Pancreas-preserving Duodenectomy Research Articles

Pancreas preserving duodenectomy (PPrD)

BackgroundPancreaticoduodenectomy has been the standard of care for managing duodenal neoplasms, but recent studies show similar overall and disease-specific survival after pancreas-preserving duodenectomy (PPrD) with potentially less morbidity. MethodsRetrospective cohort of all adult (age >18) patients who underwent PPrD with curative intent of a neoplasm in or invading into the duodenum at our institution from 2011 to 2022 (n ​= ​29), excluding tumors involving the Ampulla of Vater or the pancreas. Statistical analyses were performed using STATA. ResultsR0 resection was achieved in 93 ​% patients. Ten (34.4 ​%) experienced postoperative complications (13.7 ​% within Clavien-Dindo III-V). PPrD patients had lower rates of pancreatic leak, delayed gastric emptying, and deep surgical site infection. ConclusionsIn this case series, we demonstrate PPrD is safe and effective, with a high rate of complete resection and lower complication rate than that seen in pancreaticoduodenectomy.

Indocyanine green-fluorescent imaging for a detection of accessory pancreatic duct in pancreas-preserving duodenectomy.

Pancreas-preserving duodenectomy is indicated for select patients with a duodenal tumor in the second portion. In this procedure, identification and closure of the accessory pancreatic duct is important to prevent postoperative pancreatic fistula. A 63-y-old man was diagnosed with duodenal mucosal carcinoma in the second portion, with invasion of the major ampullary. We performed pancreas-preserving duodenectomy. Intraoperatively, indocyanine green-fluorescent imaging identified the accessory pancreatic duct clearly and it was successfully closed. Postoperative pancreatic fistula did not occur. Indocyanine green-fluorescent imaging is effective in identifying the accessory pancreatic duct in pancreas-preserving duodenectomy.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement

BackgroundThere are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy. MethodsPatients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy. ResultsWe included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35). ConclusionsPancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

Pancreas preserving duodenectomy for duodenal polyposis in familial adenomatous polyposis

Duodenal polyposis is common in familial adenomatous polyposis with a significant associated lifetime risk of cancer. Screening and regular surveillance is recommended, guided by the Spigelman stage. Pancreas preserving duodenectomy (PPD) is the preferred operation in patients needing removal of the whole duodenum. This presentation demonstrates the technique of PPD with particular emphasis on the resection and ampullary reconstruction. Initial early feeding tube placement through the cystic duct stump into the duodenum enables identification of the papilla and pancreatic duct as well as subsequent dissection. Separate trans-anastomotic pancreatic and biliary stents facilitate creation and patency of the pancreato-biliary anastomosis. The operation has similar outcomes compared to pancreaticoduodenectomy, however, the anatomical reconstruction allows for postoperative surveillance.

Pancreas-preserving duodenectomy as a treatment of choice for the isolated form of the cystic dystrophy of the duodenal wall (pure form of groove pancreatitis)

Pancreas-preserving duodenectomy as a treatment of choice for the isolated form of the cystic dystrophy of the duodenal wall (pure form of groove pancreatitis)

Tu2049 – Pancreas-Preserving Duodenectomy Approach to Treatment of Isolated Form of the Cystic Dystrophy of the Duodenal Wall (Pure Form of Groove Pancreatitis)

Tu2049 – Pancreas-Preserving Duodenectomy Approach to Treatment of Isolated Form of the Cystic Dystrophy of the Duodenal Wall (Pure Form of Groove Pancreatitis)

Postoperative outcome and quality of life after surgery for FAP-associated duodenal adenomatosis.

Prophylactic colon surgery has increased life expectancy of familial adenomatous polyposis patients. Extracolonic manifestations are life limiting, above all duodenal adenomas. Severe duodenal adenomatosis or cancer may necessitate pancreas-preserving total duodenectomy or partial pancreatico-duodenectomy, mostly after previous proctocolectomy and often after limited local resections of duodenal adenomas. Scarce information on long-term postoperative outcome and quality of life after surgery for duodenal adenomatosis is available. Aim of the present study was to analyze perioperative and long-term outcome after PD and PPTD for FAP-associated duodenal adenomatosis, including QoL and recurrence of adenomas in the neoduodenum after PPTD. Thirty-eight patients, 27 after pancreas-preserving duodenectomy and 11 after partial pancreaticoduodenectomy, were included. Pancreas-preserving total duodenectomy was associated with shorter operation time and less blood loss than partial pancreatico-duodenectomy. Clinically relevant pancreatic fistula occurred in 31.5%. In-hospital mortality was 5.3%. Long-term follow-up revealed recurrent pancreatitis after pancreas-preserving total duodenectomy in 22% of patients, two (7.4%) required re-operation. Recurrent adenomatosis was detected in 26% of patients. Quality of life was comparable to the German normal population after both surgical procedures. Patients with postoperative complications showed worse results than those without complications. Disease-specific 10-year survival rate with respect to duodenal adenomatosis was 100%. Surgery for FAP-associated duodenal adenomatosis and cancer can be carried out with reasonable morbidity rates despite previous proctocolectomy. Long-term outcome, quality of life, and survival rates are favorable.

Non-Whipple Operations in the Management of Benign, Premalignant and Early Cancerous Duodenal Lesions.

We reviewed our 20-year experience with non-Whipple operations (pancreas-preserving duodenectomy and transduodenal ampullectomy) for the treatment of benign, premalignant or early-stage malignant duodenal lesions. Twenty-four patients who underwent non-Whipple operations between January 1996 and December 2015 were identified from an institutional database and retrospectively analyzed. Between 1996 and 2015, 10 patients underwent pancreas-preserving duodenectomy and 14 patients underwent transduodenal ampullectomy. The mean follow-up was 25.8 months (range=6-54 months) and no patient was lost to follow-up. Eighteen patients had preoperative diagnosis of duodenal adenomatosis, three patients had preoperative diagnosis of duodenal adenocarcinoma, one had a bleeding polyp and two had localized inflammation. Average operative time was 145 min (range=127-168 min) for transduodenal ampullectomy and 183 min (range=173-200 min) for pancreas-preserving duodenectomy (p<0.05). The estimated blood loss for transduodenal ampullectomy was 85 vs. 125 ml for pancreas-preserving duodenectomy (p<0.05). Early postoperative complications were noted in 13 cases (54.17%). There were no postoperative (90-day) deaths observed in this series and there were no recurrences during follow-up for the patients operated on with neoplastic lesions. For carefully selected patients, transduodenal ampullectomy and pancreas-preserving duodenectomy may be used in place of the Whipple operation for benign and occasionally early-stage malignant (Tis and T1) duodenal and ampullary disease.

Pancreas-preserving partial duodenectomy of the distal region for large duodenal adenoma: report of a case

For neoplasms in the third and fourth parts of the duodenum, a duodenectomy that preserves the pancreas may provide feasible tumor clearance while avoiding the additional dissection and pancreaticoduodenectomy. We herein describe the case of a 40-year-old male patient with an adenoma in the third part of the duodenum. The patient underwent a partial duodenectomy of the distal region, preserving the pancreas and Vater's papilla. The residual duodenum and jejunum were successfully reconstructed by an end-to-side anastomosis. We also present a review of the English literature regarding pancreas-preserving partial duodenectomy of the distal region.

Pancreas-preserving segmental duodenectomy for gastrointestinal stromal tumor of the duodenum and splenectomy for splenic angiosarcoma

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract and occur rarely in the duodenum. Splenic angiosarcoma is an aggressive neoplasm with an extremely poor prognosis. We report a case of a 70-year-old man hospitalized for abdominal pain in the upper quadrants, dyspepsia and nausea, previously treated for Hodgkin lymphoma 30 years ago. Abdominal CT showed a solid nodular lesion in the third portion of the duodenum, the presence of retropancreatic, aortic and caval lymph nodes, and four nodular splenic masses. (111)In-octreotide scintigraphy revealed pathological tissue accumulation in the duodenal region, and in the retropancreatic, retroduodenal, aortic and caval lymph nodes, suggesting a nonfunctioning neuroendocrine peripancreatic tumor. At exploratory laparotomy, an exophytic soft tumor was found originating from the third portion of the duodenum. Pancreas-preserving duodenectomy with duodenojejunostomy, splenectomy and lymphnodectomy of retropancreatic aortic and caval lymph nodes were performed. Pathological evaluation and immunohistochemical studies showed the presence of a duodenal gastrointestinal stromal tumor with low mitotic activity and a well-differentiated angiosarcoma localized to the spleen and invading lymph nodes. We speculated that the angiosarcoma and duodenal gastrointestinal stromal tumors of this patient were due to the treatment of Hodgkin lymphoma with radiotherapy 30 years ago. Pancreas-preserving segmental duodenectomy can be used to treat non-malignant neoplasms of the duodenum and avoid extensive surgery. Splenectomy is the treatment of choice for localized angiosarcomas but a strict follow-up is mandatory because of the possibility of recurrence.

Robot-Assisted Subtotal Pancreas-Preserving Duodenectomy

Angiodysplasia of the duodenum is a rare disorder, often requiring surgical resection. Technical difficulties have made the use of the minimally invasive approach uncommon. Herein, we present a subtotal pancreas-preserving duodenectomy using robotic assistance. The patient is a 60-y-old female with a long medical history including chronic gastrointestinal bleeding due to angiodysplasia with intermittent melena, and requiring multiples blood transfusions. A capsule endoscopy and double-balloon upper endoscopy showed angiectasis, which appeared to be limited to the third and fourth portion of the duodenum and the proximal loops of the jejunum. Despite multiple endoscopic cauterizations, the patient continued to require blood transfusion for several years. The patient underwent a robot-assisted subtotal pancreas-preserving duodenectomy. The operation lasted 420 min with minimal blood loss. The postoperative course was uneventful. The pathology report showed multiple small bowel mucosal and submucosal distorted and dilated vasculature, consistent with angiodysplasia. At 2-mo follow-up, the patient was totally asymptomatic. A barium swallow study showed contrast passed antegrade through the duodenojejunostomy with no evidence of obstruction, stricture, or leakage. The use of robotic assistance to perform a subtotal pancreas-preserving duodenectomy for the treatment of benign duodenal disease, such as angiodysplasia, is feasible and safe. The technical advantages include a high degree of freedom offered by the robotic instruments, as well as enhanced visualization, which allows for precise microdissection and microsuture, thereby preserving the benefits of minimally invasive surgery. The use of robotic technology allows for a wider range of indications for minimally invasive surgery.

Management of duodenal adenomatosis in FAP: single centre experience

Duodenal and ampullary carcinoma in familial adenomatosis (FAP) is the third leading cause of FAP related deaths. Management of this condition is a challenging. The aim of this study was to evaluate the role of multiple targeted endoscopic biopsies and macroscopic appearance as the major determinants for surgical intervention. A secondary aim was to assess histological heterogeneity through comparing endoscopic biopsies and describe the clinical outcomes of our cohort after intervention. We reviewed our FAP surveillance database of 67 patients, between January 1999--June 2011 undergoing upper GI surveillance and where indicated, subsequent surgical intervention. Among 67 patients, 11 underwent surgical resection. Pancreas-preserving duodenectomy was performed in four patients (five procedures), and Whipple's operation in seven patients. The average size of polyps was 43 mm (range 17-65 mm), and the average number of targeted endoscopic biopsies per lesion was 7.5 (range 5-10). Two cases of high-grade (severe) dysplasia were diagnosed on endoscopic biopsies each understaged compared with the subsequent surgical specimen. All carcinomas identified have been resectable with no evidence of local spread or distant metastasis. There was one postoperative death, but no cancer related deaths. We identified both cancers at an early stage and there were no missed or late diagnoses. There have been no recurrences of carcinoma in a more than 7 years follow-up. Due to the heterogeneous nature of these lesions, comprehensive macroscopic assessment should be complemented with multiple targeted biopsies to improve the chance of early detection of advanced lesions.

Morphine-induced acute lung injury

A 38-year-old woman who had familial adenomatous polyposis was admitted to the intensive care unit with an episode of severe sepsis 5 days after undergoing a pancreas-preserving duodenectomy. Laparotomy with removal of an intra-abdominal abscess, followed by closed postoperative continuous lavage for 10 days, was performed. During two courses of planned tracheal extubation, the patient developed an acute lung injury, making a reintubation necessary. In both events, the patient received small doses of continuous morphine before the extubation. Morphine may induce the development of an acute lung injury in patients, whereas the exact pathophysiologic and pharmacologic mechanisms remain unclear.

Die Technik der pankreaserhaltenden Duodenektomie

Even in pancreatic surgery, as in other organs, there is a tendency towards subtle organ-preserving techniques. Benign duodenal tumors which cannot be resected transduodenally or multiple dysplastic duodenal adenomas in patients with familial adenomatous polyposis (FAP) usually require partial pancreaticoduodenectomy. However, pancreas-preserving duodenectomy may represent a viable alternative. This technique allows for the resection of the entire duodenum without resection of the pancreatic head. Large duodenal adenomas, multiple adenomas with dysplasia in patients with FAP, and based on the literature extended duodenal injury after trauma may represent indications for this surgical technique. Compared with duodenopancreatectomy, this intervention can be performed with a comparably low morbidity and leads to good functional results. Beside the preservation of pancreatic parenchyma and the reduction of the number of anastomoses, this technique offers the advantage of uncomplicated endoscopic follow-up. In this article we describe the surgical technique of pancreas-preserving duodenectomy and our experience with this intervention.

PANCREATIC HETEROTOPIA AND CYSTIC DYSTROPHY OF DUODENUM, AN UNCOMMON PATHOLOGY AND THE ROLE OF ENDOSCOPIC ULTRASOUND IN THE DIAGNOSIS

Pancreatic heterotopy, a rare entity, is defined as pancreatic tissue lying outside its normal location without anatomical or vascular connections with the pancreas proper. Cystic dystrophy is an uncommon and serious complication of heterotopic pancreas, usually in younger men. The mechanism by which cystic dystrophy develops is poorly understood. It is difficult to diagnose, as lesions deeper in the submucosa or the muscularis propria, are difficult to biopsy. We present an interesting and rare case of pancreatic heterotopia with cystic dystrophy of the duodenal wall, where endoscopic ultrasound clearly shows cystic changes in deeper layers of duodenum, later confirmed by surgery. Case: A 54-yr-old white male presented to the hospital after several bouts of abdominal pain. Prior to presentation, he experienced several episodes of nausea and vomiting. He also had lost approximately 15 lb over the past two months. Past history was significant for non-hodgkins lymphoma, which had been in remission for 6 years. During endoscopy, a sessile mucosal lesion with mass effect was visualized in the second part of the duodenum and biopsies were obtained. Pathology was negative for cancer, but did show edema and lymphangiectasia. Endoscopic ultrasound showed a 1 cm cystic lesion in the wall of duodenum at the second portion. A pancreas-preserving duodenectomy was performed. Duodenal specimens showed a cystic lesion in the wall of duodenum. The mucosa overlying the cyst showed a mix of acute and chronic inflammation of the lamiNaPropria. The cyst was located within the muscularis propria, which was hypertrophied. Focal areas showed an epithelial lining composed of columnar/cuboidal cells with basal nuclei and prominent brush border, suggestive of pancreatic ductal epithelium. Based on these findings, a diagnosis of heterotopic pancreas with cystic dystrophy of the duodenal wall was made. Discussion: Duodenal cystic dystrophy due to heterotopic pancreatic deposit is an uncommon pathology. In the past, it was extremely difficult to diagnose without surgery because there are no specific clinical signs. Our case demonstrates effective use of endoscopic ultrasound in precisely locating cysts in the duodenal wall when other imaging modalities, such as CT scan can not. We will present EUS images, histology slides and a detail discussion about heterotopic pancreatic cyst and the role of different diagnostic modalities.

Pancreas-sparing duodenectomy: technique and indications.

To assess the feasibility, safety, and short-term functional outcome of a pancreas-sparing duodenectomy. Prospective, uncontrolled study. University hospital, Sweden. Four patients with extensive lesions in the duodenum (2 familial polyposis, 1 villous adenoma, and 1 giant multiple lipoma). All 4 patients had a duodenectomy with sparing of 1-1.5 cm of the duodenal bulb and reinplantation of the biliary and pancreatic ducts into the jejunum. Except for one early postoperative bile leak the operative and postoperative courses were uneventful. The functional results have been promising with unaltered alimentary function in the 3 patients who had no preoperative outlet obstruction and complete resolution of symptoms in the patient with duodenal lipomas who had chronic incomplete obstruction preoperatively. Although the indications for pancreas-preserving duodenectomy are limited, the procedure can be done safely with gastrointestinal function maintained.

Pancreas-Preserving Duodenectomy in the Management of Duodenal Familial Adenomatous Polyposis

Most patients with familial adenomatous polyposis (FAP) develop disease in the duodenum. The duodenal lesions mostly occur in the periampullary region, but some patients develop diffuse polyposis involving all parts of the duodenum. These neoplastic polpys have malignant potential, and thus warrant surveillance and timely intervention. We reviewed our experience with management of FAP over a 10-year period, focusing on patients who had diffuse polyposis of the duodenum and their subsequent management. Three patients with FAP had diffuse duodenal involvement, documented by upper gastrointestinal endoscopy. Neoplasia was confirmed by endoscopic biopsy, but no patients had histologic evidence of carcinoma. The patients underwent resection of the entire duodenum from the pylorus to the ligament of Treitz with preservation of the pancreas. Our surgical technique is described. One patient had a postoperative wound infection and one patient had a biliary leak that resolved with closed suction drainage for 5 days. Long-term follow-up in these patients revealed excellent functional status. One patient had polyp recurrence in the jejunum at 5-year follow-up, but no patients have developed adenocarcinoma. We conclude that patients with duodenal polyps associated with FAP may be safely and effectively treated by pancreas-preserving duodenectomy. ( J G astrointest S urg 2002;6:82–87.)

Gastroduodenal lesions in familial adenomatous polyposis.

Prophylactic colectomy is generally recommended for patients with familial adenomatous polyposis (FAP) who are inevitably affected with large bowel cancer. After prophylactic colectomy has been performed, gastrointestinal malignancy is the leading cause of death. Duodenal adenomas are found in patients with FAP and the adenoma-carcinoma sequence exists in the FAP duodenum, suggesting that treatment of duodenal polyps might be beneficial. Several methods of treatment for duodenal lesions in patients with FAP have been reported, but the current treatment options are not ideal. The nonsteroid anti-inflammatory drugs, sulindac and aspirin, are used for chemoprevention, while recently developed cyclooxygenase-2 inhibitors may be of some use in the future. Endoscopic polypectomy has been attempted for duodenal polyps and open surgical polypectomy has proven to be effective for selected patients. Photodynamic therapy and Argon plasma coagulation may be suitable to treat carpeted polyposis. New methods of duodenal resection, such as pancreas-preserving duodenectomy and pylorus-preserving pancreaticoduodenectomy, might be considered for severe duodenal polyposis; however, because prophylactic duodenal surgery has been considered too aggressive, surveillance duodenoscopy is usually performed to detect duodenal cancer at an early stage.