Duodenal Lateral Entry and Circumferential Submucosal Dissection (D-LECS) for Early Duodenal Adenocarcinoma: A Comparative Analysis of Approaches
This study investigated the feasibility and safety of duodenal lateral entry and circumferential submucosal dissection (D-LECS) for the treatment of early duodenal adenocarcinoma. A total of 32 patients with histologically confirmed adenocarcinoma, including seven with intramucosal invasion, underwent D-LECS.All seven cases with intramucosal invasion showed no evidence of vessel invasion or positive resection margins. During a median follow-up of 35 months, no disease recurrence was detected through endoscopic or CT surveillance.
Five patients required additional surgical interventions following the initial D-LECS procedure. Three were converted to laparoscopic full-thickness tumor resection, with one necessitating a duodenojejunal bypass due to a ample duodenal wall defect. The remaining two patients underwent laparoscopic cholecystectomy and endoscopic submucosal dissection (ESD) for a remnant gastric adenoma after a prior subtotal esophagectomy,respectively. These additional procedures resulted in longer overall surgical times.
To minimize surgical bias, a comparative analysis was conducted on the remaining 25 cases, excluding those requiring the aforementioned additional procedures. The anterior and transmesocolic approaches were utilized in 4 and 21 cases, respectively. The median age of patients undergoing the anterior approach was 65 years (range 58-74 years), compared to 62 years (range 47-79 years) for the transmesocolic approach. Median body mass index (BMI) was 19.7 (range 17.6-24.6) for the anterior approach and 21.8 (range 19.7-27.5) for the transmesocolic approach.
Tumor location differed considerably between the two approaches (p < 0.01). In the anterior approach group, tumors were located in the first, second, and third portions of the duodenum in 2, 2, and 0 cases, respectively. For the transmesocolic approach,tumors were found in 0,16,and 5 cases in the first,second,and third portions,respectively. The median tumor size was 15.5 mm (range 8-20 mm) for the anterior approach and 20 mm (range 9-27 mm) for the transmesocolic approach. No statistically significant differences were observed in age, BMI, or tumor size between the two groups. The median total operation time was 258 minutes (range 168-401 minutes) for the anterior approach and 295 minutes (range 182-416 minutes) for the transmesocolic approach. Median ESD time was 45 minutes (range 20-100 minutes) for the anterior approach and 77 minutes (range 45-120 minutes) for the transmesocolic approach.Laparoscopic procedure time was 126 minutes (range 66-359 minutes) for both approaches. The median amount of bleeding was 20 mL (range 5-32 mL) for the anterior approach and 0 mL (range 0-75 mL) for the transmesocolic approach. No significant differences were found in these surgical parameters between the two approaches. Analysis revealed a trend towards a positive correlation between BMI and total operation time, laparoscopic time, and the amount of bleeding.
