Pancreas-sparing Duodenectomy Research Articles

Laparoscopic pancreas-preserving near total duodenectomy for large villous adenoma in patients with total colectomy for familial adenomatous polyposis

Most familial adenomatous polyposis (FAP) patients undergo total colectomy, but duodenal polyposis develops in up to 90% of patients with FAP and a 4% to 18% risk of duodenal and ampullary cancer remains. Laparoscopic pancreas-preserving near total duodenectomy is thought to be a potential option and can be an effective approach to preserve the pancreas. A 48-year-old male patient, who underwent laparoscopic total colectomy with end ileostomy because of FAP with colorectal cancer, was diagnosed with a 20 mm-sized duodenal adenoma in the second to the third portion. The operation was performed on December 27, 2021. Near total duodenectomy was done and type II Billroth gastrojejunostomy was done. Laparoscopic pancreas-sparing duodenectomy is shown to be safe, with favorable short-term oncologic outcome compared to laparoscopic pancreatoduodenectomy in terms of less blood loss, faster recovery time, and much less total cost.

Robotic distal pancreas-sparing duodenectomy (duodenal sleeve resection) with transmesenteric approach: robotic approach for tumors in the third and fourth parts of the duodenum.

Minimally invasive resection of the retroperitoneal duodenum is complicated because of its anatomical location, and the proximity of the ampulla of Vater and vascular structures. Benign or indolent pathology can add complexity to operative decision-making for these already challenging surgeries, and operations associated with lower morbidity may be considered. This study describes a novel robotic transmesenteric approach to duodenal sleeve resection for non-malignant lesions. A retrospective review was performed on a prospectively maintained institutional database between 2011 and 2021. The Da Vinci XI or SI platform (Intuitive Surgical, Sunnyvale, CA) was used in all cases. Critical steps in robotic sleeve duodenectomy include the following: (1) techniques for avoiding damage to the ampulla; (2) Kocherization and reverse Kocherization; and (3) A transmesenteric approach for further mobilization of the duodenum. Nineteen patients were referred by experienced gastrointestinal endoscopists after endoscopic management was deemed unsuitable or their resections were incomplete. The histological diagnoses were either symptomatic benign or indolent duodenal pathology. All 19 patients underwent robotic duodenal sleeve resection during the study period. Lesions were located in the third to fourth parts of the duodenum. The median operative time was 216min (IQR: 199-225), and the estimated intraoperative blood loss was 50ml (IQR: 50.0-93.7). The 90day readmission rate was 15.7% (3/19), and no 90-day mortality was observed. This small case series of a transmesenteric approach for robotic sleeve duodenectomy demonstrates its feasibility and safety in this potentially challenging operation.

Expanded application of pancreas sparing duodenectomy: A case series

Background: A pancreas sparing duodenectomy (PSD) consists of full thickness resection of the entire duodenum including the ampulla of Vater. The proximal jejunum is advanced to reconstruct a single biliary-pancreatic orifice and re-establish gastrointestinal continuity with pyloro-jejunostomy. First described in 1995 in Cleveland, Ohio for advanced duodenal polyposis in familial adenomatous polyposis that remains the most common indication, with expanding indications such as sporadic villous adenomas and gastrointestinal stromal tumor. The aim of this case series is to present additional unique indications for PSD as a novel solution in patients with complex surgical conditions.

Pancreas-sparing duodenectomy with preservation of peripapillary part of duodenal wall: a new option of surgical treatment for duodenal tumor lesions

Currently, with duodenal tumor lesion (duodenum), the possibility of performing economical operations that significantly improve the immediate results and quality of life of patients is increasingly being considered as an alternative to gastropancreatoduodenal resection. using the example of clinical observation, the article presents a new type of economical surgical intervention – duodenectomy with preservation of the peripapillary flap. The operation was performed in a patient with cancer of the resected stomach with a low spread of the tumor along the wall of the duodenum. At the control examination 9 months after the operation, the patient’s condition is satisfactory, without signs of impaired biliodynamics and passage of food through the intestinal tube. The proposed method differs from the existing prototype (papilloservative duodenectomy) by preserving the peripapillary flap of the duodenal wall.The insertion into the jejunum of not the fater papilla, but the surrounding wall of the duodenum eliminates its deformation and violation of patency and provides greater reliability of the formed suture, and the preservation of the small duodenal papilla with an additional pancreatic duct of Santorini can help reduce the frequency of postoperative pancreatitis and pancreonecrosis. In addition to cases of low lesions of the duodenum in gastric cancer, the method can be used in patients with non-epithelial and neuroendocrine tumors, as well as in secondary tumor invasion of the duodenum from the outside. The criterion limiting the performance of this type of operation is the distance from the edge of the tumor to the fater papilla less than 2.0–2.5 cm.Duodenectomy with preservation of the peripapillary flap can be considered as a way to improve the safety and quality of life in the surgical treatment of patients with a tumor lesion of the duodenum.

Robotic parenchymal-sparing pancreatectomy and pancreas-sparing duodenectomy avoid pancreaticoduodenectomy for benign and low-grade malignant tumours.

Parenchymal-sparing pancreatectomy (PSP) or pancreas-sparing duodenectomy (PSD) is an alternative method for patients with benign or low-grade malignant tumours at the pancreatic head or duodenum. It avoids traumatic pancreaticoduodenectomy (PD) with pancreatic function preservation and improves quality of life. However, few studies have reported on robotic PSP (RPSP) or robotic PSD (RPSD). A retrospective analysis of 17 patients with benign and low-grade malignant pancreatic head and duodenal tumours who underwent RPSP or RPSD from January 2018 to February 2022 was conducted. The demographic, perioperative, and postoperative data of all patients were collected and analysed. The operations were successful for all seventeen patients without conversion, including 10 cases of RPSP and 7 cases of RPSD. For RPSP, eight patients underwent pancreatic enucleation, and two patients underwent uncinate process resection. For RPSD, five patients underwent local duodenectomy, and two patients underwent segmental duodenectomy, with five simultaneous jejunostomies and two distal gastrectomies. The median OT and EBL were 135min and 50mL for RPSP and 220min and 100mL for RPSD, respectively. The median LOS was 8days for RPSP and 19days for RPSD. The main postoperative complications for RPSP included POPF (grade B, 6 cases), DGE (grade B, 1 case), PPH (1 case), and intra-abdominal infection (1 case). The main postoperative complications for RPSD included DGE (grade B, 1 case, grade C, 3 cases), postoperative haemorrhage (1 case), intra-abdominal infection (1 case), and duodenal fistula (1 case). One patient underwent interventional drain placement after RPSP because of POPF. RPSP or RPSD is feasible for highly selected patients with benign and low-grade malignant pancreatic head and duodenal tumours, avoiding potential pancreaticoduodenectomy.

Efficacy of endoscopic retrograde cholangiopancreatography in familial adenomatous polyposis patients after duodenectomy.

ObjectivesFamilial adenomatous polyposis (FAP) patients with Spigelman stage IV polyposis should be considered for prophylactic duodenectomy. Post‐surgical pancreaticobiliary complications occur and may require management via endoscopic retrograde cholangiopancreatography (ERCP). We aimed to assess the success and adverse events of ERCP in FAP patients after pancreas‐sparing duodenectomy (PSD) and pancreaticoduodenectomy (PD).MethodsA retrospective review of FAP patients who underwent ERCP after PSD or PD from 1992 to 2020 at a quaternary referral center was completed. The technical success of ERCP was defined as the ability to identify the anastomosis and cannulate the duct. Post‐procedural adverse events were defined by bleeding, perforation, pancreatitis, or cholangitis. Clinical outcomes included the need for surgical intervention and recurrent pancreatitis after ERCP were assessed.ResultsOf 84 FAP patients with duodenectomy, 12 patients with PSD and two patients with PD underwent 17 ERCPs for pancreatic indications and five for biliary indications. The technical success of ERCP in patients with PSD and a single neoampullary complex for pancreatic (n = 6) and biliary (n = 5) indications was 100% but for those with PD (n = 2) or PSD reconstruction with pancreatic divisum or separate anastomoses (n = 3), it was 0%. Surgical intervention was required in 50% of patients with technically failed ERCP after PSD (2/4) and PD (1/2). There were no adverse events.ConclusionsERCP is expected to be therapeutically successful for biliary complications following PSD. Assessment and potential therapy for pancreatitis post‐PSD are best in the setting of a single neo‐ampullary complex rather than in PD or PSD with pancreatic divisum.

Rare resected eight cases of duodenal adenocarcinomas.

IntroductionDuodenal adenocarcinoma is a rare malignancy; recently, it has been found to be accompanied by operative indications.MethodsNine consecutive rare cases were diagnosed with duodenal carcinoma (DC), in which clinicopathological characteristics were retrospectively examined. Age was ranged over middle-aged males and females. No clinical onset with severe symptoms was observed, and the specific treatment for accompanied diseases or habits was not found.OutcomesOne case of two T1 stage DCs that underwent pancreas-sparing duodenectomy. Stage II DC was diagnosed in three cases, and stage III DC was diagnosed in four cases. Pancreaticoduodenectomy (PD) mainly occurred in seven patients, and duodenectomy was limited in two patients. All operations were safely performed, and the postoperative course showed no severe morbidity. Histological findings showed R0 resection in eight cases and R1 at the retroperitoneal dissecting part in one case. Five patients with advanced-stage DC underwent adjuvant chemotherapy; however, four patients showed tumor recurrence within 12 months. With additional strong chemotherapy, eight patients survived up to 84 months, and one died of liver metastasis at 43 months after surgery. Three representative cases of mucosal invasion with widespread pancreas-sparing duodenectomy and advanced-stage DC cases undergoing duodenectomy or PD are shown.ConclusionIn the field of upper digestive tract surgery, duodenal adenocarcinoma and various applications of surgery or adjuvant chemotherapy for long-term survival are important.

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.

Ascending Colon Cancer with Duodenal Invasion Successfully Treated with Pancreas-Sparing Duodenectomy: A Report of Two Cases

Ascending Colon Cancer with Duodenal Invasion Successfully Treated with Pancreas-Sparing Duodenectomy: A Report of Two Cases

Side-to-side duodenojejunostomy after resection of third and fourth duodenal portions with pancreatic preservation.

Infra-ampullary duodenal lesions are rare and surgical management is controversial. Reconstruction after resection is usually performed by end-to-end or end-to-side duodenojejunostomy. The goal was to analyze our experience, perioperative management, and results after side-to-side duodenojejunostomy. Therefore, we retrospectively evaluated short- and long-term results of surgical resections of third and fourth duodenal portions for several kinds of lesions and reconstruction through duodenojejunostomy performed in our facilities between January 2012 and December 2018. In total, 12 patients were selected for our study, six were male. The median age was 66.3 (IQR: 77.3-59.4). Lesion classification was as follows: 6 cases (50%) of duodenal adenocarcinoma, 4 cases (33.3%) of gastrointestinal stromal tumors (GISTs), and 2 cases (16.7%) of benign pathology. The most frequent clinical presentation was obstruction with vomiting. The surgical technique of choice was resection of third and fourth duodenal portions with a segment of proximal jejunum. Digestive continuity was restored through side-to-side duodenojejunostomy in 11 cases (91.6%). The median operation time was 182.5min (IQR 237.5-136.3min). Nine of the 12 patients (75%) did not receive intra- or postoperative blood transfusions. Six patients (50%) experienced complications during post-op. Four of them (33%) experienced major complications (Clavien-Dindo > IIIa) and three required re-op. The median follow-up was 58.3 (95% CI 15-101.5) months. Of the 11 patients with long-term follow-up, 10 have remained asymptomatic during follow-up. The average disease-free survival (DFS) was 43.1months for adenocarcinoma, and 93months for GIST. Based on the results of our series, although small, pancreas-sparing duodenectomy could be considered a feasible and safe technique with adequate oncological results. Side-to-side duodenojejunostomy appears to be a safe technique, is easy to perform, and has good functional outcomes. More studies with a larger number of patients are necessary to confirm these findings.

The Prevalence and Significance of Jejunal and Duodenal Bulb Polyposis After Duodenectomy in Familial Adenomatous Polyposis: Retrospective Cohort Study.

To evaluate the prevalence, natural history, and severity of polyposis of the duodenal bulb and jejunum after duodenectomy in patients with FAP. Advanced duodenal polyposis stage in FAP requires consideration of duodenal resection to prevent cancer; pylorus-preserving approach of pancreas-sparing duodenectomy (PSD) is preferred. Post-duodenectomy data indicate polyps occur in the duodenal bulb and the post-anastomotic jejunum, but limited data exists regarding their significance. We identified consecutive FAP patients After duodenal resection, including pancreaticoduodenectomy, PSD, or segmental duodenectomy, at Cleveland Clinic. Medical records were used to determine time to diagnosis of duodenal bulb or jejunal polyps, length of follow up, and severity of polyposis including maximal Spigelman stage (SS) of jejunal polyposis (neo-SS). 64 patients with FAP underwent duodenectomy and endoscopic follow up. 28% underwent pancreaticoduodenectomy, 61% PSD, and 11% segmental duodenectomy. Postoperatively, 38/64 (59%) were diagnosed with jejunal polyposis, with median time to diagnosis of 55 months and follow up time of 127 months. Jejunal polyposis was advanced in 21% (neo- SS III or IV). Fifty percent were treated endoscopically, 1 patient required surgery. Jejunal polyp-free survival after duodenectomy differed by surgery type (P = 0.008). A total of 55/64 patients underwent a pylorus-preserving procedure, and 6/55 (11%) developed duodenal bulb polyps. All bulb polyps were large (>20 mm) and found after PSD. Endoscopic resection was unsuccessful in 5 patients, but no surgical intervention was required. Polyposis occurs in the remaining duodenal and jejunal mucosa in the majority of patients after surgical duodenectomy. Jejunal polyposis is advanced in 1 in 5 patients, but rarely requires surgery. Endoscopic management of jejunal polyposis seems feasible but has proven difficult for duodenal bulb polyps.

1183 Surgery Type Predicts Post-Operative Jejunal Polyp Detection in Patients With Familial Adenomatous Polyposis After Surgical Duodenectomy

INTRODUCTION: In patients with familial adenomatous polyposis (FAP), advanced duodenal polyposis by Spigelman stage requires consideration of duodenal resection to prevent duodenal cancer. Pancreas-sparing duodenectomy (PSD) is preferred over pancreaticoduodenectmy (PD). Jejunal polyps occur 41 to 78% in post-duodenectomy patients, however, the differences by surgery type have not been evaluated. METHODS: We identified consecutive FAP patients following duodenal resection, including PD, PSD, or segmental duodenectomy (SD), at Cleveland Clinic, 08/1978 - 01/2018. Jejunal polyp-free survival (JPFS) time was calculated as time from surgery to detection of first lesion, or if no polyps, time to most recent endoscopy. Severity of jejunal polyposis was classified using the Spigelman score (henceforth, Neo-Spigelman). Kaplan-Meier curves were used to estimate JPFS by surgery type. Cox proportional hazards models adjusted for age, sex, race, and presence of pre-operative jejunal polyps were used. RESULTS: 64 patients were identified (Table 1). Jejunal polyposis was detected after surgery in 38/64 patients (59.4%, Table 2). Surgery type (PSD vs PD vs SD) was a significant predictor of JPFS overall (Figure 1, P = 0.008). 5-year JPFS was 49.5% (CI 32.3–64.7%) for patients after PSD, 80.7% (CI 51.1–93.4%) after PD, and 66.7% (CI 19.5–90.4%) after SD. Comparison of PSD vs PD yielded a significant difference in JPFS (P = 0.006), as did comparison of PSD vs SD (P = 0.048). PD vs SD was not significant (P = 0.12). In comparison PD, adjusted analyses showed hazard ratio (HR) of polyp detection at 4.0 (CI 1.6 – 10.0) for PSD. HR estimate was not significant for SD (HR 2.6, CI 0.6 – 11.1). Surgery type had a significant association with Neo-Spigelman score (P < 0.037), with mean score at 4.5 ± 0.5 for PD, 5.5 ± 1.4 for PSD, and 6.3 ± 0.6 for SD. No association was found between surgery type and management of jejunal polyps (surveillance vs endoscopic resection vs surgery, P = 0.09). CONCLUSION: Jejunal polyposis occurs in the majority of FAP patients after surgical duodenectomy. We demonstrate differences in polyp-free survival by surgery type, with PSD demonstrating higher risk of jejunal polyposis in comparison to PD. Surgery type was also associated with severity of polyposis, with a tendency for higher Neo-Spigelman scores after PSD. The long-term outcomes of jejunal polyps in FAP patients requires further study, and the surgical determinants of their occurrence may merit consideration.

1193 Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis (FAP): Risks, Benefits, and Changes in Management

INTRODUCTION: Nearly all patients with FAP will develop duodenal adenomas. Ampullary/duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging system. Guidelines recommend upper endoscopic surveillance with forward and side-viewing scopes to evaluate the duodenum and visualize the papilla. There is no consensus whether the papilla should be routinely biopsied or included in Spigelman staging. Some endoscopists refrain from biopsy of the papilla due to a theoretical risk of pancreatitis. No data is available to support this risk. We aim to identify the incidence of pancreatitis after biopsy of the papilla in FAP patients and the effect of biopsy on Spigelman stage. METHODS: This retrospective cohort study identified consecutive FAP patients at the Cleveland Clinic between 1/2011-12/2018. FAP patients with ≥1 endoscopy with biopsy of the duodenal papilla were included. Patients with history of foregut surgery were excluded. Medical records determined demographics, endoscopic data, and Spigelman staging with/without biopsy. Post-procedural pancreatitis was defined as 2/3 of typical symptoms, lipase 3 times upper limit of normal, or radiography consistent with pancreatitis within 7 days of esophagogastroduodenoscopy (EGD). RESULTS: 273 FAP patients (52.4% male) with 792 EGDs with biopsy of the papilla were identified (Table 1). Cumulative times that the papilla was biopsied over the study period ranged from 1-8/patient. 2 patients developed pancreatitis. Of all EGDs with ampullary biopsy, 0.34% (3/792) developed post-procedural pancreatitis. The papilla appeared normal in 546/792 exams and 1 patient developed pancreatitis with biopsy of normal papilla. This patient was admitted for 4 days with mild acute pancreatitis (BISAP 1). The papilla was abnormal in 226 exams and 2 episodes of pancreatitis occurred in the same patient. This patient had a history of chronic pancreatitis due to alcohol abuse. Hospitalization wasn’t necessary for mild acute pancreatitis (BISAP 1). Biopsy of normal papilla increased Spigelman stage in 15 patients, one upstaged from Spigelman III to IV and had a pancreas-sparing duodenectomy. CONCLUSION: Pancreatitis after biopsy of the duodenal papilla is rare, especially in patients without a history of pancreatitis. Biopsy of normal papilla in FAP changes patient management. Physicians managing FAP should understand risks/benefits of biopsy of the papilla and include it in Spigelman staging.

2147 Adenomatous Polyp of the Biliojejunal Anastomosis and Bile Duct in a Familial Adenomatous Polyposis (FAP) Patient: A Multidisciplinary Approach to a Clinical Dilemma

INTRODUCTION: Duodenal cancer is the second most common malignancy in FAP patients, and advanced polyposis often requires duodenal resection. Post-duodenectomy FAP patients are at risk of developing polyps in the post-anastomotic jejunum. We present a challenging case of a post-duodenectomy FAP patient who developed adenomatous polyp at the biliojejunal anastomosis and bile duct. CASE DESCRIPTION/METHODS: A 36 year-old female with FAP, status-post proctocolectomy, pancreas-sparing duodenectomy for Spiegelman stage IV polyposis was found to have polyposis in the jejunum on surveillance capsule endoscopy. Push-enteroscopy revealed polyposis in the jejunum with a 15 mm polyp involving the biliojejunal anastomosis (Image 1). Given that this polyp was non-lifting, it was removed with hybrid endoscopic submucosal dissection (ESD) (Image 2). After polyp removal, there was suspicion the polyp extended into the distal common bile duct (CBD) which was confirmed with biopsies revealing low-grade dysplastic adenoma. After a multidisciplinary discussion, cholangioscopy with Habib EndoHPB radiofrequency ablation (RFA) (Boston Scientific, Marlborough, MA, USA) was planned (Image 3). The adenomatous tissue extended from the distal CBD to the proximal common hepatic duct (CHD) which was confirmed by biopsies. Biliary RFA treatment was inadequate evidenced by poor tissue response noted on cholangioscopy and repeat positive biopsies. We theorized that this was due to poor tissue apposition with the thin RFA catheter as there was no stricture. Given the patient’s young age, extent of bile duct involvement, and poor tissue response to RFA, we determined that a completion Whipple surgery would be the best long-term option. DISCUSSION: We present a unique case of a post-duodenectomy FAP patient with adenomatous polyp extending from the biliojejunal anastomosis to the proximal hepatic duct. We were able to remove the polyp at the biliojejunal anastomosis with hybrid ESD, but the biliary adenomatous tissue was not adequately treated by biliary RFA. The thin RFA catheter had poor contact on the bile duct wall as there was no stricture. If a balloon RFA biliary catheter existed that could provide better tissue contact with a normal diameter bile duct, maybe this could have been treated endoscopically. This case highlights the importance of multidisciplinary management of complex polyposis in FAP patients.

Comparison of pancreas-sparing duodenectomy (PSD) and pancreatoduodenectomy (PD) for the management of duodenal polyposis syndromes

BackgroundFamilial adenomatous polyposis affects primarily the colon but can also involve other locations within the gastrointestinal tract, including the duodenum. The aim of this study was to describe a single center experience with pancreas-sparing duodenectomy for familial adenomatous polyposis and to compare outcomes with pancreatoduodenectomy performed for duodenal polyp disease. Patients and MethodsA retrospective review of a prospectively maintained database identified patients who had undergone pancreas-sparing duodenectomy during the period 2001 to 2016. This population was matched 1:1 with a cohort of patients undergoing pancreatoduodenectomy for duodenal adenomas, both sporadic and familial, during the same time period. Baseline demographics and perioperative (short- and long-term) outcomes were compared. ResultsA total of 88 patients were included; 44 in each group. The pancreas-sparing duodenectomy cohort was younger (52.6 vs 64.3 years; P < .001) and more patients had undergone prior colectomy (100% vs 32%; P < .001) or additional prior abdominal surgery (27% vs 9% (P < .001). Median operative times were greater for pancreatoduodenectomy (391 vs 460 min; P = .002). There was no difference in any of the early postoperative complications. There was 1 30-day mortality in the pancreatoduodenectomy group secondary to aspiration. Late acute pancreatitis was more common after pancreas-sparing duodenectomy (16% vs 0%; P = .012) and exocrine pancreatic insufficiency was more common after pancreatoduodenectomy (30% vs 11%; P = .034). ConclusionPancreas-sparing duodenectomy is a reasonable option for duodenal cancer prophylaxis in familial adenomatous polyposis with high-risk features. The perioperative safety profile is comparable to pancreatoduodenectomy done for similar indications, and pancreas-sparing duodenectomy has a favorable long-term with a lesser incidence of exocrine impairment.

Tailored surgical treatment of duodenal polyposis in familial adenomatous polyposis syndrome

BackgroundTo review our experience in patients undergoing operative treatment for duodenal polypoisis associated with familial adenomatous polyposis with an emphasis on operative approach and long-term outcomes. MethodsDuodenal polypoisis associated with familial adenomatous polyposis patients undergoing operative treatment were studied retrospectively excluding patients with preoperative duodenal cancer. ResultsOf 767 patients in the database, 63 (8.2%) patients underwent operative treatment: 42 (67%) pancreas-sparing duodenectomy, 15 (24%) pancreatoduodenectomy, and 6 (9.5%) segmental duodenal resection; the majority for Spigelman stages III and IV polyposis. Overall 9.6% had adenocarcinoma postoperatively (28.6% in the pancreatoduodenectomy group; P = .01). The proportion of Spigelman stages III and IV with cancer were 9.5% and 6.5%, respectively. Pathologic upgrade to cancer in patients with low grade dysplasia and high-grade dysplasia on preoperative biopsy was 5.7% and 6.7%, respectively (P = .13). At a median follow-up of 16 years, 7.7% needed a second duodenal polypoisis associated with familial adenomatous polyposis-related operation. Progression to high grade dysplasia or cancer in the stomach occurred in 15.4% of patients. Median overall survival and recurrence-free survival was at least 16 years and 15.6 years. No significant group-based differences were noted on follow-up. ConclusionThe majority of patients with duodenal polypoisis associated with familial adenomatous polyposis can achieve long-term, cancer-free survival with organ-preserving approaches (pancreas-sparing-duodenectomy and segmental-duodenal-resection) with survival not dependent on the type of resection.

Retrospective analysis of perioperative and long-term outcomes after pancreas-sparing duodenectomy for duodenal cancer

Aims: Pancreaticoduodenectomy (PD) is the procedure of choice for malignant periampullary tumours, but is associated with significant morbidity. Pancreas-sparing duodenectomy (PSD) is technically feasible for distal duodenal cancers, and has been considered potentially safer than pancreaticoduodenectomy. However, there is little published data on either short or long-term outcomes after PSD. Our aim was to compare the outcomes of PSD and PD for duodenal cancer in a single UK centre. Methods: Patients who underwent either PD or PSD for duodenal cancer over a 21-year period (1993–2014) were identified from a prospectively maintained database. Patient demographics, tumour location, postoperative complications and histological data were compared between the two groups. Long-term overall and disease-free survivals were analysed. Results: 81 consecutive patients (median age 66 years) underwent surgical resection of duodenal cancer during the study period (PSD 21, PD 60). Patient demographics were similar in both groups. Tumours were more commonly located in the distal duodenum in patients undergoing PSD (85% vs. 9%; p < 0.001). There was no significant difference in perioperative morbidity (PSD 38% vs. PD 55%; p = 0.311), length of hospital stay (median: 10 vs. 11 days; p = 0.135) or 90-day mortality (5% vs. 12%; p = 0.672) between groups. R0 resection rates were not significantly different (PSD 75% vs. PD 92%; p = 0.112). However, lymph node yield (median 6 vs. 17; p < 0.001) and the proportion of specimens with more than six lymph nodes (35% vs. 91%; p < 0.001) were significantly lower after PSD. There was no significant difference in five-year overall (p = 0.932), disease-specific (p = 0.646) or recurrence-free (p = 0.731) survival rates between PSD (45%, 70%, 38%) and PD (45%, 61%, 36%). Conclusions: Pancreas-sparing duodenectomy is a feasible option in patients with distal duodenal cancer, but does carry a significant morbidity rate, comparable to pancreaticoduodenectomy. Although lymph node yield is lower after a pancreas-sparing resection, this does not appear to negatively impact on long-term survival.

Pancreas sparing duodenectomy versus pancreaticodudoenectomy for duodenal carcinoma: a comparison study

Background: Pancreas-sparing duodenectomy (PSD) may be an alternative to pancreaticoduodenectomy (PD) for duodenal cancers located distant from the ampulla. PSD avoids the potential complications of a pancreaticoenteric anastomosis, but the long-term outcomes are unknown. Methods: Patients who underwent surgical resection of duodenal cancer were identified from a prospectively maintained database. Clinical and pathological data were collected, and long-term cancer-related outcomes were analyzed. Results: 19 patients underwent PSD and 60 PD between January 1993 and March 2014. Morbidity (p=0.196), 90-day mortality (p=0.379) and length of stay (p=0.137) were similar in both groups. However, there were more anastomotic leaks in the PD group (33% versus. 5%; p=0.017). Lymph node yield (p<0.001) was significantly lower after PSD. There was no significant difference in five-year overall (p=0.943), disease-specific (p=0.781) or recurrence-free (p=0.695) survival rates. No significant difference in the lymph node ratio (LNR) between the groups. Conclusions: PSD avoids the risks of a pancreatic anastomosis associated with PD. Despite a significantly lower lymph node harvest, similar survival outcomes can be achieved with PSD in patients with duodenal carcinoma not involving D 2 .

Surgical approach for tumours of the third and fourth part of the duodenum. Distal pancreas-sparing duodenectomy

The anatomic complexity of the duodenum makes surgical resection challenging. We describe our experience with distal pancreas-sparing duodenectomy (PSD) for tumours that arise in the third and fourth parts of the duodenum. Between July 2008 and January 2012 eight patients underwent surgical resection for tumours in the distal parts of the duodenum. Short and long-term outcomes of treatment are retrospectively analyzed. We used the Cattell and Braash surgical approach in six patients. Seven patients underwent a segmental resection of the distal duodenum with a duodenojejunal anastomosis and in one case we performed a wedge local excision with primary closure. There were 5 gastrointestinal stromal tumours (GIST), 1 primary duodenal adenocarcinoma, 1 metastasis of a lung adenocarcinoma and 1 patient with malignant duodenocolic fistula caused by advanced sigmoid colon carcinoma. Median operating time was 200 min and median intraoperatory blood loss 162 mL. Three patients showed postoperative complications and one of them died. There was no reoperation. Median hospital stay was 10 days (range, 7–28 days). The patient with primary adenocarcinoma died after 12 months due to hepatic metastases. All of five patients with GIST are alive without recurrence (mean follow up of 65.6 months), as well as the patient with metastatic duodenal infiltration (45 months after surgery). Segmental resection of the third and fourth portions of the duodenum is reliable and feasible. The Cattell and Braash manoeuvre provides a good exposure and makes this kind of resection easier.

Laparoscopic pancreas-sparing subtotal duodenectomy.

Primary adenocarcinoma of the duodenum is a rare digestive malignancy which is commonly treated by radical surgical resection, pancreaticoduodenectomy being the technique of choice. Complete tumor resection obtaining free margins should be the standard of treatment for primary adenocarcinoma of the duodenum. Segmental duodenal resection is an appropriate operation for selected cases of primary adenocarcinoma of the duodenum of the 3rd and 4th portions of the duodenum. We present the case of a 67-year-old woman suffering from an infra-ampullary large villous polypoid mass affecting the 3rd portion of the duodenum. Multiple endoscopic biopsies did not disclose any malignancy, and abdominal CT and endoscopic ultrasound found no extraduodenal involvement. A 3rd and 4th portion pancreas-sparing duodenectomy was carried out using a totally laparoscopic approach. Intra-operatory duodenoscopy was done to safeguard the papilla of Vater. Recovery was uneventful and the patient was discharged on the 7th postoperative day. The final diagnosis was primary adenocarcinoma of the duodenum (free resection margins). After forty-five months of follow-up, the patient is free of disease. We recommend this procedure for treatment of an infra-ampullary benign and pre-malignant duodenal pathology; it can also be a treatment option and an alternative to a pancreaticoduodenectomy in very selected cases of tumors confined to the duodenum. Expertise in both pancreatic surgery and laparoscopic techniques is required.