Long-Term Outcomes after Elective versus Emergency Surgery for Small Bowel Neuroendocrine Tumors

Abstract

Small bowel neuroendocrine tumors (SBNETs) are often indolent, but occasionally, patients present with acute symptoms requiring emergent operative intervention. Our aim was to determine whether emergency surgery for SBNETs affects long-term outcomes. An institutional database was reviewed to identify patients with SBNET diagnosed between 1990 and 2015. Need for emergency resection (ER) was compared with elective resection (ELR). One hundred and thirty-four patients met inclusion criteria. Median age was 59 years (range, 21–91), and median tumor size was 1.5 cm (range, 0.1–5). Median follow-up time was 5.5 years. One hundred (74.6%) patients had ELR, whereas 34 (25.4%) required ER. ELR had a higher number of lymph nodes resected (median 12.5 vs 8 ER, P = 0.04); however, there was no difference in the number of positive nodes (median 3 vs 2, P = 0.85). There were 45 (33.6%) recurrences (31 [31.0%] ELR vs 14 [41.7%] ER, P = 0.29) and 13 (9.7%) deaths (7 [7.0%] ELR; 6 [17.6%] ER). There was no significant difference in 5-year disease-free survival (ELR 72.6% vs ER 77.9%, P = 0.71) or overall survival (ELR 97.2% vs ER 96.6%, P = 0.81). Although patients undergoing ER have significantly fewer lymph nodes resected, they have comparable recurrence rates and long-term outcomes with those patients undergoing ER.

How to Manage Small Intestine (Jejunal and Ileal) Neuroendocrine Neoplasms Presenting with Liver Metastases?

“…More specific symptoms for siNENs may be diarrhoea (21%) or flushing (9%) as signs of serotonin overproduction. Partial (18%) or total bowel obstruction of both functioning and non-functioning tumours may require emergent operative interventions [ 29 ]. However, all these symptoms are unspecific and may also be found in NENs located in other parts of the GI tract [ 28 •].…”

Surgery and Perioperative Management in Small Intestinal Neuroendocrine Tumors

“…Most patients with SI-NETs (nearly 80%) present nonspecific symptoms mainly related to the local effect of MLNM than to the primary tumor [ 4 , 5 , 66 ]. Among them, 12.5% to 33% need emergency surgery [ 5 , 12 , 67 ]. Acute symptoms requiring emergency surgery are small bowel obstruction (80%), pain (10%), and less frequently mesenteric ischemia, intussusception or gastrointestinal bleeding [ 5 , 12 ].…”

“…Among them, 12.5% to 33% need emergency surgery [ 5 , 12 , 67 ]. Acute symptoms requiring emergency surgery are small bowel obstruction (80%), pain (10%), and less frequently mesenteric ischemia, intussusception or gastrointestinal bleeding [ 5 , 12 ]. Emergency surgery raises some questions, including (i) a higher risk of postoperative complications, (ii) an inadequate surgical act (lack of lymphadenectomy, multiple primary tumors left in place, or extensive small bowel resection), and (iii) an earlier relapse [ 5 , 12 ].…”

“…Acute symptoms requiring emergency surgery are small bowel obstruction (80%), pain (10%), and less frequently mesenteric ischemia, intussusception or gastrointestinal bleeding [ 5 , 12 ]. Emergency surgery raises some questions, including (i) a higher risk of postoperative complications, (ii) an inadequate surgical act (lack of lymphadenectomy, multiple primary tumors left in place, or extensive small bowel resection), and (iii) an earlier relapse [ 5 , 12 ]. In order to limit those risks, patients should be referred to specialized centers [ 68 ], but an oncologic resection may not be possible in an emergency context.…”

“…MLNM are typically larger than primary tumors and associated with dense desmoplastic fibrosis leading to retractile mesenteritis. When extending to the small bowel and the mesenteric vessels, MLNM can cause acute symptoms of abdominal pain, bowel obstruction, mesenteric ischemia, and digestive hemorrhage which may require emergency surgery in up to 25% of cases [ 5 , 12 ]. The liver is the most common metastatic site.…”