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Open Antrectomy, Duodenal Resection, and Gastrojejunostomy for a Multiple Endocrine Neoplasia Tumor

David Berger, MD
Massachusetts General Hospital

Transcriptions

Today’s case is a woman who has a neuroendocrine tumor in the first portion of her duodenum. This is a tumor that we've been following. It’s slowly grown, and her and her oncologist have decided they’d like to have it removed.

There are two issues really with this case. One is identifying the tumor. The tumor’s been marked endoscopically with a tattoo. If I can remove just a small segment of the first portion of the duodenum, I will do that. Otherwise, if I have to do a resection, I will probably proceed with a resection of the first portion of the duodenum. If I can save the pylorus I will, but more likely than not, I'll have to resect a little bit of the stomach as well, and then we’ll reconstruct with the gastrojejunostomy. So the operation will unfold by entering the abdomen. We will then proceed with a wide Kocher maneuver and free up the duodenum. At that point I'll try and identify where the tumor is. If necessary, I’ll perform an endoscopy to see if I can see the tumor. However, I know the tumor is small enough that the endoscopist couldn't see it without a endoscopic ultrasound. Consequently, I'll have to use the tattoo marks that were placed endoscopically. Once I’ve established where the tumor is, I'll do my best to try and figure out what kind of operation I'll proceed with. If I can do a local resection, I will; if not, I'll have to proceed with resecting the duodenum and primarily the pylorus and a little bit of stomach - in which case I'll do a retrocolic gastrojejunostomy as a reconstruction.

CHAPTER 1

So I think that the big issue for us in this case is gonna be what are we going to do, right? There’s the tattoo. That’s good. Alright, let's do a Kocher. We're going to do a wide Kocher, right? Oh for lymph nodes? No, not even for lymph nodes - just to get mobility so that we can do… What do you think? Through here? No...

Okay so, now, the next thing to do is to take this down. And then we'll just end up taking a little bit of stomach? I don't know what we're going to take yet honestly. I mean - I guess we could do like a little - we can even do a wedge if I can feel it. Right, I mean - we want to do as little as possible. She's young girl, and this is - small tumor - small tumor. I mean ideally, I'd like to do pretty minimal amount. Okay, so that’s that. The big issue for us to try not to miss it, right? Yeah. Well they couldn't see it on a scope. Oh it was only on the ultrasound? Yeah, yeah. Oh - I was wondering how they were - cuz the difference between 5 and 7 millimeters didn't - right - no, that's about right.

Another gastric, right? Yep, slide it up. Scissors. Tie please. So there's our pancreas, and the problem of course with this is trying to figure out - where the actual thing is. Wow - that's a bummer. There I see nothing. I can't feel it. That’s a huge bummer right for her. Well see the problem is though if it's on the underside... Alright, let’s go through here. Pull that back. That take this right here. Yep, schnitz.

So we just entered the lesser sac - I mean the greater - the lesser sac, and now we're going to try to isolate and come underneath this duodenum. And then we're going to have to make a decision about whether or not we need to take it out. If can't feel it, we're going to end up having to do a - like a, you know, duodenal resection and then... Get your cautery now. Pickups. It’s up here. So this comes down, right there. Lift up with this spot-lap pad. Come right down on me. Turn right there. Right there.

So now we're coming underneath the first portion of the duodenum - on top of the head of the pancreas. See it right there? You can see that you're underneath that right there, right? Take that there. So you see, we’re completely under the mark now. Of course, all I feel is the pylorus. I don’t feel anything any different. Okay schnitz. Cut.

Now what we're going to do is we're going to isolate the head of the pancreas. So we’re going to take this down here. This is going to be - you can take that. This is the right colic vein right there. 3-0. Stay right there. So we haven't done anything yet to limit ourselves. We haven't taken any vessels that are problem yet. Thank you.

Alright so, there’s the mark. We are - should be like this. We’re pretty much under it, and I can't feel it. So if we're under it and I can't feel it, then we're going to have to do a resection to get it out because - you know what I mean? Alright, so hold that up there.

CHAPTER 2

Get your cautery in your other hand. Come right here. We’re isolating the gastroepiploic, right? So now, we're going to take the gastroepiploic, right? That’s the right gastroepiploic coming off of the GDA. Alright, tie. Go underneath. So we're going to end up having to resect the first portion of the duodenum, right? Right. Have in the room TI-55 4.8 please. Don't open it. Let me put this in here to make a pretty picture.

That's the head of the pancreas. That's the first portion of the duodenum. See how we've isolated the bulb? Now we can take a little more back - hold that up there - cuz we've got to get - schnidt. We’ve got to get to beyond the mark, right? Yeah. So we're going to do schnidt, schnidt right there. 3-0. I have that.

So we’re basically cutting the first portion of the duodenum off of where it is attached on the pancreas right? Schnidt. So we still got this right here - this last little bit. Wait a minute - you got to put your hand - you got to pull here and you got to slide that that way. See the difference in the angle? Okay, cut. Okay, tie. Hold that retractor for me please. K, tie that. Hold that for one second. Can you hold that for me? Just like that is all I need. Is it ok to just cut that little dam? You just go around it. It keeps coming off. Push against it. No, don’t hold this way - bring it that way. Now go and lift up on this. That one - pull. Cut. K - now just tow like that.

So now, do you see how you've got the entire first portion of the duodenum and duodenal bulb up? Yeah, yep. Right? There's the pylorus. There's the bulb. Now I still can't feel the tumor, but it's up high enough now that we can do what we need to do. So hold that like that. Give her a cautery.

K - so. Now the question is - close there. Good. Alright. So now we're way beyond it. I think now we're obligated to take it. I can't - I can't for the life of me feel the tumor. And - and the ampulla and CBD are - ampulla is here. I mean no - that's - that’s way down there, but look - you’re way up. You’re not taking anything, right? You're not taking anything that's coming in. Oh right, right, okay. Can we have the TI-55 4.8 please? So this is pylorus. Feel the pylorus? Alright, let's give them a good video shot.

The - the lesion - the tattoo. So you want to bring that in. C’mon. You want to reticulate it, and you want to slide it down - no, no. K - hold that with one hand. I have this. You got it? Yeah. I got it. This needs to be all the way down there, right? I mean, think about what we're trying to do. We're trying to take this as far down... Okay, you can take that. Take it. No, no, no, no, no, no! Now do it. Here? Yep. Knife please. You got to lock it, right? Put that up.

Okay so, see that? That’s stapled off really into the second portion. Do we need to get a margin? Like - I mean a frozen. You mean to see if we can find it? Just to make sure we didn’t, you know - I mean, what else we going to do? I can't take out anymore. I'm not going to do a whipple. Oh, that’s true. Thank you. You’re welcome. Bye! So let's go right here.

CHAPTER 3

Schnidt. Schnidt. So I'm going to want this to go to path, and I'm gonna want them to see if they can find this. For the life of me, I can't find it.

Okay let's take this little bitty vessel here. 3-0. Yeah. Then we're going to want an ILA 100. We resected into the second portion of the duodenum. Pardon? I said we resected it into the second portion of the duodenum. Wait we can - you can feel that. Well the pylorus is here, right? We resected the whole first portion. We resected the entire tattoo. Bovie right here. Score this way. And how many millimeters was it supposed to be? 7 millimeters deep. Seems like something that should be palpable. Schnidt. That 3-0 is done.

So I need it walked over to path, and then I need someone to call from path when they get it and they look at it. Alright, it's antrum and first portion of the duodenum, and there’s supposed to be a neuroendocrine tumor in the duodenal bulb by the tattoo. And I resected the whole tattoo. ILA 100. So you want this sent to frozen? I want it as them to find the tumor - I don't care that they do a frozen. I just want them to confirm that the tumor is in there. Take it. I need one. Okay, so here is the specimen. Antrum and duodenal bulb - and you can see we resected this all the way back. You can't take anymore. It's a Whipple or bust. I'm not going to do a Whipple for 7 millimeters.

CHAPTER 4

Okay so now what we need to do is bring up or gastrojejunostomy. She is - adipose stuff too, huh? Yep. The window’s right there. This way up and down. So now we're making a retrocolic window for a gastrojejunostomy. Okay, so that’s our window. Now we’re gonna just find the ligament of Treitz, which is there. We're going to go down, and then we're going to bring up a limb through our hole. Hold that. Okay. Stitches please. Can you just buzz that right there? And actually that right there. Pickups. Grab that. Buzz me. K - that’s alright - save that. Okay so, let's go right here, and let's go right through here. Stop. Do you have a stitch? So you were here, so right go right about there. Go right through that, lower. Snap. No more snaps after this. Snap. I'll take another stitch. Give her a stitch. Go right here. Go here. So right now - right about there. Go right through that - lower. Snap. No more snaps after this. Stitch. Fire up the silks. Another pile of pickups to me. And right here. Good. Up right here. Here. Here.

I’m certainly not going to do a Whipple on here without - no way. Package of 3-0 silk please. Is she paralyzed, do you think? Too close. Hold these this way. Get your cautery. Right there. And you cut from the - right there - the - towards me. Good. Now blue. Hold that over that way. Hold that over that way. Alright, go ahead. Stay up high. Stay up high. Good. Stay high. Always stay high, right? Stay high.

Okay. Vicryls. 3-0 Vicryl runners please. So now what we're going to do is sew the stomach to the jejunum, which is set it up right here. So you start here, right? You're going to run to me, and we're going to do just what we did yesterday, right? K - go in, right here. This is a Singer sewing machine, right? Now you hold that. Pull that towards you. Pull it towards you. So we're doing our anastomosis. This is our inner layer of running 3-0 vicryl. Pull it towards you. By pulling towards herself, she is setting herself up to put the next stitch in. Push down, turn your wrist. There you go. That's a good bite. And towards you. This way - right, like that - help yourself. You are too far back on the stitch where you're pulling. No - this way. Bite’s no good. The angle is all wrong. Everything about it was wrong. Go ahead. Put it in right here. Pull towards you. Pull towards you. Pull towards you. Oh look at that - is that not? Angle.

Was that - was that my suture? You come over. Do - do you mind checking it? Oh - oh sure. Bring it into the corner. Right into the corner, right here. No, that’s too deep. Get a pickups in your hand. 45 out. Grab right here. Going to come in here and out here. Now you’re going to go 90, right? So you’re going to go straight out, right here. Now you’re going to go straight in. Now you’re going to go 45. You're hurting yourself. Push that in with the tip. Turn it up. Now 45 that way. 45 out. 45 in. And that turns your corner. Now backhanded it in, and bring it out here. Snap your stitch. Hold these up. Hold them up to help you. Go ahead. Get under there. Push this down. After this we're going to use interrupted 3-0 silks. Taking way too big - oh, how much mucosa - serosa you got. So you're moving your feet, which is good. You're setting yourself to get your stitches in more perpendicular. Good, better.

So I haven't heard from the pathology people. Weren’t they going to call us? Oh, you told them? Great. Thanks. Thank you.

So right under here. Yep. Then load it backhand, and you're going to come in here and out here. In hear, out here. That's a canal stitch to lock the last one - just on the last one, right? Cuz all we're trying to do is bury the last one under. So we go that way, and then we take this this way. And sew this. Yep, now tie it. Pull ‘em up. So you can see, it looks like you don't even need to have any silks on the top, right? If you've done it right. We're still going to put in the second layer, but you can see it looks like you're done. Alright, start right here - little bite - and right into there. Good. That was nice bite. Excellent. Stitch. Get a perpendicular bite - turn your wrist. Don't get too close. Okay, that's fine. If you get too close, you will - good. And now right here, just fire them right across - doesn’t need to be that close together. Right there.

So we're in pretty good shape cause I don't have much more I can do. So if I can't do this - if it's not out, he - she needs a Whipple, and I - I can't really - I can’t really do a Whipple. Way too much for this.

There. Just one more? Yep. It’s going to go right in there. Pull that over that way. Go right in that space. Oh - it’s just that. Good - no, it was good. That was nice. That was good. So if you're not retracting - like if you're trying to do the inner layer this way - like if you retract funny, then it won't imbricate this nicely, right? Right, if you don't lay your stitches in properly, symmetrically, then it doesn't imbricate in, right? Or like if you pulled up at the wrong - between the wrong - yeah, that won’t work either. It won’t rotate over. True with doing an anastomosis on some other survey I’ve seen - appreciate how the mirror image is difficult.

I don't need a frozen. I just need to know that - well, I'd like to know that the specimen is there. Norm on that. Alright, can you hear me? Yes sir. Hi, this is Dr. Black-Schaffer calling from pathology regarding a patient. Yes sir. The - the short description that you wanted on your specimen - we opened it and just adjacent to the - between the stomach and the duodenum, there was a 0.7 centimeter mucosal nodule. Brilliant. Thank you. Do you want another resection? No sir. Thank you. Thank you very much. Awesome.

Okay, and right there. Yep. Alright guys, that's good news. So I want us to be right - see that right there to there - in there and through that. Yeah, and then through that - no, cut edge, see it? Cut edge - it’s right there. Oh here? Yep. Okay, tie that. Tie that. Number 1 Prolene next. Cut those three please.

It’s amazing. I couldn't see that thing - couldn’t feel it. It's because it was up against the pylorus, right? Well, it was up against the pylorus. That makes a ton of sense.

Alright, if there's a break in the table, will you please take it out? Number 1 Prolene.