France. E-mail address: [email protected] (A. Pasquer).
http://dx.doi.org/10.1016/j.jviscsurg.2016.11.002 1878-7886/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Pasquer A, Poncet G. Small bowel neuroendocrine tumors surgery: Technical point — with video. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2016.11.002
+Model JVS-664; No. of Pages 2
ARTICLE IN PRESS
2
A. Pasquer, G. Poncet
Authors’ contribution Manuscript content warranty: A.P., G.P.; study design: A.P., G.P.; manuscript revision: A.P., G.P.; references research: A.P., G.P.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.jviscsurg.2016.11.002. Figure 1.
Disclosure of interest The authors declare that they have no competing interest.
References
Figure 2.
[1] Landry CS, Lin HY, Phan A, et al. Resection of at-risk mesenteric lymph nodes is associated with improved survival in patients with small bowel neuroendocrine tumors. World J Surg 2013;37(7):1695—700. [2] Pasquer A, Walter T, Hervieu V, et al. Surgical management of small bowel neuroendocrine tumors: specific requirements and their impact on staging and prognosis. Ann Surg Oncol 2015;22(Suppl. 3):742—9. [3] Lardière-Deguelte S, de Mestier L, Appéré F, et al. Toward a preoperative classification of lymph node metastases in patients with small intestinal neuroendocrine tumors in the era of intestinal-sparing surgery. Neuroendocrinology 2016;103(5):552—9.
Figure 3.
Please cite this article in press as: Pasquer A, Poncet G. Small bowel neuroendocrine tumors surgery: Technical point — with video. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2016.11.002