NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

Cover of Surgical Treatment

Surgical Treatment: Evidence-Based and Problem-Oriented.

Show details

Benign tumors of the duodenum and stomach

, M.D. and , M.D.

Author Information

, M.D.1 and , M.D.2.

1 Minimally Invasive Surgical Centre, Department of Surgery, National University Hospital, Singapore
2 General and Videoscopic Surgery, Saladillo Clinic, Saladillo, Buenos Aires, University of La Plata Medical School, Argentine

Introduction

Benign tumors of stomach and duodenum are not common and constitute only 5–10% of all stomach tumors, and 10–20% of all duodenal tumors. Though these lesions are benign, some of them can become malignant. Therefore, early diagnosis, correct treatment and proper longterm follow-up are important. Over the recent years, the incidence of these lesions is rising due to a higher level of suspicion exhibited by clinicians, and the availability and wide application of diagnostic tools, such as gastrointestinal endoscopy.

Classification

Stomach

A.

Epithelial:

  • Hyperplastic Polyps
  • Adenomatous Polyps

B.

Mesenchymal:

  • Leiomyoma
  • Leiomyoblastoma
  • Neurogenic
  • Vascular
  • Lipoma

C.

Others:

  • Inflamatory Pseudotumors
  • PeutzJegher’s Polyps
  • Cystic Tumors

Duodenum

A.

Epithelial:

  • Adenoma (tubular, villous, tubulovillous)
  • Brunner’s Gland Adenoma

B.

Mesenchymal:

  • Leiomyoma
  • Leiomyoblastoma
  • Lipoma
  • Vascular
  • Fibroma
  • Neurogenic

C.

Others:

  • Familial Adenomatosis Polyposis
  • Gardner’s Syndrome
  • Peutz-Jeghers Syndrome
  • Duodenal Gangliocytic Paraganglioma

Presenting symptoms and diagnosis

Most patients with benign stomach and duodenal tumors remain asymptomatic for long periods of time. When symptoms are present, these depend on the tumor size, location and complications arising from the tumor (eg: bleeding and ulceration). The most common presenting symptoms are bleeding (acute or chronic), abdominal pain and discomfort, nausea, weight loss, intestinal obstruction and as for periampullary tumors, such as adenomas in the papilla of Vater, recurrent pancreaticobiliary complications including jaundice, cholangitis, and pancreatitis may occur. Patients may be referred by another physician to the out-patient clinics with one of the above symptoms, or be admitted as an emergency due to massive upper gastrointestinal bleeding. Rarely, they may also present with intestinal obstruction.

In the diagnosis of upper gastrointestinal tumors, the conventional contrast study has been the main method of investigation. Conventional CT scan is another non-invasive procedure in the investigation of distal gastric and duodenal tumors. In the last few years, endoscopic ultrasonography has been proven to be helpful in the diagnosis of submucosal tumors. Today, the most important diagnostic tool is the VOGD (video-oesophagus-gastro-duodenoscopy) with multiple biopsies. It is crucial to note that a definite diagnosis cannot be achieved without definitive histopathology, especially in patients with periamullary tumors, for which ERCP is useful, and smooth muscle tumors like leiomyoma and leiomyblastoma. Currently other new high technologies in imaging such as Spiral CT Scan and Electro Beam CT Scan with 3-D reconstruction can be used for diagnosis. The most common benign lesions in the stomach are polyps (epithelial tumors) and they constitute 75% of all benign stomach tumors. The other common benign stomach tumors are leiomyomas. In the duodenum, the most common benign lesion is adenoma including Brunner’s gland adenomas, followed by leiomyomas and lipomas.

Epithelial tumors of the stomach

According to results published by Orlowska in 1995, the potential of these lesions becoming malignant poses a much more worrying problem than the clinical symptoms themselves. Orlowska found that 1.3% of Hyperplastic Polyps (HP) and 10% of Adenomas were malignant. Her results support the belief that gastric HP, like adenomas, can become malignant, thus she concluded that it is sensible to differentiate a subgroup of Foveolar Hyperplasia (FH) from HP, since FH will not become malignant unless their histology changes to that of HP. The view that FH and HP belong to the same category accounts mainly for the widespread underestimation of the malignant potential of HP. While it was believed that polyps that become malignant exceed 2 cm in diameter, Orlowska found cancer cells in very small polyps (diameter ≈ 5 mm).

Leiomyoma/Leiomyoblastoma

These tumors constitute 2% of all resected neoplasms of the stomach, and occur most frequently in males between fifty and seventy years old. 10–20% of leiomyomas of the small intestine are located in the duodenum. They are usually asymptomatic, but present with anemia in 50% of cases as a result of mucosal ulceration. Leiomyomas are usually located in the corpus (40%) or in the antrum (25%). Even when histopathologic tests are conducted, it is difficult to distinguish benign lesions from malignant ones, partly because leiomyomas are not encapsulated. The relationship between Leiomyoma (LM), Leiomyoblastoma (LMB) and Leiomyosarcoma (LMS) is still unknown. The “enigma” of LMB is its unusual histology, coupled with a somewhat unpredictable clinical progression. Important in the assessment of the malignant potential of LMB is the mitotic count, with counts over 5 for 50 high power fields, implying the possibility of malignancy and subsequent metastasis. The accepted rate of malignant transformation is around 12%.

Duodenal adenomas in familial adenomatous polyposis (FAP)

This association is being increasingly recognized. Early diagnosis and longterm surveillance of asymptomatic patients with this disease allows the opportunity to diagnose and treat duodenal tumors at an early stage, thereby avoiding the dismal prognosis once invasive cancer has developed in patients who have survive for a mean period of 13 months.

Duodenal (periampullary) tumors

These tumors are rare. Villous and tubulovillous adenomas remain the most common of such benign tumors and many have probably undergone malignant change at the time of diagnosis. The presenting symptoms are uncharacteristic, and endoscopy and ERCP are the most sensitive tools for diagnosis. In the post-operative histology of one third of patients with adenoma, we can observe severe third degree dysplasia (1).

Neurogenic gastric and duodenal tumors

These tumors constitute 4% of all benign neoplasms in stomach and 3% to 6% of all small bowel tumors. The most common tumors are neurilemomas (schwanomas) and neurofibromas. About 40% of tumors present with bleeding, and mechanical occlusion is not an unusual manifestation in the duodenum.

Lipoma

Gastric lipoma is a benign tumor that occurs infrequently (1–3% of all benign gastric tumors), and it is usually located in the antrum. Most lipomas are found in the submucosa (95%), and they usually occur singly. The most common clinical presentation (50– 60%) is gastrointestinal hemorrhage caused by ulceration of the tumor. Currently, CT scanning is the study of choice which identifies fatty tissue because of its low attenuation numbers, but the definitive diagnosis is reached with the excision of the lesion and its anatomopathologic study. In the duodenum we can observe approximately 35% of small intestine lipomas.

Brunner’s Gland Adenoma

This is the most common hamartoma, often found in the proximal duodenum. It is believed to indicate hyperplasia of Brunner’s glands, perhaps in response to excessive gastric acid secretion. Such hyperplasia has not been associated with malignant degeneration. These tumors are usually smaller than 1 cm, with multiple and polypoid incidence. As they are asymptomatic, Brunner’s gland adenomas are often incidental findings during endoscopy or radiographic examination.

Treatment Options

The treatment options for benign stomach and duodenal tumors are wide and varied. They range from endoscopic resection in the case of small, well-defined lesions to pancreatoduodenectomy in periampullary tumors with high suspicion of malignancy. One of the most common complications of benign tumors is bleeding which can be treated using endoscopic fibrin glue injection. Stomach lesions can be treated with endoscopic snare resection, laser ablation or mucosal resection (EMR). On the other hand, traditional open procedures with local and wedge resections or gastrectomies can be done. Recently, with the development of technology and new surgical techniques, laparoscopic or combined laparoscopic-endoscopic approach with or without intraorgan surgery have achieved good results comparable to open surgery. This new method of treatment has the advantages of less pain, shorter period of recovery, better immune response, and earlier discharge. For benign duodenal tumors, endoscopic treatment is only limited to small polypoidal lesions. Open surgery is the main mode of treatment for the rest of the tumors. The Minimally Invasive Therapy (MIT) through laparoscopy has been attempted in the treatment of benign duodenal tumors other than polypoidal lesions. Though there are only a few reports available on this method of treatment, it is highly promising. New tools like ultrasonics sheares, staplers and intracorporeal sutures are also used more frequently.

The treatment of benign periampullary tumors remain controversial. Certain questions have to be answered before one can decide on the best treatment: What is the proportion of benign tumors which become malignant? How can an accurate diagnosis be arrived pre-operatively? What are the means of intraoperative diagnosis? Only when these important issues are fully considered can surgeons choose among endoscopic resection, open surgery with local resection or pancreatoduodenectomy.

The treatment for Leiomyoma and Leiomyoblastoma is surgical resection. This tumor should be removed with a portion of gastric (or duodenal) wall sufficient to encompass the site of origin from the smooth muscle.

In general, it is recognized that very small lesions are well resected by endoscopy. The place of conventional open surgery in the removal of these benign tumors is reduced. Patients can now benefit from the Minimally Invasive Surgery, which has widely-recognized advantages, as the benign nature of these tumors permits safe laparoscopic excision.

References

1.
Alstrup N, Burcharth F, Hauge C, Horn T. Transduodenal excision of tumors of the ampulla of Vater. Eur J Surg. (1996);162:961–967. [PubMed: 9001878]
2.
Di Lorenzo N, Sica G, Gaspari A. Laparoscopic resection of gastric leiomyoblastoma. Surg Endosc. (1996);10:662–665. [PubMed: 8662409]
3.
Geis W, Baxt R, Kim H. Benign gastric tumors (Minimally invasive approach) Surg Endosc. (1996);10:407–410. [PubMed: 8661789]
4.
Halpin R, Thomson S, Catterall N, Haffejee A. Smooth muscle tumors of the stomach: clinicopathological aspects. J R Coll Surg Edinb. (1993);38:23–27. [PubMed: 8437148]
5.
Lacy A, Tabet J, Grande L, García-Valdecasas J, Fuster J, Delgado S, Visa J. Laparoscopic-assisted resection of a gastric lipoma. Surg Endosc. (1995);9:995–997. [PubMed: 7482220]
6.
Orlowska J, Jarosz D, Pachlewski J, Butruk E. Malignant transformation of benign epithelial gastric polyps. Am J of Gastroenterol. (1995);90:2152–2159. [PubMed: 8540506]
7.
Schoenberg M, Treistschke F, Harada N, Beger H. Benign tumor of the ampulla of Vater: surgical treatment and prognosis. Eur J Surg. (1998);164:765–770. [PubMed: 9840306]
8.
Seeling M, Hinder R, Floch N, Klingler P, Seelig S, Branton S, Woodward T. Endo-organ and laparoscopic management of gastric leiomyomas. Surg Laparosc Endosc. (1999);9:78–81. [PubMed: 9950137]
9.
Van de Walle P, Dillemans B, Vandelanotte M, Proot L. The laparoscopic resection of a benign stromal tumour of the duodenum. Acta Chir Belg. (1997);97:127–129. [PubMed: 9224516]
10.
Waldrep D, Morgenstern L, Alshak N (1993) The enigma of leiomyoblastoma: spectrum a rare gastric tumor. Am Surg . [PubMed: 8489088]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6948
PubReader format: click here to try

Views

  • PubReader
  • Print View
  • Cite this Page

Related information

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...