Introduction: There is controversy over the best technique for resecting small bowel NETs and performing right hemicolectomies in patients with appendiceal NETs at risk of nodal involvement. Most guidelines recommend open over laparoscopic surgery but a survey suggests that surgeons favour a laparoscopic approach. We have reviewed a series of 14 consecutive primary (not recurrent) small bowel NET resections and post-appendicectomy right hemicolectomies including operative technique and histology results.
Method: 14 consecutive patients with surgically managed small bowel NETs or requiring a post-appendicectomy right hemicolectomy for an appendix NET (according to UKINETs guidelines) were identified and a database was created. This included operative technique and histology results including lymph nodes counts and adequacy of resection. Histology results were compared according to NET location and operative technique.
Results: Appendix NETs: 4 patients underwent an elective right hemicolectomy for a histologically confirmed grade 1 well-differentiated appendiceal NET following an appendicectomy. All resections were attempted laparoscopically; 1 was converted to open due to adhesions. Histology revealed no lymph node involvement. Mean number of resected lymph nodes was 22.5 (range 12-51). Small Bowel NETs: 10 patients underwent an ileal or ileocolic resection for a (or multiple) well differentiated grade 1 & 2 ileal NETs. 3 cases were carried out via a laparoscopic or laparoscopic-assisted approach and 7 cases by laparotomy. Involved lymph nodes were present in all patients. An average of 14.6 nodes (range 12-18) were identified in the laparoscopic specimens and 6.1 nodes (range 1-9) in the open specimens. Histologically clear margins were achieved in all cases.
Conclusions: Appendix NETs: A laparoscopic right hemicolectomy should be considered in all patients with appendiceal neuroendocrine tumours who require a nodal assessment. Small Bowel NETs: A laparoscopic approach can be safely utilised in selected patients with small bowel NETs, particularly when involved nodes are close to the bowel wall or along the ileocolic pedicle. The importance of palpating the small bowel and factors affecting the decision on surgical approach are discussed.