DOI:10.2214/AJR.06.1017
AJR 2007; 189:56-60
© American Roentgen Ray Society
Imaging-Guided Minimally Invasive Laparoscopic Resection of Intraluminal Small-Bowel Tumor: Report of Two Cases
Joon Seok Lim1,
Woo Jin Hyung2,
Mi-Suk Park3,
Myeong-Jin Kim3,
Sung Hoon Noh2 and
Ki Whang Kim3
1 Department of Diagnostic Radiology, Institute of Gastroenterology, Yonsei
University College of Medicine, Seoul, South Korea.
2 Department of Surgery, Yonsei University College of Medicine, 134
Shinchondong, Seodaemoon-Gu, Seoul, South Korea.
3 Department of Diagnostic Radiology, Yonsei University College of Medicine,
Seoul, South Korea.
Received August 25, 2006;
accepted after revision November 8, 2006.
Address correspondence to W. J. Hyung
(wjhyung{at}yumc.yonsei.ac.kr).
Abstract
OBJECTIVE. The purpose of our study was to introduce a method of
effective localization of intraluminal small-bowel tumors. Our adapted
technique, performed on two patients, consists of preoperative 3D distance
measurement with MDCT data and intraoperative laparoscopic sonographic
guidance.
CONCLUSION. Combining distance measurement on reformatted MDCT
images with intraoperative laparoscopic sonography results in accurate
localization of small-bowel tumors. Use of this technique may allow minimally
invasive laparoscopic treatment of patients.
Keywords: abdominal imaging • CT • MDCT • small bowel • sonography
Introduction
Laparoscopy and intraoperative enteroscopy have been recommended for the
management of small intraluminal small-bowel tumors that are amenable to
surgical therapy [1].
Intraoperative enteroscopy is somewhat invasive and time-consuming and hinders
the laparoscopic procedure because air distention for enteroscopy can impede
mobilization of the bowel [2].
In contrast, laparoscopic sonography has been acknowledged as a noninvasive,
effective, and time-saving procedure with which intraluminal gastric
submucosal tumors can be easily detected during laparoscopic surgery
[2]. Unlike localization of
gastric tumors, however, localization of small-bowel tumors with laparoscopic
sonography is not simple and fast. It is unlikely that the entire length of
the small bowel can be thoroughly searched with laparoscopic sonography alone.
Even approximate location of bowel segments needing laparoscopic sonographic
examination would make tumor localization easier and less time-consuming. The
development of 3D software programs has made feasible 3D distance measurement
with thin-slice data from CT. To 3D measurement we added laparoscopic
sonography to localize intraluminal small-bowel tumors as exactly as possible
to enable minimally invasive laparoscopic treatment of two patients.
Subjects and Methods
Patients
Our study was conducted under the official approval of our institutional
review board. The laparoscopic procedures were proposed in advance to the
patients. The procedures and their innovative nature were explained in
concrete detail, and written consent was sought and obtained. Both patients
presented with melena and were admitted for detection of the bleeding focus.
Patient 1 had undergone renal allograft transplantation 13 years previously.
Patient 2 had no significant medical or surgical history.
Esophagogastroduodenoscopy and colonoscopy of both patients failed to reveal
the source of bleeding. However, small-bowel radiographic series (patient 1)
and CT scans performed at another institution (patient 2) showed submucosal
small-bowel tumors.
CT Technique
CT with 16-MDCT (patient 1) and 64-MDCT (patient 2) scanners (Sensation 16
and 64, Siemens Medical Solutions) was performed for preoperative localization
of the tumors. The patients fasted for at least 6 hours before CT. To improve
bowel tracing and visualization of small-bowel lesions, 700 mL of dilute (17%)
water-soluble contrast material (meglumine diatrizoate, Gastrografin,
Schering) was orally administered at 15-minute intervals over 45 minutes. CT
images were obtained approximately 15 minutes after the end of the oral
intake. Twenty milligrams of scopolamine (Buscopan, Boehringer Ingelheim) was
injected IV immediately before the examination. Contrast medium with an iodine
concentration of 370 mg I/mL (iopromide, Ultravist 370, Schering) was
administered with a power injector (Multilevel CT, Medrad) at a rate of 4
mL/s.
Two-phase images (arterial phase from the diaphragmatic dome to the level
of the iliac crest, portal phase from the diaphragmatic dome to the level of
the symphysis pubis) were obtained. The scanning parameters for 16-MDCT were
350 mAs at 120 kVp; detector collimation, 1.5 mm; table speed, 24 mm per
rotation; gantry rotation time, 0.5 second. The parameters for 64-MDCT were
350 mAs at 120 kVp; table speed, 24 mm per rotation; detector collimation, 0.6
mm; gantry rotation time, 0.5 second. A reconstruction section thickness of
3.0 mm and a reconstruction interval of 3.0 mm were used for interpretation of
axial and coronal images on a PACS.
View larger version (136K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —46-year-old man with cystic lymphangioma causing
gastrointestinal bleeding. Preoperative coronal reformatted CT image shows
multilobular low-attenuation mass (arrows) in mid jejunum. Lesion has
intraluminal growth pattern.
|
|
View larger version (71K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —46-year-old man with cystic lymphangioma causing
gastrointestinal bleeding. Curved planar reformatted image shows measured
distance (42.6 cm) between level of ligament of Treitz (arrowhead)
and proximal margin of lesion (arrow).
|
|
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D —46-year-old man with cystic lymphangioma causing
gastrointestinal bleeding. Laparoscopic photograph shows sonographic probe
searching lesion. Serosal color change is present in proximal portion of
presumed location (arrows).
|
|
Preoperative Localization by Means of Distance Measurement
CT scans showed intraluminal submucosal masses without a serosal component
in the mid jejunum of one patient and in the mid ileum of the other. The
jejunal mass measured 4.5 cm and the ileal mass 2.2 cm in longest diameter.
The measurements were made with an electronic caliper. All CT image sets were
transferred to a PC. The section thickness and reconstruction interval for
patient 1 were 3 mm and 3 mm, and for patient 2 were 1 mm and 1 mm. The images
were displayed and processed with a commercially available software program
(Rapidia, Infinitt).
Curved planar reformations were made by interactive placement of a cursor
on a stack of axial, sagittal, or coronal sections along the course of the
small bowel from the ligament of Treitz or the ileocecal valve to a proximal
margin of the tumor. The location of the ligament of Treitz was defined as the
point at which the inferior mesenteric vein crossed over the beginning of the
jejunum [3]. The ligament of
Treitz or ileocecal valve was used as reference point for intraoperative
localization because these structures are easily spotted and readily
identified. Of these two landmarks, the one closer to the lesion was
designated the starting point. That is, the ligament of Treitz was used for
the midjejunal lesion, and the ileocecal valve for the midileal lesion. The
plane thus prescribed yielded a 2D image showing the entire course of the
small bowel from the reference point to the tumor. On the curved planar
images, the distance was measured by tracing an electronic cursor along the
relevant length of small bowel. All reformations and distance measurements
were acquired in less than 30 minutes by a radiologist in a 3D CT
laboratory.
View larger version (101K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F —46-year-old man with cystic lymphangioma causing
gastrointestinal bleeding. Photograph of specimen shows intraluminal mass with
papillary growth pattern. Pathologic finding was cystic lymphangioma.
|
|
Operation and Intraoperative Localization with Measured Distance and Laparoscopic Sonography
Under general anesthesia, each patient was placed in the Trendelenburg
position. Three trocars were used. A 10-mm trocar was placed at the umbilicus
by open technique and used for a camera port. A 12-mm trocar for laparoscopic
sonography and linear stapling was inserted at the right mid-clavicular line
approximately 2 cm below the level of the umbilicus. A 5-mm trocar was placed
at the right lower abdomen under laparoscopic vision after establishment of
pneumoperitoneum.
After trocar placement, the preoperatively measured distance was
reestimated for calculation of the exact locus of the lesion. Starting from
the reference anatomic structure, serial laparoscopic measurements were
obtained with a 10-cm length of suture material on the serosal side of the
small bowel. At this presumed location on the small bowel, laparoscopic
sonography was performed for exact localization of the lesion. A laparoscopic
probe with a flexible tip equipped with a 7.5-MHz linear transducer (Aloka)
was set up perpendicular to the intestinal wall. To search for the final site
of the lesion, a radiologist performed laparoscopic sonography making small,
slow, transverse, and rotating motions all over and along the intestinal
surface.
Results
Patient 1
Patient 1 was a 46-year-old man. Preoperative CT showed an intraluminal
4.5-cm submucosal mass approximately mid jejunum
(Fig. 1A). The preoperatively
measured distance—that is, the distance from the ligament of Treitz to
the proximal margin of the lesion—was 42.6 cm
(Fig. 1B). During the
laparoscopic procedure, the surgeon estimated this distance on the serosal
side of the small bowel using a 10-cm length of suture material
(Fig. 1C). A questionable
serosal color change (Fig. 1D)
was found over the proximal portion of this presumed site of the lesion, which
had been determined by distance measurement. A radiologist performed
laparoscopic sonography to confirm the presence of the intraluminal
small-bowel lesion (Fig. 1D).
The laparoscopic sonographic image revealed the lesion at the corresponding
location (Fig. 1E). All
intraoperative localization procedures were performed in less than 15 minutes.
Segmental resection was successful, and the total duration of the operation
was 115 minutes. Cystic lymphangioma was confirmed at pathologic examination
(Fig. 1F).
Patient 2
Patient 2 was a 56-year-old man. Preoperative CT showed an intraluminal
2.2-cm submucosal fatty mass approximately mid ileum, a finding suggestive of
lipoma (Fig. 2A). Estimated
from the curved planar reformatted image, the distance from the ileocecal
valve to the lesion was approximately 36.5 cm
(Fig. 2B). The surgeon measured
this distance using the same procedure as for patient 1. He also tried to
ascertain the presence of a questionable mass, palpating with graspers around
the proximal location of the mass. Because the presence of a solid mass lesion
at the corresponding location had been confirmed with laparoscopic sonography
(Figs. 2C and
2D), segmental resection was
performed. The duration of intraoperative localization was less than 15
minutes and of the entire operative procedure was 100 minutes. At pathologic
examination, the lesion was confirmed to be ulcerated lipoma
(Fig. 2E).
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C —56-year-old man with ulcerated lipoma causing
gastrointestinal bleeding. Laparoscopic photograph shows questionable bulbous
contour (arrows) without serosal color change in proximal portion of
presumed location of lesion. Laparoscopic sonographic probe is searching
lesion.
|
|
Discussion
The combined method of 3D distance measurement and laparoscopic sonography
was feasible in localizing intraluminal tumors in the small bowel in
preparation for laparoscopic surgery. This technique accelerates
intraoperative localization of the lesion, facilitating laparoscopic surgery
for small intraluminal small-bowel tumors.
Laparoscopic surgery has evolved into an extremely useful tool for managing
abdominal lesions, especially in benign diseases
[4]. However, because it is not
possible to use tactile sensation to locate lesions during laparoscopy,
laparoscopic surgery presents challenges in localizing tumors and determining
the extent of resection. Because they frequently do not have outwardly
identifiable serosal changes that can be seen on laparoscopy, intraluminal and
submucosal tumors are particular obstacles to laparoscopic surgery. Douard et
al. [5] reported that
intraoperative enteroscopy is a valuable technique for exploration because it
allows intraoperative guidance for complete inspection of the small bowel.
This technique, however, is highly complex and invasive, and additional
enterotomy is required. Laparoscopic surgery for a small intraluminal gastric
submucosal tumors also presents problems in tumor localization. Hyung et al.
[2] suggested laparoscopic
sonography as an alternative for overcoming this problem. Unlike exploration
of the stomach, however, exploration of the entire small bowel with
laparoscopic sonography is impossible.
The development of MDCT has enabled accurate detection and localization of
bleeding sites and neoplasms in hollow viscera
[6,
7]. However, even when a lesion
is well visualized on CT, intraoperative localization is difficult because
preoperative imaging yields only a rough approximation of the locus of the
lesion, and this estimate may not be a reliable guide. To overcome this
problem, we used a curved planar display to delineate the entire course of the
small bowel from a reference point to the tumor and measured the length of
this segment.
Curved planar reformation yields 2D images that show the entire course of
an anatomic structure [8,
9]. Thus the technique is
useful for displaying a complex anatomic structure with a tortuous course
[9]. However, distances
calculated by clicking the cursor on the computer screen are not absolutely
reliable for exact intraoperative localization. Intrinsic small-bowel
peristalsis and elasticity can cause variation in the measured distances, and
bowel tracing can follow the wrong loop because of the presence of collapsed
loops. In addition, stretching of the small bowel for laparoscopic measurement
can cause inaccuracy.
To overcome the problems of using 2D images, we added intraoperative
laparoscopic sonography to the localization procedure. The laparoscopic
sonographic probe was placed at the proximal end of the segment of bowel
presumed to contain the lesion, and the surgeon took serial measurements with
a 10-cm length of suture material. Knowing the most proximal possible site of
the lesion, the surgeon looked for a subtle change in the color of the serosa
(patient 1) and for a questionable mass (patient 2). These clues, however,
were insufficient for determining the location for and extent of surgical
resection. Laparoscopic sonography was necessary for accurate confirmation of
the tumor locations, and resection was successful in both patients. Another
limitation was that this combined technique could be used only for small-bowel
lesions detectable on preoperative CT. Our method is not applicable for
localizing hidden bleeding small-bowel lesions not visualized on CT. In such
cases, intraoperative enteroscopy may be more helpful.
We concluded that the combination of distance measurement on reformatted
MDCT images and intraoperative laparoscopic sonography can be used for
accurate localization of small bowel tumors and thus for a minimally invasive
laparoscopic treatment.
References
- Kovacs TO. Small bowel bleeding. Curr Treat Options
Gastroenterol 2005; 8:31
-38[CrossRef][Medline]
- Hyung WJ, Lim JS, Cheong JH, Lee YC, Noh SH. Tumor localization
using laparoscopic ultrasound for a small submucosal tumor. J Surg
Oncol 2004; 86:164
-166[CrossRef][Medline]
- Chou CK, Chang JM, Tsai TC, Mak CW, Hou CC. CT of the
duodenojejunal junction. Abdom Imaging1995; 20:425
-430[CrossRef][Medline]
- Robinson TN, Stiegmann GV. Minimally invasive surgery.
Endoscopy 2004;36
: 48-51[CrossRef][Medline]
- Douard R, Wind P, Panis Y, et al. Intraoperative enteroscopy for
diagnosis and management of unexplained gastrointestinal bleeding.
Am J Surg 2000;180
: 181-184[CrossRef][Medline]
- Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointestinal
bleeding: detection and localization with arterial phase multi-detector row
helical CT. Radiology 2006;239
: 160-167[Abstract/Free Full Text]
- Patak MA, Mortele KJ, Ros PR. Multidetector row CT of the small
bowel. Radiol Clin North Am 2005;43
: 1063-1077[CrossRef][Medline]
- Nino-Murcia M, Jeffrey RB Jr. Multidetector-row CT and volumetric
imaging of pancreatic neoplasms. Gastroenterol Clin North
Am 2002; 31:881
-896[CrossRef][Medline]
- Gong JS, Xu JM. Role of curved planar reformations using
multidetector spiral CT in diagnosis of pancreatic and peripancreatic
diseases. World J Gastroenterol 2004;10
: 1943-1947[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
