Perforation of duodenal 2nd portion after EMR-C for carcinoid tumor Hyun Joo Suh Department of medicine, Samsung medical center Sungkyunkwan university, School of medicine

M/73, 최 OO Chief complaint Past medical history 우연히 발견된 십이지장 종양 10년 전부터 간헐적 식후 불편감, 속쓰림 있어옴. 1달 전 지역의원에서 내시경검사 시행받고 십이지장 종양있어 전원됨. Past medical history HTN, stable angina with PCI BPH(+)

Review of system Physical examination dyspepsia(+) postprandial epigastric sorness(+) diarrhea/constipation(-/-) hematemesis/hematochezia/melena(-/-) Physical examination Soft & flat, Tenderness/rebound tenderness(-/-) No palpable mass Skin rash (-)

Endoscopic finding ERCP EUS EGD EGD: On just distal to ampulla of vater, 1.0cm sized round nodular lesion with central slit like depression with vascular ectasia EUS: 8.6*5.3 mm sized heterogenous hypoechoic lesion originated from submucosal layer. No regional LAP No definitive evidence of muscular invasion ERCP EUS EGD

Chest X-ray & Abdomen pelvis CT Biopsy Carcinoid tumor Chest X-ray & Abdomen pelvis CT No distant metastasis No regional LAP

EMR-C (2007-08-21) Muscle layer SM layer

Carcinoid tumor Size: 0.6*0.4*0.33cm No microvascular tumor emboli Negative resection margin (less than 0.01cm apart from deep resection margin)

Clinical course Fever, RLQ. Pain Chest X-ray: no free air

Abdomen CT (post EMR #1) Free air Free air and localized peritonitis in right side retroperitoneum  conservative treatment (NPO, antibiotics) Free air

EGD (post EMR #7) Frank perforation (+) frank perforation(+)  GS consultation NPO, TPN, anti지속 Frank perforation (+)

post EMR #7 V/S은 stable

Abdomen CT (post EMR #15) hydronephrosis abscess Complicated fluid collection communicating with duodenum 2nd portion Stenosis of Rt. proximal ureter encased by inflammatory fluid collection with hydronephrosis hydronephrosis abscess

post EMR #16 PCD insertion Double-J catheter insertion

post EMR #25 post EMR #28 SOW 시작 SFD 시작, Antibiotics D/C

Abdomen CT (post EMR #31) Disappearance of abscess Marked interval decrease of complicated fluid collection Presence of fistular tract can not be evaluated Disappearance of abscess

Duodenal carcinoid 2% of carcinoids (Fewer than 100 cases) Treatment Endoscopic resection - Indication 1) Safe for small duodenal SMT, <1cm 2) confined to submucosa Muscular layer involvement cause intestinal perforation 3) No evidence of metastasis - Complication 1) Perforation 2) bleeding Local excision Whipple operation Radical excision for large tumor with evident regional node metastasis

Iatrogenic perforation of duodenal 2nd portion One patient after EMR for carcinoid tumor - conservative treatment Hiroaki et al. Gastrointest Endosc 1998;47: 466-70 Six patients during EST - non surgical management, one of them go to surgery - improvement of symptom within 24hrs, correlated with spontaneous recovery(p<0.01) Chung et al. Am J Surg 1993;165:700-3 12 patients during EST - 11, nonoperative treatment vs 1, surgery - median length of stay 6.7 days - early diagnosis is essential for optimum outcome Güitrón-Cantu et al. Rev Gastroenterol Mex 2003;68(1):6-10

surgical treatment vs non surgical management Diagnosis clinical suspicion CT : choice * delayed diagnosis d/t lack of abdominal rigidity free air on simple X ray Treatment surgical treatment vs non surgical management : controversial, non invasive trend prompt nasogastric suction and antibiotics endoscopic repair surgery – simple closure, difficult d/t anatomy may need Wipple’s operation