Surgical Strategy and Outcomes in Duodenal Gastrointestinal Stromal Tumor.
BACKGROUND
The surgical management of duodenal gastrointestinal stromal tumors (DGIST) is poorly characterized. Limited resection may be technically feasible and oncologically safe, but anatomic considerations may compromise the resection margins due to the proximity of critical structures, thereby necessitating more extensive resections such as pancreaticoduodenectomy.


METHODS
Patients undergoing surgery for DGIST at two institutions from 1994 to 2014 were identified. Clinicopathologic and survival data were analyzed to compare outcomes in patients treated with limited or radical resection.


RESULTS
Sixty patients underwent surgery for DGIST. Pancreaticoduodenectomy was performed in 38 % while the rest underwent limited resections. The most common type of limited resection was wedge resection and primary closure (49 %) followed by segmental resection with an end-to-end or side-to-side duodenojejunostomy (27 %). The pancreaticoduodenectomy group tended to have larger tumors with the majority located in D2/3 (87 %) and at the mesenteric border (91 %). The pancreaticoduodenectomy group also had significantly greater intraoperative blood loss, longer operative time, longer hospital stay, and higher 90-day morbidity and readmission rates. The 5-year relapse-free survival, recurrence-free survival, and overall survival for the pancreaticoduodenectomy versus limited resection were 81 versus 56 % (p = 0.05), 64 versus 53 % (p = 0.5), and 76 versus 72 % (p = 0.6), respectively. A surgical algorithm based on the location and size of the tumor is proposed.


CONCLUSIONS
Limited resection of DGIST is safe, but may be associated with lower 5-year relapse-free survival. Pancreaticoduodenectomy is recommended for selected patients with DGIST when an R0 resection cannot be performed without removing the ampulla or part of the pancreas.
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.|Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.|Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.
Ser Yee
SY
Lee
Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.|Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.
Brian K P
BK
Goh
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Eran
E
Sadot
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Rahul
R
Rajeev
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Vinod P
VP
Balachandran
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Mithat
M
Gönen
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
T Peter
TP
Kingham
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Peter J
PJ
Allen
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Michael I
MI
D'Angelica
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
William R
WR
Jarnagin
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Daniel
D
Coit
Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.|Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore, Singapore.
Wai Keong
WK
Wong
Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.|Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore, Singapore.
Hock Soo
HS
Ong
Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.|Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.
Alexander Y F
AY
Chung
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. dematter@mskcc.org.
Ronald P
RP
DeMatteo
D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D004384:Duodenoscopy; D005260:Female; D046152:Gastrointestinal Stromal Tumors / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007582:Jejunostomy; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D016577:Pancreaticoduodenectomy; D010359:Patient Readmission / Q000706:statistics & numerical data; D015996:Survival Rate; D016896:Treatment Outcome