Laparoscopic Pancreas-Preserving Resection for Adenocarcinoma of the Third Portion of the Duodenum

Abstract

Primary adenocarcinoma of the duodenum is a rare digestive malignancy. Radical surgical treatment respecting the oncological principles (complete tumor resection and free margins) usually requires pancreaticoduodenectomy. In selected cases, segmental duodenal resection has also been considered. Laparoscopic resection has been reported so far only for benign disease and in one case for malignant disease.1–3 We present the video (6′25″) of a 73-year-old patient with a large polypoid lesion of the third portion of the duodenum with a pancreas-sparing duodenectomy using a totally laparoscopic approach, accomplishing a successful radical margin-free resection (second report in the Literature for duodenal tumor involving the third portion of the duodenum). A 73-year-old obese man with chronic obstructive pulmonary disease (COPD) was admitted to our unit for severe anemia. An esophagogastroduodenoscopy (EGD) revealed the presence of a bleeding ulcer of the duodenal bulb and behind a large friable polypoid mass (3-cm diameter) with a large base, in the third portion of the duodenum, 3 cm from the papilla of Vater. Multiple endoscopic biopsies were taken (adenomatous polyp, high-grade dysplasia). A laparoscopic approach was planned with five trocars. After dissection of the Treitz ligament, which allowed for visualization of the fourth duodenum, the gastrocolic ligament was opened toward the hepatic flexure of the colon. A complete Kocher's and Cattel's maneuver allowed to reach the second and clearly visualize the third of the duodenum. An intraoperative EGD confirmed the localization of the tumor, 4 cm from the papilla of Vater. The decision of a segmental resection was taken instead of a pancreaticoduodenectomy, given the distance of the tumor from the papilla that allowed for an R0 resection, and the severe comorbidities of the patient. The first jejunal limb distal to the duodenojejunal ligament was sectioned using a 2.5-mm stapler. The peripancreatic area was carefully examined, and no enlarged lymph nodes were clearly seen. The duodenum was completely separated from the pancreas using ultrasonic shears. The distal duodenum was passed behind the mesenteric vessels and sectioned infra-ampullary between the second and third portion. A transmesocolic side-to-side duodenojejunostomy allowed the reconstruction of the alimentary tract. The enterotomy was closed with a double-layer continuous suture (2/0 polyglycolic acid). The specimen was placed in an endobag and retrieved through the umbilical port. An endoscopic pneumatic control of the anastomosis at the end of the operation confirmed the absence of leaks and the adequate distance from the ampulla. The operation lasted 210 minutes. Recovery was uneventful: the patient was allowed soft diet on postop day 7 after both methylene blue and Gastrographin tests were negative for leakages. He was discharged on the postop day 10. Final pathologic report revealed a primary duodenal adenocarcinoma (moderate differentiation) of 3 cm in diameter with an initial extension to the muscular layer, over a villous adenoma. Proximal (4 cm) and distal margins were free of tumor. There was neither microvascular nor perineural invasion; the seven lymph nodes harvested were negative for metastasis (pT2N0). Twenty-four-month endoscopic and radiologic follow-up has confirmed the good oncological results, the patient being free of disease. Drs. Valentino Fiscon, Giuseppe Portale, Giovanni Migliorini, and Flavio Frigo have no conflicts of interest or financial ties to disclose. Runtime of video: 6 mins