2019, Number 3
GIST in second portion of duodenum, surgical approach, case report and literature review
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Language: English/Spanish [Versi?n en espa?ol]
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ABSTRACT
Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms, although annual reported incidence rates worldwide are less than 20 per million. These tumors are a primary gastrointestinal disease that can arise anywhere in the digestive tract in adults. Duodenal lesions represent approximately 3 to 5%, although duodenal gastrointestinal stromal tumors are relatively rare, they account for almost 30% of all primary tumors of the duodenum, they originate most frequently in the second portion of the duodenum, followed in order by the third, fourth and first portion. We present the case of a 54-year-old patient with a history of neurofibromatosis, which occurred with episodes of bleeding of three years of evolution, with diagnosis of duodenal polyp; the histopathological study reported gastrointestinal stromal tumor, with an immunohistochemical study that was positive for CD117, CD34 and DOGL, with an account of less than 2 mitosis / 50 CAP. Surgical management was decided, a 3-cm tumor was identified in the lateral wall of the duodenum. In the second portion, wedge resection and primary closure were performed in two suture lines. Local resection is appropriate when feasible and pancreaticoduodenectomy should be reserved for lesions that are not amenable to local resection.INTRODUCTION
Esophageal stricture is an uncommon pathology worldwide and its evaluation is different in each patient. For centuries, keystone treatment has been the dilation of esophageal light. Since the 17th century1-4 it has evolved from using a whalebone to endoscopic controlled radial pressure with a balloon. Its greatest success is in asymptomatic non-recurrent patients. Careful patient selection and goals have allowed the development of a technique specific to each endoscopic surgeon.1
Esophageal stricture is an intrinsic decrease in the light of the esophagus assessed by endoscopy, resulting from various etiologies.1
They are divided into simple and complex, and the initial diameter, the possibility of passing the endoscope and its symmetry are evaluated.
Simple: concentric and symmetric, luminal diameter > 12 mm, or those that allow the passage of the endoscopy equipment.
Complex: < 12 mm, asymmetric and angular, without passing of the endoscope.
Simple stenoses were evaluated in this protocol, being short, straight, and focal. Most of them are peptic and allow the passage of the endoscope, requiring two or three dilations, to prevent recurrence. Up to 35% of them require a new intervention.
Complex stenoses are characterized by being long (> 2 cm), tortuous, and of a small diameter that impedes the passage of the endoscope. They are associated with ingestion of caustics, radiation, ischemic anastomosis, photodynamic therapy or sclerotherapy for the management of Barrett's esophagus or neoplasms, or as a complication of common procedures that can be underestimated, as the placement of a nasogastric tube.5 They are known to have a high recurrence despite multiple treatments. Refractory and recurrent stenoses require at least four sessions of dilation and usually recur in less than two to four weeks.
The typical symptomatology is progressive with dysphagia, from solids to liquids. Patients refer to being able to ingest only a liquid diet and perform maneuvers on each swallow to free the passage of the liquid.
ESOPHAGEAL DILATION
Esophageal dilation with polyvinyl chloride dilators is the universal treatment because it allows an immediate, firm, flexible and well-known response so that the patient has the comfort to continue with his daily activities.4
TREATMENT MATERIAL
There are, worldwide, optimal and adequate treatments classified according to each patient's pathology:
Esophageal dilators are the first materials for treatment, they are flexible, offer radial and longitudinal force, and provide an immediate effect. One disadvantage is that dilation is a blind procedure and should only be indicated in those patients well aware of their disease and its complications. This means knowing the type of stenosis and the etiology, being aware of symptoms, and being able to undergo dilation before it becomes an emergency.
Metal-guided dilators offer doctor and patient the security of being in the esophageal light and applying the appropriate treatment. Usually, the guide tip is located in the gastric antrum to continue the introduction of the dilator, either under fluoroscopic or endoscopic vision. Reports suggest the latter practice as safe and accurate. It takes longer to perform and should be done by trained physicians.
The controlled radial expansion uses a hydropneumatic dilation balloon that can be done through the working channel of an endoscope. The application of radial force is as effective at 10 seconds as it is at two minutes. It is important to know the anatomy of each stenosis in each patient, since the risk of perforation is always present, being the risk higher than in the procedures mentioned above.
SELF-
Methods of self-dilation have been described in several countries, they have been demonstrated to be reliable, safe and effective to avoid the surgical approach of simple refractory stenosis, that in which it is not possible to reach a diameter greater than 14 mm in five sessions, in two weeks.2
These methods provide independence from the hospital, the ease of performing the procedure at home and improve the conditions that prevented an adequate passage of the bolus through the esophagus. The methods and techniques have been adequately described.4-8
Education begins in the endoscopy room, with a previous upper endoscopy to ensure there is a simple stenosis, to measure and classify it, and to design a strategy for treatment. Afterward, the teaching continues with the dilators, explaining their calibers, and lengths, as well as their markings (10 cm distal to the stenosis), the procedure, the lidocaine mouthwashes, correct lubrication, previous cleaning and the adequate moment for action. The patient must pass the dilator through the mouth and pharynx and thence to the esophagus, through the area of stenosis. Finally, they must extract the dilator carefully by themselves.
In Mexico, esophageal strictures are mostly due to the accidental ingestion of caustics by children, or even adults. It is also a complication of gastroesophageal reflux. One of the treatments with less affection to the esophageal anatomy and that allows adequate rehabilitation is the use of a dilator. This is why we propose it to patients who can perform this procedure at home with comfort and safety. Contraindications are greater in patients with pharyngeal or cervical deformities, or large thoracic aneurysms. Also, the risk of perforation is greater in the case of malignant stenosis.
Cardiopulmonary disease is a relative contraindication and such patients should be thoroughly evaluated. The risk-benefit ratio must be individualized and carefully considered. Severe coagulopathy is also a condition where it should be deferred.
METHODS
Clinical records from the General Hospital of Mexico were reviewed to evaluate patients with a history of esophageal stricture of any etiology.
A table was drawn up with their names, type of stricture, last date of dilation, number of dilations, the material used, and the caliber used for the previous dilation in French units. Their telephone numbers were sought and they were requested by the Gastrointestinal Endoscopy Service.
All patients diagnosed with simple esophageal stenosis (less than 2 cm in length, passable through the endoscope, not associated with diverticula, carcinoma, hiatal hernia, tortuosity, or alteration in esophageal shape) were selected. The ideal candidates were those with stenosis in the middle and distal esophagus.
SAMPLE
- • All patients diagnosed with esophageal stricture of any etiology.
INCLUSION CRITERIA
- • Patients over 18 years of age.
- • With simple esophageal stricture of any cause (peptic, caustic and authorize self-dilation at home).
EXCLUSION CRITERIA
- • Patients with complex stenoses previously evaluated by endoscopy, including neoplastic and post-operative ones.
- • Pregnant patients.
- • Patients under 18 years of age.
Each patient meeting these inclusion criteria was appointed for an explanation of the procedure to be performed.
- 1. Initial panendoscopy was done, to assess the length of the stricture, its type, and classification. Always with done with a Savary dilator, and taking of a biopsy.
- 2. Once the assessment concluded, the patient is educated. Doubts about the stenosis, etiology, treatment, and procedure to be used are addressed.
- 3. The patient must be able to understand the mechanism to be followed and then agree to sign an informed consent for self-dilation.8
- 4. Education consists of the following steps:
- a. Placing the patient in a room of the Endoscopy Service, without noise or external distractors. If they have a family member available, they are allowed to support them.
- b. The self-dilation must be performed on the same day as the diagnostic and therapeutic endoscopy and not later than 48 hours following this event. More time may result in restenosis of the patient's esophageal tract.
- c. A Maloney dilator of the same caliber measured in French or smaller should be used for pre-dilation.
- d. The dilator should cross 10 to 12 cm distal to the stricture and marked with tape so that the patient can identify the site where they should perform the dilation (since not having a mark, could mean an incomplete procedure).4
- e. Once the patient has understood the procedure several elements are given to them for self-treatment: a plastic kidney tray with sterile water, Maloney-type dilators, lubricating gel, and gauze pads. The dilator is correctly lubricated.
- f. The patient is seated in a chair and asked to take the dilator with both hands and direct them towards his mouth, passing through his pharynx, into the esophagus by swallowing and keeping the mark on his upper dental arch holding the dilator in his esophagus for only two seconds, and removing it slowly, as they are not expected a tolerance due to position and stimulation.
- g. An endoscopy is performed, verifying that there are no complications.
- h. Three patients were located with the described clinical characteristics, which allowed education for esophageal dilatation, adequately evaluating their background and explaining each and every one of their doubts in a clear, simple manner and with understandable language.
CASE 1
A female 56-year-old patient with no personal history of pathology or major surgery. Since age 35 she had had gastroesophageal reflux, which resulted in esophageal stricture. A simple, short, 12 mm stenosis was located at approximately 30 cm from the dental arch, the squamocolumnar junction was found one centimeter below. Endoscopy showed an image with the characteristics described (Figure 1). The patient was educated after endoscopy and dilation was satisfactorily achieved, starting with a 28 French Maloney type dilator and scaling the caliber up to 30 French (Figures 2 and 3). With this treatment, an immediate dilation of 13 mm was achieved without signs so restenosis. At the last check-up, the patient had an adequate passage of the alimentary bolus without complications, which was verified by monthly endoscopy for up to six months.
CASE 2
Male 66-year-old diabetic patient with four years of evolution. He was diagnosed with gastroesophageal reflux disease 15 years before and treated with proton pump inhibitors with an adequate response. The patient stopped taking the treatment for four years for economic reasons, despite the persistence of heartburn and retrosternal pain. He came to our hospital for evaluation. On endoscopy, a simple concentric esophageal stenosis was evident, from one to 29 centimeters from the upper dental arch, with an approximate circumference of 10 mm. We proposed management by self-dilation. After acceptance and training on the technique, the patient was discharged for follow-up, established at six months with monthly endoscopic evaluation. This allowed the endoscopic team to assess adequate permeability and passage, and to document the clinical improvement reported by the patient (Figures
DISCUSSION
Esophageal stricture in Mexico has a similar frequency when compared to worldwide statistics. It has decreased, probably due to proton pump inhibitors and the prevention of different pathologies, including the ingestion of caustics.3-6 Patients in our hospital's Gastrointestinal Endoscopy Unit have various etiologies of simple esophageal stenosis. We can attend to each of them individually and propose the self-dilation procedure once the characteristics of these patients have been evaluated.9
The Canadian literature already mentioned this resolution using self-dilation with 26 patients, since the 1960s with Sullivan's team, giving great importance to gastroesophageal reflux stenosis, 7 reserving treatment for those patients in whom the stenosis was constant and prevented adequate evolution and, of course, nutrition.
The fears this procedure can trigger are reduced by giving doctor-patient confidence; by explaining that it is a safe method, it will reduce the number of endoscopies to be performed and there will always be support from the doctor.
New Zealand, a developed country, demonstrated that costs and the number of endoscopic events can be reduced.6
It has even been mentioned that the procedure performed by the patient himself, with polyvinyl dilators, has not had significant differences as compared with controlled radial dilation, proposed in those stenoses that do not respond, an example of which are radiation stenoses.5 It should be noted that the rule of "3" consisting of dilation with two more diameters, consecutive from the initial diameter, should always be respected to avoid complications.4-6
Finally, although there is extensive experience worldwide with esophageal stenosis and dilation itself, it is in the last few decades that a more open approach to dilation has been adopted and proposed to patients. Although this series is small, we are trying to implement it and keep up with the world literature to achieve large volumes of patients.5-8,10
The purpose of this educational project is to offer another option to those candidates to perform the self-dilation at home, obtaining benefits such as a decrease of transfers, costs, time, accessibility, and clinical improvement.
Training for the endoscopic physician in this type of technique and patient education is indispensable. Audiovisual and written information can be accessed through various endoscopic associations, such as the American Society for Gastrointestinal Endoscopy (ASGE) in their clinical guide: esophageal self-dilation: a teaching guide for physicians (dv049).
REFERENCES
AFFILIATIONS
1 First year Resident of the University Course of Gastrointestinal Endoscopy at the National Autonomous University of Mexico. Gastrointestinal Endoscopy Unit.
2 Physician attached to the Gastrointestinal Endoscopy Service. Internal Medicine. Gastroenterologist, GI Endoscopy.
3 Physician attached to the Gastrointestinal Endoscopy Service.Gastrointestinal Endoscopy Service, Surgical Tower, Unit 310, General Hospital of Mexico "Dr. Eduardo Liceaga".
4 Head of the Gastrointestinal Endoscopy Unit U-310.Gastrointestinal Endoscopy Service, Surgical Tower, Unit 310, General Hospital of Mexico "Dr. Eduardo Liceaga".
Ethical considerations and responsibility: Data privacy. According to the protocols established in the authors\' workplace, they declare to have followed the protocols on the privacy of patient data while preserving their anonymity. The informed consent of the patient referred to in the article is held by the author.
Funding: No financial support was received for this work.
Conflict of interest: The authors declare that there is no conflict of interest in carrying out this work.
CORRESPONDENCE
Dr. Fernando Miguel Alvarado-Blanco. E-mail: drfalv@hotmail.comReceived: 17/02/2018. Accepted: 13/05/2019