Surgical Treatment

For several authors, surgical intervention is the treatment of choice for DTs. A complete excision is recommended because partial excision may trigger a prompt recurrence. However, considering that DTs are basically benign, the advantage of surgery may be weighed with its consequences.

A different approach must be considered for abdominal wall or mesenteric DTs. Common opinion is that abdominal wall DTs can be removed, since the surgical procedure is relatively easy and the possibility of a radical removal is high even in presence of a huge mass. In order to obtain clear margins on histo-

logical examination excision in the muscular tissue is recommended, often with the sacrifice of most abdominal wall muscles. It is therefore important to treat DTs when they are small, otherwise a large mus-culoaponeurotic defect of the abdominal wall requires reconstruction with synthetic devices or myocuta-neous flaps. However, some authors [16, 26, 114] maintain that surgery is not advisable even for DTs of the abdominal wall. In fact, the recurrence rate varies from 25 to 100% of cases, even when the DT has been radically resected [13,15, 87] and the iterative operation can provoke the development of DT within the mesentery [18, 21-31]. Against imperative surgery, it must be considered that DTs can cease to grow [27] or even regress spontaneously [14,33]. We are in favour of surgery for this type of DT, but believe it necessary to adopt a chemoprevention of the recurrence just after surgery. We treated 15 abdominal-wall DTs with radical surgery and employed SERMs as adjuvant therapy in the postoperative period. Recurrence was observed in two patients.

Conversely, mesenteric DTs can be removed only when small and relatively distant from the root of the small-bowel mesentery; since there is no plane of cleavage around the mass, enucleation is impossible and a concomitant resection of the surrounding intestinal tract is frequently needed. Otherwise, the risk is to remove a large part or the whole of the small bowel. Treatment of intra-abdominal DTs is usually reserved to cases in which complications occur such as small-bowel obstruction, bowel perforation, intestinal bleeding, hydronephrosis or deterioration of the functional results after IPAA. When surgery is chosen with curative intent, radical resection is achieved in about 20% of cases [14-16] with a mortality rate ranging from 2 to 10% [14, 19, 21]. In the other 80% of cases, partial resection or biopsy alone with or without intestinal bypass were performed. Severe complications are reported in up to 60% of cases [14]. Short-bowel syndrome, following wide or multiple bowel resections, is reported in 4.7-20% of cases [19,21,34]. Long-term parenteral nutrition and small-bowel transplantation can be necessary in some of these patients. The recurrence rate is around 70-80% (Table 3). The personal attitude was to avoid surgery and treat the lesions medically with SERMs or, in rare cases of refractory response, cytotoxic drugs. In the majority of cases we could arrest the growth of DTs and observe regression of symptoms and mass.

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