Open Antrectomy, Duodenal Resection, and Gastrojejunostomy for a Multiple Endocrine Neoplasia Tumor
Table of Contents
This video describes the surgical technique for an open duodenal resection and antrectomy, which was performed for a neuroendocrine tumor of the duodenal bulb. In this procedure, we start with an upper midline laparotomy and proceed with mobilization of the distal stomach, duodenum, and head of the pancreas. To mobilize, we Kocherize the duodenum, then ligate that right gastric artery and dissect the gastrohepatic ligament, followed by ligation of the right gastroepiploic vessels and take down the gastrocolic ligament exposing the lesser sac. Once the structures are adequately mobilized, we dissect the first portion of the duodenum off of the head of the pancreas and transect it with a TA stapler. The antrectomy is performed next, removing the specimen. For the reconstruction, we perform a retrocolic end-to-side hand-sewn gastrojejunostomy. This technique can be used for multiple indications, including peptic ulcer disease and other mass lesions of the antrum, pylorus, or duodenal bulb.
Neuroendocrine tumors (NETs) arise from the secretory cells of the diffuse neuroendocrine system, which includes the alimentary tract and pancreas. NETs are the second most common digestive cancer after colorectal cancer. Approximately 70% of NETs occur in the small intestine or colon, 12% in the pancreas, and 5% in the appendix.1 NETs are heterogenous in character, the majority have indolent growth, and a subset will secrete hormones or bioactive amines resulting in functional disorders.2 Carcinoid tumors are a type of NET arising from enterochromaffin cells that produce serotonin. Other types of NETs can produce insulin, glucagon, somatostatin, gastrin, or vasoactive intestinal peptide (VIP). NETs are diagnosed using a combination of clinical presentation, biochemical markers, pathology, and imaging.3 The aggressiveness of NETs is determined primarily by tumor grade, which is variable based on location.4 The incidence has increased over the last four decades, but this is thought to be partly attributed to increased diagnostic imaging. Twenty-seven percent of patients will present with metastatic disease at time of diagnosis.5
Given the heterogeneity of NETs, namely the variability in biologic aggressiveness and secretion of bioactive chemicals, management of these tumors often require a more personalized approach. In general, surgical resection remains the only curative therapy for NETs, though for small duodenal lesions, endoscopic resection may also be acceptable.6 In this video, we perform a duodenal resection with antrectomy for a duodenal NET in a 48-year-old woman. The mass had benign features on clinical workup, however, due to an increase in size of the lesion on surveillance endoscopy, the decision was made to proceed with surgical resection with curative intent.
The patient is a 48-year old woman with a history of gastroesophageal reflux disease who was found to have a tumor in her duodenal bulb on esophagogastroduodenoscopy. An endoscopic ultrasound was performed to further characterize the lesion, which was found to be 5 mm in maximal dimension and appeared submucosal. The lesion was tattooed, and the patient was followed with routine endoscopy to monitor the mass. Two years later, the mass had grown modestly, and she was referred to the surgical clinic for resection. Her other medical history is notable for obesity, diabetes mellitus, and hypertension. She has no prior abdominal surgical history. Her last colonoscopy was three years ago and was normal. She has an American Society of Anesthesiologist score (ASA) of 2 and her body mass index (BMI) is 31.
The patient had an unremarkable physical exam. In the office, she presented in no apparent distress with normal vitals. She had a normal habitus. Her abdominal exam was unremarkable with no evidence of prior surgical scars, hernias, or tenderness to palpation. Her abdomen was soft and non-distended.
Figure 1: Endoscopic Images (A) Endoscopic image of duodenum. Yellow arrows point to blue ink tattoo from prior endoscopic marking of the mass. The lesion is small and not visible on conventional endoscopy. (B) Endoscopic ultrasound image of the neuroendocrine tumor, which is capture within the yellow box. The lesion is subepithelial on ultrasound.
The clinical course of NETs is highly variable. Low grade, well differentiated lesions typically have an indolent course with low metastatic potential, whereas high grade NETs rapidly progress with distant spread. Survival is also associated with tumor location, and pancreatic NETs with high grade features have dismal 5-year survival rates of less than 10%.7 The sequence of genetic and epigenetic alterations that drive NET development is variable when comparing low versus high grade lesions, but also when comparing origin of cell type, indicating that the molecular pathology and subsequent clinic course is heterogenous among NETs.
The only potential curative therapy for NETs is surgical resection of the tumor. Nonetheless, the patient should discuss the risks and benefits of an operation with their surgeon. In certain instances, attempt with endoscopic resection is reasonable for small lesions with low-risk features. For metastatic disease, surgery may be indicated if the entirety of disease is extirpatable, or in situations where debulking might significantly improve quality of life for hormone secreting masses. However, in most cases of metastatic disease, cytotoxic chemotherapy and anti-hormonal therapy are the mainstays of treatment.
The rationale for surgical resection for non-metastatic NET is complete disease removal with curative intent.
There are several caveats to surgical resection for NETs. First, surveillance may be considered for duodenal NETs that are less than 1 cm in diameter with low-risk features, endoscopic resection is acceptable.8 Second, for high grade lesions, the role of surgery is less clear due to the increased risk of distant spread and poor prognosis. Third, non-curative surgical debulking may be considered in certain cases of metastatic disease to improve quality of life for hormone-secreting tumors.
As we have shown in this video, the main procedural steps for this operation are as follows: (1) upper midline laparotomy, take down falciform ligament, explore peritoneal cavity; (2) Kocherization of the duodenum; (3) ligate the right gastric artery, takedown of the gastrohepatic ligament; (4) ligate the right gastroepiploic artery, takedown of the gastrocolic ligament, and entry into the lesser sac; (5) mobilization of the first portion of the duodenum off of the head of the pancreas; (6) transect the duodenum with a TA stapler; (7) transect the antrum of the stomach with an ILA stapler; and (8) perform a Billroth II reconstruction with a retrocolic end-to-side Hoffmeister gastrojejunostomy. This approach allows for an extensive mobilization of the duodenum and distal stomach to ensure negative resection margins.
Duodenal NETs are rare, representing less than 5% of primary duodenal neoplasms and less than 10% of all NETs.9 The majority of duodenal NETs are non-functional, less than 2 cm in diameter, and incidentally discovered in otherwise asymptomatic patients.8 These tumors typically present in the deep mucosa and have a submucosal appearance on endoscopy. The standard treatment for duodenal NETs is surgical resection. However, for lesions that are low grade, have small size, and are non-functional, endoscopic resection can be considered.10 Observation for low-grade, small lesions is not recommended due to risk of lymph node metastasis.
The type of surgical resection depends on the location and size of the lesion within the duodenum. Ampullary tumors tend to have worse prognosis and often require a pancreaticoduodenectomy for negative margins and adequate nodal yield. Duodenal NETs on the anti-mesenteric border of the bowel can sometimes be resected in a wedged fashion if sufficiently small and with low-risk features. For other cases, a segmental duodenal resection is necessary. In the case or our patient, we elected to perform a D1 resection with antrectomy. We chose this procedure because the lesion was not localizable intraoperatively and therefore was not amenable to a wedged resection.
Operative time: 68 minutes
Estimated blood loss: 50 mL
Fluids: 1700 mL crystalloid
Length of Stay: Discharged from hospital to home without services on postoperative day 4
Morbidity: no complications
Final pathology: neuroendocrine tumor, grade 1, stains positive for gastrin
- 10-blade scalpel
- Debakey forceps
- Abdominal wall hand-held retractor
- Schnidt clamp
- 3-0 and 2-0 silk ties for ligation of mesentery
- Metzenbaum scissors
- ILA stapler
- TA stapler
- 3-0 vicryl and 3-0 silk for gastrojejunostomy
- 1-0 Prolene suture for fascial closer
- Skin stapler
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
We would like to thank Theresa Kim, MD for assisting in this operation.
- Frilling A, Akerstrom G, Falconi M, Pavel M, Ramos J, Kidd M, Modlin IM. Neuroendocrine tumor disease: an evolving landscape. Endocr Relat Cancer 2012;19:R163-85. https://doi.org/10.1530/ERC-12-0024
- Cives M, Strosberg JR. Gastroenteropancreatic Neuroendocrine Tumors. CA Cancer J Clin 2018;68:471-87. https://doi.org/10.3322/caac.21493
- Oberg K, Couvelard A, Delle Fave G, Gross D, Grossman A, Jensen RT, Pape UF, Perren A, Rindi G, Ruszniewski P, Scoazec JY, Welin S, Wiedenmann B, Ferone D, Antibes Consensus Conference p. ENETS Consensus Guidelines for Standard of Care in Neuroendocrine Tumours: Biochemical Markers. Neuroendocrinology 2017;105:201-11. https://doi.org/10.1159/000461583
- Kloppel G, La Rosa S. Ki67 labeling index: assessment and prognostic role in gastroenteropancreatic neuroendocrine neoplasms. Virchows Arch 2018;472:341-9. https://doi.org/10.1007/s00428-017-2258-0
- Dasari A, Shen C, Halperin D, Zhao B, Zhou S, Xu Y, Shih T, Yao JC. Trends in the Incidence, Prevalence, and Survival Outcomes in Patients With Neuroendocrine Tumors in the United States. JAMA Oncol 2017;3:1335-42. https://doi.org/10.1001/jamaoncol.2017.0589
- Partelli S, Bartsch DK, Capdevila J, Chen J, Knigge U, Niederle B, Nieveen van Dijkum EJM, Pape UF, Pascher A, Ramage J, Reed N, Ruszniewski P, Scoazec JY, Toumpanakis C, Kianmanesh R, Falconi M, Antibes Consensus Conference p. ENETS Consensus Guidelines for Standard of Care in Neuroendocrine Tumours: Surgery for Small Intestinal and Pancreatic Neuroendocrine Tumours. Neuroendocrinology 2017;105:255-65. https://doi.org/10.1159/000464292
- Strosberg JR, Cheema A, Weber J, Han G, Coppola D, Kvols LK. Prognostic validity of a novel American Joint Committee on Cancer Staging Classification for pancreatic neuroendocrine tumors. J Clin Oncol 2011;29:3044-9. https://doi.org/10.1200/JCO.2011.35.1817
- Sato Y, Hashimoto S, Mizuno K, Takeuchi M, Terai S. Management of gastric and duodenal neuroendocrine tumors. World J Gastroenterol 2016;22:6817-28. https://doi.org/10.3748/wjg.v22.i30.6817
- Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, Abdalla EK, Fleming JB, Vauthey JN, Rashid A, Evans DB. One hundred years after "carcinoid": epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol 2008;26:3063-72. https://doi.org/10.1200/JCO.2007.15.4377
- Kulke MH, Shah MH, Benson AB, 3rd, Bergsland E, Berlin JD, Blaszkowsky LS, Emerson L, Engstrom PF, Fanta P, Giordano T, Goldner WS, Halfdanarson TR, Heslin MJ, Kandeel F, Kunz PL, Kuvshinoff BW, 2nd, Lieu C, Moley JF, Munene G, Pillarisetty VG, Saltz L, Sosa JA, Strosberg JR, Vauthey JN, Wolfgang C, Yao JC, Burns J, Freedman-Cass D, National comprehensive cancer n. Neuroendocrine tumors, version 1.2015. J Natl Compr Canc Netw 2015;13:78-108. https://doi.org/10.6004/jnccn.2015.0011
After adequate general endotracheal anesthesia was obtained, the patient was sterilely prepped and draped in standard fashion.
- Midline abdominal incision, enter peritoneum
- Entry of Lesser Sac using Wide Kocher Maneuver
- Evaluation of Pylorus and Duodenum
- Ligation of right gastroepiploic artery and right gastric artery
- Examine Pylorus and Duodenum for tumor
- Division of Duodenum
- Mobilization of stomach and division of short vessels along the lesser and greater curvature
- Resection of Antrum and send specimen for pathology
- Mobilization of Jejunum to stomach in retrocolic fashion
- Two layer anastomosis
- Interrupted 3-0 silk (outer layer)
- Running 3-0 Vicryl (inner layer)
- Lembert Sutures
- Bring anastomosis through trap and suture in place
- Abdominal Fascia closed with #1 Running Prolene
- Skin closed with staples
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.
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.
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.
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.
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.