The incidence of DGIST is low, and patients are typically asymptomatic. Surgical resection can achieve radical cure, but there is no consensus on the choice of operation mode. The size of the tumour varies from patient to patient when the diagnosis is confirmed, and most tumours are located in the descending part of the duodenum [15]. Some of the tumours are close to the nipple and often invade the whole duodenum and pancreas. All of the above factors affect the choice of surgical method; therefore, the basis for these selections should be explored. It is helpful to provide a reference for the scientific and reasonable selection of surgical methods to treat DGIST. The principle of the operation is to completely remove the tumour, ensure the negative margin and intact capsule, and maintain the original anatomical and physiological function of the duodenum as much as possible [16–19].
The location of the tumour and the extent of tumour invasion to surrounding tissues determine the specific surgical method. For DGISTs, limited resection should be adopted as much as possible because PD involves the removal of multiple organs, and the operation risk and complication rate are high [20, 21]. According to the guidelines and consensus of experts, limited resection is recommended for tumours with a distance from the nipple greater than 2 cm. PD is recommended for patients with difficulty in tumour dissociation and tumours with a distance from the nipple less than 2 cm that invades the pancreatic head or is closely related to the superior mesenteric vein and superior artery [14, 22].
Robotic surgery has more advantages than laparoscopic surgery in duodenal dissociation, tumour resection, duodenal repair and duodenojejunostomy. It is easy for surgeons with experience in RPD to dissociate any part of the duodenum. Endoscopic ultrasound is an important method for the diagnosis of GIST that can confirm the origin and scope of tumours. Abdominal CT can reveal the tumour location, shape, size, growth mode and its relationship with the gastrointestinal tract [23]. The combination of multiple examinations can improve the diagnostic rate of DGIST and clarify the lesion site and its invasion to surrounding organs. Because duodenoscopy often cannot accurately locate the tumour location during surgery, we routinely use intraoperative ultrasound combined with preoperative imaging examination to determine the tumour location during surgery [24]. All the tumours of patients in this study were finally found and located during robotic resection.
Our results revealed significant differences in the mean operation time and intraoperative blood loss between the robotic group and the open surgery group. These findings suggested that robotic surgery not only has the same therapeutic effect as traditional open surgery but also has the advantages of a shorter operation time, less intraoperative bleeding and smaller surgical incision. Such robotic operations are recommended to treat DGIST in medical centres with robotic surgical conditions and corresponding experience.
Tumour rupture should be avoided as much as possible during DGIST resection because it is a high-risk factor for postoperative recurrence and metastasis [3, 5, 7–11]. Tumours located in the horizontal segment of the duodenum are often closely related to the superior mesenteric vein and superior artery. If the inflammation and adhesion around the tumour are serious, it is difficult to dissociate the duodenum. Therefore, 2 patients who underwent robotic surgery were converted to open surgery in the present study. Avoiding tumour rupture is the most important factor for surgeons to make decisions regarding surgical conversion.
Postoperative DGE, abdominal bleeding, POPE and bacteraemia are common complications in both robotic surgery and open surgery for DGIST. The treatment principle of postoperative complications of the two surgery methods is the same as that of conventional gastrointestinal surgery and PD [6, 16, 17]. Patients with medium and high risk of recurrence were recommended to take imatinib for 3 years to avoid tumour recurrence [14]. In this group of patients, one patient had liver metastasis 2 years after drug withdrawal, and another patient developed liver metastasis 9 years after the operation. This finding indicates whether the oral targeted drug time should be extended after surgery.
The limitation of this study is that the sample size of patients was too small, and a large amount of case data should be accumulated in future research.