PMC7333481_01
(a, b) Gastrointestinal endoscopic images show no mucosal lesion.
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GI endoscopy showed no mucosal lesion (Figure 1(a) and (b)).
(a:Axial view, b:Coronal view, c:Sagittal view) CT images show a large well-defined mass measuring 4 cm x 4 cm originating from the DJJ without evidence of lymphadenopathy or metastatic disease (white arrowheads). The mass is abutting the first jejunal branch of the superior mesenteric artery and vein (white arrow). CT: computed tomography, DJJ: duodenojejunal junction.
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The radiologist suspected the lesion was a GIST or some other small bowel tumor (Figure 2(a)-(c)).
(a) Intraoperative images show a mass measuring 4 cm x 4 cm originating from the serosal surface of the DJJ at the anti-mesenteric surface. (b) The first jejunal branch of the superior mesenteric vein is observed in this image (white arrow). (c) The ligament of Treitz and the feeding vessels from the first jejunal branches are dissected (white arrow). (d) The third part of the duodenum is transected and stapled after obtaining a tumor-free margin. (e) The second and third parts of the duodenum are exposed by dissecting the posterior leaflet of the transverse mesocolon up to the midcolic vessels (white arrow = second part of the duodenum, black arrow = pancreas). (f) Laparoscopic side-to-side duodenojejunostomy is performed after resection of a GIST (Echelon Flex  Endopath  Stapler 60 mm Blue Cartridge (Ethicon Endo-Surgery, J&J)). (g) Images obtained after segmental resection of the small bowel (white arrow = distal end of jejunum, black arrow = proximal end of jejunum). DJJ: duodenojejunal junction; GIST: gastrointestinal stromal tumor.
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The branches from the first jejunal vessels were carefully divided (Figure 3(a)-(c)). The DJJ proximal to the tumor was excised with a linear stapler (Echelon Flex  Endopath  Stapler 60 mm Blue Cartridge (Ethicon Endo-Surgery, J&J)), and segmental resection was performed to include the area affected by the tumor by transecting the jejunum distal to the tumor with a linear stapler after obtaining a tumor-free margin (Figure 3(d)). To restore bowel continuity, the second and third parts of the duodenum were exposed by dissecting the transverse mesocolon up to the midcolic vessels, and after adequate mobilization, the distal loop of the jejunum was anastomosed with the third part of the duodenum in a side-to-side manner using a linear stapler (Figure 3(e) and (f)). The point of entry of the stapler was laparoscopically sutured. The surgical specimen was placed in a retrieval bag and removed from the abdominal cavity (Figure 3(g)).