title: Limited resection for duodenal gastrointestinal stromal tumors: Surgical management and clinical outcome.
abstract: OBJECTIVE
  To analyze our experience in patients with duodenal gastrointestinal stromal tumors (GIST) and review the appropriate surgical approach.
  
  
  METHODS
  We retrospectively reviewed the medical records of all patients with duodenal GIST surgically treated at our medical institution between 2002 and 2011. Patient files, operative reports, radiological charts and pathology were analyzed. For surgical therapy open and laparoscopic wedge resections and segmental resections were performed for limited resection (LR). For extended resection pancreatoduodenectomy was performed. Age, gender, clinical symptoms of the tumor, anatomical localization, tumor size, mitotic count, type of resection resectional status, neoadjuvant therapy, adjuvant therapy, risk classification and follow-up details were investigated in this retrospective study.
  
  
  RESULTS
  Nine patients (5 males/4 females) with a median age of 58 years were surgically treated. The median follow-up period was 45 mo (range 6-111 mo). The initial symptom in 6 of 9 patients was gastrointestinal bleeding (67%). Tumors were found in all four parts of the duodenum, but were predominantly located in the first and second part of the duodenum with each 3 of 9 patients (33%). Two patients received neoadjuvant medical treatment with 400 mg imatinib per day for 12 wk before resection. In one patient, the GIST resection was done by pancreatoduodenectomy. The 8 LRs included a segmental resection of pars 4 of the duodenum, 5 wedge resections with primary closure and a wedge resection with luminal closure by Roux-Y duodeno-jejunostomy. One of these LRs was done minimally invasive; seven were done in open fashion. The median diameter of the tumors was 54 mm (14-110 mm). Using the Fletcher classification scheme, 3/9 (33%) tumors had high risk, 1/9 (11%) had intermediate risk, 4/9 (44%) had low risk, and 1/9 (11%) had very low risk for aggressive behaviour. Seven resections showed microscopically negative transsection margins (R0), two showed positive margins (R1). No patient developed local recurrence during follow-up. The one patient who underwent pancreatoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local recurrence. Another patient died in complete remission due to cardiac disease. Seven of the nine patients are alive disease-free.
  
  
  CONCLUSIONS
  In patients with duodenal GIST, limited surgical resection with microscopically negative margins, but also with microscopically positive margins, lead to very good local and systemic disease-free survival.
authors.affiliation: Jens Hoeppner, Birte Kulemann, Goran Marjanovic, Ulrich Theodor Hopt, Department of General Surgery, University of Freiburg, 79106 Freiburg, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Hoeppner
authors.forename: Birte
authors.initials: B
authors.lastname: Kulemann
authors.forename: Goran
authors.initials: G
authors.lastname: Marjanovic
authors.forename: Peter
authors.initials: P
authors.lastname: Bronsert
authors.forename: Ulrich Theodor
authors.initials: UT
authors.lastname: Hopt
keywords: Duodenum; Gastrointestinal stromal tumor; Limited resection; Surgery; Survival