Open Antrectomy and Duodenal Resection for Neuroendocrine Tumor

CHAPTER 0

Today's third 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 a little bit of stomach - in which case I'll do a retrocolic gastrojejunostomy as a reconstruction.

CHAPTER 1

All right, can we have a knife, please? So I think that the big issue for us in this case is gonna be what are we going to do, right?

And 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... I think I can... No. Are you through? 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 a young girl, and this is a small tumor. A small tumor. I mean ideally, I'd like to do a, you know, pretty minimal amount. Okay, so that's that. The big issue for us to try not to miss it, right? Yeah. Is there any - nah. What? I was wondering if there was any benefit in like rescoping. 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. Yep. 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, huh? There I see nothing. No, I can't feel it. That’s a huge bummer, right? For her. I guess we could try to get an ultrasound in here or something, but... No, but doing it on the bowel doesn't really work. 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, Schnidts. 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 a spot lap pad. Come right down along there. Right there. And 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, Schnidts. 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... Another Schnidt. We're going to take the gastroepiploic, right? That’s the right gastroepiploic coming off of the GDA. Okay, cut. Is this a? Yep, take it. Okay. 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. Cutting the first portion of the duodenum off of where it is attached on the pancreas, right? So we still got this right here - this last little bit. Right? 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. Okay, 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 down? 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. There you go. Cut. Okay, 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? Right? Oh, yeah, yep. 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. Now the question is - buzz there. 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. Okay. 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? I feel the pylorus, here. Alright, let's give them a good video shot. The - the lesion - the tattoo. Alright, anyway... So you want to bring that in. You want to reticulate it, and you want to slide it down - no, no. Okay, hold that with one hand. I have this. You got it? This needs to be all the way down there, right? I mean, think about what we're trying to do. Right. 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? Okay. 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. 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. Okay. Take it. I need one. Okay, so here is the specimen. Antrum and duodenal bulb. 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 a 7-mm neuroendocrine tumor. No.

CHAPTER 4

Okay so now what we need to do is bring up our gastrojejunostomy. She is... Yep. Okay, buzz here. The window’s right there. This way up and down. So now we're making a retrocolic window for a gastrojejunostomy. That’s our window. Now 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. Just buzz that right there? That, right there. Pickups. Grab that. Buzz me. Okay, that’s alright. Save that. Okay so, let's go right here.

And let's go right through here. Snap. I'll take another stitch. Give her a stitch. Let's see - we're here. Go right - yeah, right about there. Go right through that - lower. Here? Yep. 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 her without... No way, no. Is she paralyzed, do you think? Needle. One more. Nah, it's too close. Hold these this way. Get your cautery. Right there. And you cut on the... Right there, yep. 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 duodenum, which is set 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? Okay, go ahead, right here. Good. 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. Get lower on the stitch where you’re pulling. Right here. No - that bite’s no good. The angle is all wrong. Everything about it was wrong. Go ahead. Put it in right here. Turn your wrist. Pull towards you. Pull towards you. Pull towards you. Oh look at that - is that not? Angle. Was that - was that my pager? Yes. Make a move. 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. Just push that in with the tip. Turn it out. Now 45 that way. 45 out to 45 in. And that turns your corner. Now backhand it in, and bring it out here. Snap your stitch. Hold these up. Hold them up to help you. Go ahead. Right under there. Push this down. After this we're going to use interrupted 3-0 silks. Taking way too big - oh, look 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 Connell stitch to lock the last one. Oh, just on the last one? It's 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. 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 a 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. If I can't do this - if it's not out, she needs a Whipple, and I - I can't really - I can’t really do a Whipple. Way too much for this. There. Yep. Just one more? It’s going to go right in there, right? 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. It's true, if we were doing an anastomosis on some other service, and 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. The short portion of duodeunm specimen, we opened it, and just adjacent to the junction between the stomach and the duodenum, there was a 0.7-centimeter submucosal nodule. Brilliant. Thank you. Do you want another resection? No, sir. Thank you. Thank you, very much. Awesome. That's good. Okay. And right there. Yep. Alright guys, that's good news. I'll take one more stitch. The other one's to your 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. 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? Oh, maybe it was just in the right cross-section that they could see it. 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.

CHAPTER 5

[No Dialogue.]