1. 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

2. 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(+)

3. 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 (-)

4. 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

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

6. EMR-C ( )
Muscle layer
SM layer

7. 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)

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

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

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

11. post EMR #7
V/S은 stable

12. 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

13. post EMR #16
PCD insertion
Double-J catheter insertion

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

15. 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

16. 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

17. Iatrogenic perforation of
duodenal 2nd portion
One patient after EMR for carcinoid tumor
- conservative treatment
Hiroaki et al. Gastrointest Endosc 1998;47:
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

18. 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