The impact of multidisciplinary team on surgical procedure and complications in duodenal tumor patients

Abstract

Background

Local resection (LR) offers comparable prognosis to pancreaticoduodenectomy for benign and low-grade malignant duodenal tumors (DT). However, the LR rate remains low due to the difficulty in determining appropriate indications. This study aims to assess the impact of multidisciplinary team (MDT) on surgical procedure (SP) and complications in DT.

Methods

Clinical data from Centers A and B between 2019 and 2023 were analyzed. Utilizing the unique setting of Center A which operated both MDT and single-discipline treatment (SDT) pathways in parallel, we compared three cohorts: A-MDT, A-SDT, and B-SDT (from Center B). Following this comparison, a multivariate logistic regression analysis was performed, collapsing the groups into MDT and SDT categories to isolate its effect on outcomes.

Results

A total of 66 patients were included in study, with 22 patients in each group. The proportion of patients undergoing LR was 91% in A-MDT, 68% in A-SDT, and 55% in B-SDT, showing a statistical difference (P = 0.027). Furthermore, statistical differences were observed in length of hospital stay, length of postoperative hospitalization, duration of surgery, hemorrhage, bowel obstruction, major adverse events, Clavien-Dindo classification, and comprehensive complication index (P < 0.05). These results indicate that the MDT was superior to SDT. However, overall survival did not differ (P > 0.05). Multivariate logistic regression revealed that MDT was an independent predictive factor for lower comprehensive complication index (P = 0.008, OR = 5.13, 95% CI [1.59–18.61]), and SDT was an independent risk factor for selecting LR (P = 0.047, OR = 0.2, 95% CI [0.03–0.83]). Further analysis showed significantly higher rates of low-tension magnetic resonance imaging (Lt-MRI), endoscopic procedures involving the surgeon, and endoscopic local excisional biopsies in A-MDT, compared with A-SDT and B-SDT.

Conclusion

The MDT enhances the selection of LR for patients with DT, reduces the incidence and severity of complications and accelerates patient recovery, with no impact on overall survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-026-15835-4.

Introduction

Duodenal tumors (DT) account for about 1% of all gastrointestinal tumors. The incidence of primary DT is approximately 0.5%, with benign tumors constituting 35% and malignant small bowel tumors about 17% [1]. Recently, advancements in endoscopic technology and equipment have led to an increased detection rate [2, 3]. DT exhibits a variety of pathological types, including duodenal adenocarcinoma, duodenal stromal tumors, duodenal neuroendocrine tumors (D-NETs), adenomas, leiomyomas, lipomas, and Brunner’s gland adenomas [4], primarily occurring in the descending and bulb part [5, 6].

The accuracy of preoperative biopsy is relatively low, ranging from 68% to 74%, which may be due to the low incidence and the underdeveloped standards for tissue pathology [7, 8]. Additionally, local mucosal defects and exposure of the submucosa to bile and pancreatic juice post-biopsy can lead to severe inflammation and fibrosis, complicating endoscopic resection [7]. One study found that 24.6% of patients who could have undergone endoscopic mucosal resection had to switch to endoscopic submucosal dissection due to poor submucosal lifting caused by preoperative biopsy [8]. Furthermore, preoperative adjunctive examinations, such as endoscopic ultrasound (EUS) and radiographic imaging with computed tomography (CT), magnetic resonance imaging (MRI), and on occasion positron emission spectroscopy (PET), are often insufficient for comprehensive and accurate assessment of tumor conditions.

The potential surgical procedures (SP) mainly include pancreaticoduodenectomy and local resection (LR). Pancreaticoduodenectomy is the standard treatment for adenocarcinomas and more advanced other malignant neoplasms, especially if there are enlarged lymph nodes noted on imaging [9], but this procedure involves a wider resection and requires restitution of pancreato-biliary and intestinal reconstruction, with higher postoperative complication and mortality rates [10], with a 90-day mortality rate reaching 9.2% [11]. Recently, with advancements in surgical techniques, the use of laparoscopic, endoscopic, and robotic technologies has made LR increasingly applicable for treating benign and low-grade malignant DT [12]. Studies have shown no statistical difference in long-term prognosis between LR and pancreaticoduodenectomy for treating low-grade malignant DT [13], and LR offers advantages such as shorter hospital stays, lower complication rates, and lower mortality compared to pancreaticoduodenectomy [14]. Many studies suggest that, when tumor size, location, and pathological characteristics permit, LR should be preferred [15].

LR can achieve comparable therapeutic outcomes, yet defining the criteria for its application remains challenging. In recent years, MDT have evolved and proven to be an effective treatment model for refractory tumors [16, 17], but they have not yet been fully implemented for DT. Our center utilizes its expertise in endoscopic surgery to establish a specialized MDT for the diagnosis and treatment of DT, conducting a thorough evaluation of the tumor. To assess the impact of the MDT on SP and complications, this study analyzed the clinicopathological data of 66 patients who underwent surgical treatment between 2019 and 2023 at two healthcare institutions.

Methods

The methods of MDT

MDT comprises surgeons, endoscopists, pathologists, radiologists, and medical oncologists. Each member leverages their specialized expertise to provide comprehensive medical care for patients. It is important to note that surgeons must also be proficient in endoscopic procedure and diagnostics, or have the ability to refer patients appropriate for endoscopic LR to gastroenterologists with these skills. Additionally, all relevant examinations for each patient are performed personally by the team physicians.

To ensure optimal treatment for patients, all patients in A-MDT undergo Lt-MRI, endoscopic evaluation involving surgeon, and in some cases, endoscopic resection biopsy. The Lt-MRI requires patients to drink a substantial amount of water prior to the examination and to receive an injection of scopolamine to promote duodenal filling and reduce bowel motility [18]. This enhances contrast and facilitates more accurate assessment of tumor location, size, and depth of invasion. The endoscopic evaluation involving surgeon allows for a more direct visualization of the tumor’s local anatomical features, which is crucial for surgical planning. For patients whose diagnosis remains unclear through conventional methods but who are candidates for endoscopic resection, a local resection under general anesthesia can be performed, with immediate rapid pathological assessment to avoid unnecessary pancreaticoduodenectomy. Preoperative comprehensive evaluation of suspected D-NETs requires supplementary Ga⁶⁸ PET-CT [19]. EUS and abdominal CT are widely utilized across all three groups.

The discussion of MDT includes, but is not limited to, the following aspects: location, size, depth of invasion, histopathological type, growth pattern, lymph node metastasis, infiltration of surrounding tissues and organs, relationship with the duodenal ampulla, further examination, biopsy methods, SP.

Study population

This study retrospectively included all patients with DT between 2019 and 2023 at Centers A and B whose preoperative evaluation suggested localized disease and were independently reviewed by the research team as having anatomical feasibility for potential LR. Based on the treatment pathway received, the enrolled patients were categorized into three groups: A-MDT, A-SDT, and B-SDT. At Center A, the assignment to either MDT or SDT was not randomized; patients were managed via the MDT pathway when accessible, while others were managed via the SDT pathway due to factors such as variations in clinical pathways or urgent circumstances. In contrast, all patients at Center B were managed via SDT during the study period. The inclusion criteria for the study were as follows: (1) postoperative pathological examination confirmed primary DT; (2) age between 18 and 70 years; (3) complete pathological data and signed informed consent. The study excluded patients with preoperative assessments showing adenocarcinoma beyond the mucosal layer, invasion into surrounding tissues or organs, lymph node metastasis, or distant metastasis. These patients were prioritized for pancreaticoduodenectomy treatment. Given the unique location of the ampulla of Vater and the associated surgical challenges, tumors at this site were analyzed separately, excluding those located in the descending part. LR includes both surgical local resection and endoscopic resection. The indications for each surgical approach are detailed in Supplementary Table 1.

Data collection

Basic clinicopathological information was extracted from the hospital’s electronic system, including sex, age, body mass index (BMI), smoking and drinking, medical history (abdominal surgery, cardiovascular disease, cerebrovascular disease and diabetes). Additional data collected included length of hospital stay, length of postoperative hospitalization, SP, duration of surgery, transfusion, hemorrhage, tumor information (location, pathological type, size, completeness of resection) and postoperative complications such as intra-abdominal hemorrhage, duodenal fistula, pancreatic fistula, biliary fistula, pulmonary embolism, pulmonary infection, wound infection, localized infection, intra-abdominal abscess, bowel obstruction, pulmonary atelectasis, and vomiting.

Follow-up

Follow-up of the 66 enrolled patients was conducted through outpatient visits, inpatient reviews, and telephone follow-ups. The main focus of the follow-up was on the patients’ survival status. Additionally, detailed records were kept of all test results obtained during each follow-up visit. These results included changes in clinical symptoms, imaging findings, and laboratory test indicators to comprehensively assess the patients’ health status and the long-term management effectiveness of the tumor. The median follow-up time was 1.85 years (interquartile range, IQR, 0.96 to 2.70 years), with a mean follow-up of 2.02 years. Complete follow-up data were available for all patients; there were no loss-to-follow-up cases.

The definition of perioperative complications

Postoperative bleeding was defined as a reduction in hemoglobin level exceeding 3 g/dL, unrelated to hemorrhage [20]. The definition and grading of pancreatic fistula were based on the International Study Group of Pancreatic Fistula criteria [21]. Postoperative complications were graded using the Clavien-Dindo classification [22]. The comprehensive complication index was calculated using an online tool with the formula:√(∑MRV × MRV phys-pat) / 2 [23]. Major adverse events were defined as exceeding Clavien-Dindo classification-II, and severe adverse events were defined as Clavien-Dindo classification-IIIb or higher.

Statistical analysis

Statistical analyses will be performed using R-4.3.2 software. Fisher’s exact test or Chi-square test will be used to assess differences in proportions between groups. Kaplan-Meier (K-M) methods will be used to plot survival curves and analyze survival rates among different groups. Pearson correlation analysis will be applied to explore linear relationships between variables. Normally distributed variables are presented as mean ± SD and compared by ANOVA. Non-normally distributed variables are presented as median [IQR] and compared using the Kruskal–Wallis H test. The level of statistical significance will be set at P < 0.05. Univariate-Multivariate logistic regression was employed to assess the impact of MDT on comprehensive complication index and SP, using the A-MDT group’s mean comprehensive complication index as the cutoff for dichotomization.

Results

Patient demographics and clinical characteristics

A total of 175 patients with DT were screened, and 66 patients were ultimately enrolled in this retrospective analysis, with 22 patients in each group, with complete pathological data and follow-up information. The average ages for the A-MDT, A-SDT, and B-SDT were 54 ± 8, 59 ± 11, and 58 ± 10 years, respectively. The male proportions for the three groups are 55%, 55%, and 50%, respectively. Tumors predominantly occurred in the descending part (70%). Tumor types were mostly borderline (65%), followed by benign tumors (29%), with malignant tumors (6%) being relatively rare, and duodenal stromal tumors being the most common. Only 3 patients (5%) required conversion from planned local resection to pancreaticoduodenectomy due to positive margin (n = 1), unsuspected lymph node metastasis (n = 1), or technical concerns regarding incomplete resection (n = 1).

The study showed no statistical differences among the groups in terms of sex, age, BMI, smoking and drinking, history of abdominal surgery, cerebrovascular disease, cardiovascular disease, diabetes, location, pathological type and size. Detailed patient demographics and clinical characteristics are shown in Table 1. For detailed surgical methods and pathological results, refer to Supplementary Tables 1 and 2.

Table 1.

Demographic and clinical characteristics of patients with DT in A-MDT, A-SDT, and B-SDT groups

Characteristic	A-MDT	A-SDT	B-SDT	P-value
	N = 22	N = 22	N = 22
Sex, male	12 (55%)	12 (55%)	11 (50%)	0.941
Age, mean (SD)	53.5 (7.65)	58.9 (10.5)	57.9 (10.1)	0.150
BMI, mean (SD)	23.5 (2.59)	24.5 (3.54)	23.4 (3.56)	0.467
Smoking, yes	1 (5%)	4 (19%)	2 (9%)	0.482
Drinking, yes	1 (5%)	3 (14%)	4 (18%)	0.510
History of abdominal surgery, yes	6 (27%)	4 (18%)	5 (23%)	0.772
Cardiovascular disease, yes	3 (14%)	9 (41%)	7 (32%)	0.126
Cerebrovascular disease, yes	0	2 (9%)	3 (14%)	0.356
Diabetes, yes	1 (5%)	1 (5%)	2 (9%)	>0.99
Other diseases, yes	5 (23%)	8 (36%)	6 (27%)	0.596
Surgical procedure				0.027
Pancreaticoduodenectomy	2 (9%)	7 (32%)	10 (46%)
Surgical local resection	12 (55%)	15 (68%)	12 (55%)
Endoscopic resection	8 (36%)	0	0
Duration of surgery, median (IQR)	180 [129;208]	225 [165;300]	306 [250;432]	< 0.001
Transfusion, yes	0	3 (14%)	2 (9%)	0.191
Hemorrhage, median (IQR)	22.5 [5.00;65.0]	70.0 [33.8;100]	100 [62.5;200]	0.001
Location				0.053
bulb	1 (5%)	4 (18%)	2 (9%)
descending part	16 (73%)	9 (41%)	7 (32%)
horizontal part	0	4 (18%)	4 (18%)
ascending part	0	2 (9%)	3 (14%)
ampulla	5 (23%)	3 (14%)	6 (27%)
Pathological type				0.051
benign	10 (46%)	2 (9%)	7 (32%)
borderline	11 (50%)	19 (86%)	13 (59%)
malignant	1 (5%)	1 (5%)	2 (9%)
Size, median (IQR)	2.00 [1.12;2.45]	2.30 [1.50;3.88]	2.30 [1.57;2.92]	0.193
Complete resection, yes	20 (90%)	22 (100%)	21 (96%)	0.767
Intra-abdominal Hemorrhage, yes	1 (5%)	4 (18%)	4 (18%)	0.366
Duodenal fistula, yes	1 (5%)	0	0	>0.99
Pancreatic fistula, yes	0	4 (18%)	1 (5%)	0.117
Biliary fistula, yes	0	2 (9%)	4 (18%)	0.152
Pulmonary embolism, yes	0	0	1 (5%)	>0.99
Pulmonary infection, yes	3 (14%)	5 (23%)	6 (27%)	0.649
Wound infection, yes	4 (18%)	3 (14%)	3 (14%)	>0.99
Localized infection, yes	1 (5%)	5 (23%)	2 (9%)	0.251
Intra-abdominal abscess, yes	0	1 (5%)	4 (18%)	0.117
Intestinal obstruction, yes	0	4 (18%)	6 (27%)	0.028
Pulmonary atelectasis, yes	7 (32%)	6 (27%)	7 (32%)	0.931
Vomiting, yes	8 (36%)	5 (23%)	10 (46%)	0.281
Clavien-Dindo classification				0.005
I	16 (73%)	5 (23%)	5 (23%)
II	5 (23%)	10 (46%)	9 (41%)
IIIa	0	5 (23%)	4 (18%)
IIIb	1 (5%)	2 (9%)	2 (9%)
IVb	0	0	2 (9%)
Major adverse events, yes	1 (5%)	7 (32%)	8 (36%)	0.029
Serious adverse events, yes	7 (32%)	2 (9%)	4 (18%)	0.197
Comprehensive complication index, median (IQR)	8.66 [8.66;19.4]	22.6 [20.9;29.6]	28.6 [21.3;34.4]	< 0.001
Length of stay in hospital, median (IQR)	16.0 [14.2;20.8]	16.0 [14.2;20.8]	27.0 [22.2;32.5]	< 0.001
Postoperative stay, median (IQR)	9.00 [7.25;11.0]	11.5 [10.2;17.0]	16.5 [12.0;20.8]	< 0.001

DT Duodenal tumors, A-MDT Multidisciplinary team at Center A, A-SDT Single-discipline treatment at Center A, B-SDT Single-discipline treatment at Center B, SD Standard deviation, BMI Body mass index, IQR Interquartile range

The LR rate for duodenal tumor under MDT

In this study, approximately 43% of patients receiving LR participated in MDT. The LR rate were analyzed in A-MDT, A-SDT, and B-SDT, and subgroup analysis was conducted based on tumor location and pathological characteristics. Results showed a statistical difference in SP among the three groups (P = 0.027). Specifically, the A-MDT had a LR rate of 91%, significantly higher than the A-SDT (68%) and B-SDT (55%) in Table 1.

The choice of SP may be closely related to location. For tumors located in the descending part (excluding the ampulla), surgical management differed significantly among the groups (P = 0.003), with all patients in the MDT group undergoing LR, which accounted for 64% (16/25) of all LR procedures. In contrast, the LR rate for A-SDT and B-SDT were 24% and 12%, respectively. Among patients with ampullary tumors, surgical procedure differed. No patients in the A-SDT or B-SDT groups underwent LR, whereas 2 of the 5 patients in the A-MDT group did. There was no statistical difference for tumors located in the bulb, horizontal, or ascending parts (P > 0.99), with nearly all of these tumors (95%) undergoing LR. Detailed data are shown in Supplementary Table 3.

There may be also a close association between pathology and SP. For benign tumors, there was a significant difference among the three groups (P = 0.003). All patients in the MDT group underwent LR, accounting for 77% (10/13) of all patients who received LR. In comparison, only 8% and 15% of patients in A-SDT and B-SDT underwent LR. For borderline tumors, there were no significant differences (P > 0.99). Similarly, there were no significant differences for malignant tumors (P = 0.50). Detailed data are shown in Supplementary Table 3.

The impact of MDT on the selection of SP

Univariate logistic regression was conducted on variables potentially affecting the choice of SP. The analysis revealed statistical differences in tumor size and group. Subsequently, these two variables were included in multivariate logistic regression. The results indicated that SDT is an independent risk factor in the selection of LR, P = 0.047, OR = 0.2, 95%CI (0.03–0.83), shown in Table 2.

Table 2.

Univariate and multivariate logistic regression analysis to evaluate the impact of MDT on surgical procedure

Characteristic	Univariate logistic regression		Multivariate logistic regression
	OR (95%CI)	P	OR (95%CI)	P
Age	0.96 (0.90–1.01)	0.14	not selected
Sex	1.79 (0.61–5.56)	0.30	not selected
Smoking	1.01 (0.20–7.54)	0.99	not selected
Drinking	0.63 (0.14–3.38)	0.56	not selected
History of abdominal Surgery	0.76 (0.22–2.78)	0.66	not selected
Cardiovascular disease	0.59 (0.19–1.89)	0.36	not selected
Cerebrovascular disease	0.58 (0.09–4.69)	0.57	not selected
Diabetes	1.23 (0.15–25.72)	0.86	not selected
Other diseases	1.76 (0.53–6.97)	0.38	not selected
Location	1 (NA)	0.99	not selected
Pathological type	1.52 (0.44–1.48)	0.49	not selected
BMI	0.89 (0.75–1.05)	0.18	not selected
Group
MDT	Reference		Reference
SDT	0.15 (0.02–0.64)	0.02	0.20 (0.03–0.83)	0.047
Size	0.64 (0.40–0.95)	0.04	0.70 (0.43–1.05)	0.11

MDT Multidisciplinary team, OR Odds ratio, CI Confidence interval, BMI Body mass index, SDT Single-discipline treatment

Perioperative complications in duodenal tumor patients under MDT

We compared the impact of the three surgical approaches on postoperative complications. Significant differences were observed in key perioperative outcomes—including duration of surgery, hemorrhage, intra-abdominal hemorrhage, pancreatic fistula, vomiting, Clavien-Dindo classification, major adverse events, comprehensive complication index, and postoperative length of stay—among patients undergoing pancreaticoduodenectomy, surgical local resection, and endoscopic resection (all P < 0.05) (Supplementary Table 4). Notably, the endoscopic resection group exhibited the lowest complication rate and fastest recovery.

Having established these differences, we next compared outcomes across treatment pathways (A-MDT, A-SDT, B-SDT) with all cases included. There was a significant difference in duration of surgery A-MDT was 180 min (IQR, 129 to 208), compared to 225 min (IQR, 165 to 300) in A-SDT and 306 min (IQR, 250 to 432) in B-SDT, P < 0.001. The incidence of bowel obstruction was significantly different among the groups (P = 0.028), with A-MDT having no cases, compared to 18% in A-SDT and 27% in B-SDT. There were also significant differences in major adverse events (P = 0.029), though there were no significant differences in severe adverse events. In terms of Clavien-Dindo classification and comprehensive complication index, and with P = 0.005 and P < 0.001 respectively. The A-MDT predominantly exhibited Clavien-Dindo classification-Ⅰ (73%), whereas A-SDT and B-SDT primarily showed Clavien-Dindo classification-Ⅱ (46%) and (41%), respectively. The comprehensive complication index of A-MDT was 8.66 (IQR, 8.66 to 19.4), lower than 22.6 (IQR, 20.9 to 29.6) for A-SDT and 28.6 (IQR, 21.3 to 34.4) for B-SDT. There were statistical differences in both length of hospital stay and length of postoperative hospitalization (P < 0.001). A-MDT had 16 (IQR, 14 to 21) days in length of hospital stay and 9 (IQR, 7 to 11) days in length of postoperative hospitalization. Detailed data are shown in Table 1.

To avoid confounding by minimally invasive endoscopic resection, a sensitivity analysis compared pathways after excluding these cases. Results showed that the A-MDT group still had shorter duration of surgery, lower comprehensive complication index, and shorter postoperative length of stay than both SDT groups (Supplementary Table 5). To assess the overall effectiveness of the MDT management pathway, an intention‑to‑treat analysis was conducted (Supplementary Table 6). The intention‑to‑treat analysis demonstrated that A-MDT maintained its superiority over both SDT groups across all key perioperative outcomes, including duration of surgery, hemorrhage, Clavien-Dindo classification, major adverse events, comprehensive complication index, and postoperative length of stay (all P < 0.05).

The impact of MDT on comprehensive complication index

The A-MDT had an average comprehensive complication index of 13.3. This value was used as a threshold to categorize comprehensive complication index into a binary variable for analysis. Univariate logistic regression was performed on variables potentially affecting comprehensive complication index, revealing statistical differences in SP and Group. These variables were then included in multivariate logistic regression. The results indicated that MDT and LR were independent predictive factors for comprehensive complication index, with MDT having a P-value of 0.008, an OR of 5.13 (95% CI: 1.59–18.61), and LR having a P-value of 0.018, an OR of 0.08 (95% CI: 0.004–0.45), as shown in Table 3.

Table 3.

Univariate and multivariate logistic regression analysis to evaluate the impact of MDT on comprehensive complication index

Characteristic	Univariate logistic regression		Multivariate logistic regression
	OR (95%CI)	P	OR (95%CI)	P
Age	1.01 (0.96–1.07)	0.67	not selected
Sex	0.94 (0.34–2.55)	0.90	not selected
Smoking	4.11 (0.65–80.33)	0.20	not selected
Drinking	4.94 (0.80-65.52)	0.15	not selected
History of abdominal surgery	1.93 (0.57–7.70)	0.31	not selected
Cardiovascular disease	0.78 (0.26–2.36)	0.65	not selected
Cerebrovascular disease	NA (NA)	0.99	not selected
Diabetes	1.89 (0.23–39.51)	0.59	not selected
Other diseases	0.57 (0.19–1.71)	0.31	not selected
Location	1.51 (0.29–8.73)	0.62	not selected
Pathological type	2.07 (0.69–6.35)	0.19	not selected
BMI	1 (0.85–1.17)	0.95	not selected
Hemorrhage	1.00 (0.9996-1.01)	0.24	not selected
Transfusion	NA (NA)	0.99	not selected
Duration of surgery	1 (1-1.01)	0.06	not selected
Group
MDT	Reference		Reference
SDT	7.29 (2.42–24.16)	< 0.001	5.13 (1.59–18.61)	0.008
Surgical procedure
Pancreaticoduodenectomy	Reference		Reference
Local resection	0.05 (0.003–0.29)	0.006	0.08 (0.004–0.45)	0.018
Size	1.30 (0.88–2.07)	0.22	not selected

MDT Multidisciplinary team, OR Odds ratio, CI Confidence interval, BMI Body mass index, SDT Single-discipline treatment

Components of precision assessment of MDT

Further analysis indicated that all patients in A-MDT underwent Lt-MRI, whereas this examination was not performed in A-SDT and B-SDT. In A-MDT, all endoscopic procedures were conducted with the surgeon involving, either by direct operation or under observation. Endoscopic local resection biopsy accounted for 43% of all biopsies in A-MDT, with an accuracy of 100% (Table 4). Additionally, 8 patients in the A-MDT underwent endoscopic resection, with a 36% rate of all surgery (Supplementary Table 1). EUS and CT scans were essential in diagnosing DT and were widely used across all three groups, so no differential analysis was performed.

Table 4.

Underlying influencing factors in MDT

Underlying Influencing Factors		A-MDT N = 22	A-SDT N = 22	B-SDT N = 22
Lt-MRI		22	0	0
Endoscopic Procedures Involving the Surgeon	The Surgeon Himself	9	0	0
	Participation of Surgeons in Observation	13	0	0
Endoscopic Local Resection Biopsy		6	0	0

A-MDT Multidisciplinary team at Center A, A-SDT Single-discipline treatment at Center A, B-SDT Single-discipline treatment at Center B, Lt-MRI Low tension magnetic resonance imaging

Survival analysis

The median follow-up was 22.2 months (IQR, 11.5 to 32.4 months), with a mean follow-up of 24.2 months. This study employed a Cox proportional hazards model stratified by pathological type to adjust for the potential confounding effects of differences in the composition of benign and malignant lesions on intergroup survival comparisons. The analysis results showed no statistically significant differences in overall survival risk among the three groups (A-SDT vs. A-MDT: HR = 0.61, 95% CI 0.04–8.47, P = 0.711; B-SDT vs. A-MDT: HR = 0.44, 95% CI 0.04–5.28, P = 0.517). The Kaplan–Meier survival curves are shown in Fig. 1. The 1‑, 2‑, and 3‑year survival rates remained consistently high and comparable across the three groups (A‑MDT group: 100%, 92%, 92%; A‑SDT group: 96%, 96%, 96%; B‑SDT group: 95%, 95%, 95%), indicating an overall favorable prognosis for the cohort. In summary, within this low-risk cohort of duodenal tumor patients, the multidisciplinary treatment model did not significantly improve nor worsen postoperative survival outcomes.

Fig. 1.

Survival analysis. Survival analysis using the Kaplan-Meier method revealed no statistical difference in overall survival among the three groups

Discussion

In the past, pancreaticoduodenectomy was the primary SP for many patients. With advancements in medical technology, LR has emerged as an effective alternative to pancreaticoduodenectomy for benign and low-grade malignant DT, achieving comparable therapeutic outcomes with reduced invasiveness and faster postoperative recovery. Numerous studies indicated no significant difference in overall survival between patients undergoing pancreaticoduodenectomy or LR for benign or low-grade malignant DT [24, 25]. However, notable differences exist in postoperative complication rates and mortality, a viewpoint supported by related meta-analyses [15], the LR rate remains low. Although MDT is an effective approach for refractory tumors, such as esophageal cancer, etc [17, 26], it is rarely applied to DT. This study reveals the impact of MDT on SP and postoperative complications for DT.

The comprehensive complication index is frequently used to evaluate short-term postoperative prognosis [26] and is a primary outcome in this study. The findings suggest that both LR and MDT are linked to a reduced comprehensive complication index following surgery.

Our research indicates that MDT is an independent predictive factor for LR and can improve LR rate. Subgroup analysis based on tumor location revealed that MDT significantly enhanced LR rate for tumors in the descending and ampullary parts, whereas the effect was not significant in bulb, horizontal, and ascending parts. This may be because the complex local anatomy of the descending and ampullary parts benefits from more precise preoperative assessments provided by MDT.

Additionally, subgroup analysis based on pathology showed that MDT increased LR rate for benign DT, with more patients undergoing LR. MDT did not significantly impact outcomes for borderline or malignant tumors, likely due to the higher invasiveness and complexity of these tumors, particularly in the descending and ampullary parts, leading surgeons to prefer pancreaticoduodenectomy. This observation is consistent with Liu et al.‘s research [5]. However, the LR rate of borderline or malignant tumors remained higher in A-MDT than in the other two groups.

In this study, there were no significant differences in the years of experience or professional titles among the surgeons. However, the surgeons in the MDT group routinely possessed and were proficient in endoscopic techniques, enabling them to consider endoscopic resection as a feasible and routine option within a comprehensive treatment decision-making framework, whereas surgeons in the SDT groups lacked training in such advanced techniques.

MDT contributes to improved LR rate potentially due to factors such as the use of Lt-MRI, endoscopic local resection biopsy, and endoscopic procedure involving the surgeon. Lt-MRI enhances diagnostic accuracy for biliopancreatic diseases, clearly visualizing the relationship of the lesion to surrounding tissues and organs. Pre-examination hydration and muscle injection of scopolamine reduce gastrointestinal motility, minimizing diagnostic interference. In A-MDT, all duodenal tumor patients underwent Lt-MRI.

Endoscopic techniques play a crucial role in increasing LR rate. Recent studies focused on the treatment of superficial duodenal epithelial tumors [27, 28], particularly those smaller than 20 mm [29, 30]. European neuroendocrine tumor society recommend endoscopic resection for non-ampullary D-NETs ≤ 10 mm [31]. Endoscopic methods continue to evolve, and our study found that A-MDT had a 36.36% rate of endoscopic resection, whereas A-SDT and B-SDT had no patients undergoing endoscopic treatment. The involvement of the surgeon in endoscopic evaluation can offer more precise tumor assessment, thereby assisting the surgeon in formulating a more optimal surgical plan, expand the range of SP, such as employing combined endoscopic techniques for tumor resection, which can enhance both the effectiveness and safety of the treatment.

In A-MDT, a non-ampullary D-NETs with a 19 mm diameter, infiltrating the mucosal muscular layer but without evidence of surrounding organ invasion, lymph node metastasis, or distant metastasis, underwent endoscopic resection after MDT discussion. The patient remained recurrence-free and without lymph node metastasis during three years of follow-up. The complete resection rate of A-MDT was slightly lower than the other two groups, likely due to the inclusion of endoscopic resection cases requiring additional surgery if initial resection was incomplete.

Considering the variability in surgical techniques, after excluding 8 patients from A-MDT who received endoscopic resection and one who underwent combined endoscopic-surgical treatments, a further analysis of LR rate was performed. Although there were no statistical differences among the three groups, the LR rate in A-MDT (84.6%) remained higher than that in A-SDT and B-SDT.

Endoscopic resection not only serves as a therapeutic method but also as a biopsy technique, significantly improving biopsy accuracy by obtaining larger tissue samples and avoiding issues related to mucosal exposure to digestive fluids. Results from endoscopic resection can guide further treatment decisions. In A-MDT, one patient with preoperative biopsy suggesting an adenoma was found to have D-NETs during intraoperative frozen section, with subsequent Ga⁶⁸-PET-CT revealing abdominal aortic lymph node metastasis, leading to additional pancreaticoduodenectomy. Combining surgical expertise with endoscopic techniques effectively improves LR rate for DT.

Pancreaticoduodenectomy is no longer the sole SP for malignant DT, as some non-invasive (carcinoma in situ) and intramucosal invasive lesions can be treated with LR due to their negligible or absent risk of lymph node metastasis [29, 32, 33]. The choice of SP should not solely depend on increasing tumor diameter. LR can be selected if technical conditions are met and no surrounding organ invasion, lymph node metastasis, or distant metastasis is detected. Further analysis of clinical data from three groups revealed cases with similar tumor location, pathology, and size where patients in A-SDT and B-SDT underwent pancreaticoduodenectomy, while those in A-MDT received LR. For example, a 15 mm mucosal ampullary carcinoma underwent LR, with no recurrence or metastasis observed during follow-up. Another case, a 13 mm ampullary adenoma in the A-MDT, had an excellent long-term survival after LR. Similarly, a 75 mm descending duodenal stromal tumor treated with LR had good long-term survival. MDT evaluation led to the selection of LR in cases initially considered for pancreaticoduodenectomy, resulting in favorable outcomes.

This study demonstrates that the success of an MDT is driven by continuous cross‑disciplinary engagement and learning, beyond mere structural implementation. As therapeutic landscapes shift, active mutual understanding among surgeons, endoscopists, and other specialists regarding all available options is critical. Only through such collaboration can the MDT’s collective expertise be effectively translated into truly personalized and optimal care.

There are some limitations in this study. Firstly, the retrospective design may introduce selection bias, potentially affecting the objectivity and comprehensiveness of the results. Secondly, the relatively short follow-up period might impact the assessment of long-term tumor prognosis. Thirdly, this study is not applicable to highly invasive duodenal tumors. Lastly, the small sample size may influence the results of statistical analyses.

In conclusion, MDT enhances the LR rate of DT, reducing the incidence and severity of complications, accelerating recovery, and not affecting long-term prognosis. This study suggests that Lt-MRI, endoscopic procedures involving surgeon, and endoscopic local resection biopsy may play significant roles in improving LR rate.

Abbreviations

LR

Local resection

DT

Duodenal tumors

MDT

Multidisciplinary team

SP

Surgical procedure

A-MDT

Multidisciplinary team at center A

A-SDT

Single-discipline treatment at center A

B-SDT

Single-discipline treatment at center B

Lt-MRI

Low-tension magnetic resonance imaging

D-NETs

Duodenal neuroendocrine tumors

EUS

Endoscopic ultrasound

CT

Computed tomography

MRI

Magnetic resonance imaging

PET

Positron emission spectroscopy

BMI

Body mass index

IQR

Interquartile range

Authors’ contributions

Z.X.J, K.W, K.L and Y.K.Z contributed equally to this work. Z.X.J, K.W, K.L and Y.K.Z contributed to the study design and literature search. Z.X.J, Y.K.Z, S.H.D, Y.H.C, J.N.G, L.Q, D.L.C, F.L.Z, N.H, J.W.D, H.W.C.W and W.T.C collected and analyzed the data. Z.X.J, F.W.M, J.W, M.C, Y.F.X and G.X.W contributed to the literature search and the writing of the manuscript. K.W, J.L.W, K.X.T, X.F.L and K.L.C contributed to the assessment of literature quality, review and revise of the manuscript. X.F.L and K.L.C are the correspondent authors. All authors read and approved the final manuscript.

Funding

This study was supported by the National Natural Science Foundation of China [grant numbers 82170678] and 2021 Clinical Research Fund of Union Hospital, Wuhan [grant numbers F016.02004.22001.015], and Cross-disciplinary Research Support Program at Huazhong University of Science and Technology [grant numbers 2023JCYJ022].

Data availability

The data sets generated and/or analyzed during this study are not publicly available, but are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was provided by the Ethical Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China on 2 March 2024 (0040 − 01), and consent from all participants was documented.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.