Surgical Management of Small Bowel Neuroendocrine Tumors: Specific Requirements and Their Impact on Staging and Prognosis

Abstract

Systematic palpation of the entire small bowel detects more multiple NETs than preoperative imaging. Systematic surgery with extensive LN resection is associated with low local recurrence. High CgA levels and carcinomatosis are linked with shorter survival.

Update on Surgical Management of Small Bowel Neuroendocrine Tumors

“…Surgical resection of the primary tumor with locoregional mesenteric lymph node dissection and metastasectomy, if feasible, is the only curative approach (16), although R0 resections have been reported to be feasible in only 20% of cases (17); however, it has been reported that the current rate is even higher (18).…”

“…However, technique standardization and specific guidelines for its role are still under debate (27). Whole small bowel (from Treitz ligand to the ileocecal valve) inspection and palpation with both hands is of great importance for pinpointing otherwise undetectable tumors (10,18). Preoperative CT-or MRI-angiography may be useful in determining the tumor and the lymph nodes sites in relation to the vessels, so that the optimal surgical resection is feasible, with adequate length of small bowel left behind (at least three jejunal arteries) in order to prevent short bowel syndrome (28,29).…”

“…Residual metastatic lymph node disease may result in mesenteric ischemia or recurrent obstructive episodes, therefore a thorough investigation and dissection of malignant lymph nodes is important (14). Concurrent cholecystectomy is also preferable because the adjuvant treatment with SSAs and, possibly, chemoembolization may cause cholestasis, with a high risk of complications such as necrotic cholecystitis (18,29).…”

“…Furthermore, the 'pizza pie' approach should be abandoned and the inverse approach should become standard (28). Lymphadenectomy should precede enterectomy with possible ileoceccal valve preservation (10,18,28,35). R0 resection of both primary tumor and lymph node metastases is feasible in 80% of cases (10,18,19,36).…”

“…Lymphadenectomy should precede enterectomy with possible ileoceccal valve preservation (10,18,28,35). R0 resection of both primary tumor and lymph node metastases is feasible in 80% of cases (10,18,19,36). Only in a minority of patients with bulky mesenteric masses is optimal debulking not feasible (36).…”