Total Duodenectomy Research Articles

Laparoscopic Pancreas-preserving Total Duodenectomy for Familial Adenomatous Polyposis

Patients with duodenal polyps associated with familial adenomatous polyposis (FAP) have a considerable risk of developing duodenal carcinoma. Prophylactic resection of the duodenum for Spigelman stage III disease is the treatment of choice to prevent progression to cancer. Pancreaticoduodenectomy and pancreas-preserving total duodenectomy (PPTD) are the techniques that have been described for the surgical treatment of duodenal polyposis. We report the first case of laparoscopic PPTD in a patient with previous total colectomy for FAP and Spigelman stage III duodenal polyposis. A laparoscopic total dissection of the duodenum was carried out and the restoration was achieved performing pancreatico-biliary-jejunostomy and gastrojejunostomy. The postoperative period was uneventful. Laparoscopic PPTD can be performed safely in selected cases for the management of FAP.

Pancreas‐preserving total duodenectomy: a 10‐year experience

Traditionally, severe pathology of the duodenum has been treated by a pancreaticoduodenectomy using Whipple's operation. Pancreas-preserving total duodenectomy (PPTD) was introduced in the late 1990s as an alternative to Whipple's operation for selected diseases of the duodenum. We report our 10 years' experience with this operation. In the period from 1999 to 2010 13 patients (mean age 50 years) underwent PPTD. Ten patients had duodenal adenomatosis (Spigelman stage IV). Two patients had large solitary tubulovillous adenomas, and one patient had multiple duodenal gastrointestinal stromal tumor lesions. No mortality was observed. Six patients (46%) had a total of ten postoperative complications. Three patients (23%) had leakage of the ampullo-jejunostomy anastomosis, and one patient (8%) had leakage of the duodeno-jejunostomy anastomosis; all were treated conservatively with good results. One patient had recurrent episodes of pancreatitis, which disappeared spontaneously 3 months after operation. Three patients suffered from wound dehiscence, and two patients had postoperative pneumonia. Mean hospital admittance was 19 days (range 9-50 days). All patients were well at a mean follow-up of 56 months (range 2-134 months). Pancreas-preserving total duodenectomy appears to be a safe and valuable treatment option for patients with selected diseases of the duodenum.

Biochemically curative surgery for gastrinoma in multiple endocrine neoplasia type 1 patients

To search for the optimal surgery for gastrinoma and duodenopancreatic neuroendocrine tumors in patients with multiple endocrine neoplasia type 1. Sixteen patients with genetically confirmed multiple endocrine neoplasia type 1 (MEN 1) and Zollinger-Ellison syndrome (ZES) underwent resection of both gastrinomas and duodenopancreatic neuroendocrine tumors (NETs) between 1991 and 2009. For localization of gastrinoma, selective arterial secretagogue injection test (SASI test) with secretin or calcium solution was performed as well as somatostatin receptor scintigraphy (SRS) and other imaging methods such as computed tomography (CT) or magnetic resonance imaging (MRI). The modus of surgery for gastrinoma has been changed over time, searching for the optimal surgery: pancreaticoduodenectomy (PD) was first performed guided by localization with the SAST test, then local resection of duodenal gastrinomas with dissection of regional lymph nodes (LR), and recently pancreas-preserving total duodenectomy (PPTD) has been performed for multiple duodenal gastrinomas. Among various types of preoperative localizing methods for gastrinoma, the SASI test was the most useful method. Imaging methods such as SRS or CT made it essentially impossible to differentiate functioning gastrinoma among various kinds of NETs. However, recent imaging methods including SRS or CT were useful for detecting both distant metastases and ectopic NETs; therefore they are indispensable for staging of NETs. Biochemical cure of gastrinoma was achieved in 14 of 16 patients (87.5%); that is, 100% in 3 patients who underwent PD, 100% in 6 patients who underwent LR (although in 2 patients (33.3%) second LR was performed for recurrence of duodenal gastrinoma), and 71.4% in 7 patients who underwent PPTD. Pancreatic NETs more than 1 cm in diameter were resected either by distal pancreatectomy or enucleations, and no hepatic metastases have developed postoperatively. Pathological study of the resected specimens revealed co-existence of pancreatic gastrinoma with duodenal gastrinoma in 2 of 16 patients (13%), and G cell hyperplasia and/or microgastrinoma in the duodenal Brunner's gland was revealed in all of 7 duodenal specimens after PPTD. Aggressive resection surgery based on accurate localization with the SASI test was useful for biochemical cure of gastrinoma in patients with MEN 1.

Solid Pseudopapillary Tumor of the Pancreas: An Unexpected Finding After Minor Abdominal Trauma

A 20-year-old female college student presented to the emergency department with epigastric pain and vomiting several hours after being struck in the abdomen with a soccer ball. She had no significant past medical or surgical history. On examination the patient was afebrile and hemodynamically stable. Her abdominal examination was significant for epigastric and right upper quadrant tenderness. Computed tomography (CT) of the abdomen and pelvis was obtained to rule out traumatic intra-abdominal injury. CT revealed a multi-septated cystic mass at the pancreatic neck measuring 6.1 9 6.6 cm, with associated mural nodules and rim enhancement (Fig. 1). The mass appeared to invade the posterior wall of the stomach and compress the portal vein near the confluence of the superior mesenteric vein and splenic vein. Lymphadenopathy of the celiac axis and greater curvature of the stomach was noted. The patient was admitted and underwent endoscopic ultrasound with fine needle aspiration of the cystic pancreatic mass. Cytology from this procedure showed clusters of polygonal cells with abundant cytoplasm, surrounding fibrovascular structures in a background of blood and necrotic debris. Mitotic figures were not apparent. The findings were interpreted as consistent with solid pseudopapillary tumor of the pancreas. The patient was taken for surgical resection at which time there was noted to be extensive inflammatory change surrounding the tumor, involving the duodenum and transverse mesocolon, with adherence of the tumor to the SMV, portal vein and hepatic artery. The patient ultimately required total pancreatectomy, duodenectomy, splenectomy, partial gastrectomy and right hemicolectomy for complete resection. Final pathology revealed a solid pseudopapillary neoplasm with borderline malignant potential, 6.5 cm in greatest dimension, with negative lymph nodes (0/25). There was submucosal inflammation and necrosis of the adjacent posterior wall of the stomach, but microscopic examination showed no evidence of tumor invasion into any adjacent structures. The patient recovered from surgery and received an insulin pump for insulin replacement. With three-year follow up with CT surveillance, she has no evidence of tumor recurrence.

Pancreas-Sparing Total Duodenectomy

Pancreas-sparing total duodenectomy (PSTD), which allows preservation of the pancreas in its entirety is a promising procedure for benign or premalignant lesions at duodenum without invading the pancreas. We report two cases of tubular adenoma of Ampulla of Vater and a GIST of duodenum, which were resected by PSTD. The proximal duodenum was transected at 2 cm distal of pylorus and the distal end was cut in the distal portion of the Treitz ligament. The proximal jejunal limb was used for biliary-pancreatic duct systems reconstruction with end-to-side anastomosis and distal jejunum was anastomosed to duodenal bulb with an end-to-side anastomosis. Although a pancreatic fistula occurred in one patient, it was improved by conservative management. PSTD is a challenging surgical technique and requires excellent knowledge of anatomy. If performed for appropriate indications, PSTD is a useful alternative to formal pancreatoduodenecotmy and can be done safely with gastrointestinal function maintained.

Complications and follow-up after pancreas-preserving total duodenectomy for duodenal polyps

Patients with duodenal polyps are at risk of duodenal cancer. Pancreas-preserving total duodenectomy (PPTD) is an alternative to partial pancreatoduodenectomy. Twelve patients (seven men and five women) with a median age of 59 (interquartile range (i.q.r.) 50-67) years underwent PPTD for large (over 20 mm) solitary polyps or multiple (more than three) duodenal polyps confined to the muscularis propria on endoscopic ultrasonography. Median hospital stay was 21 (i.q.r. 10-36) days with no deaths and no blood transfusion. Six patients developed postoperative complications, one requiring reoperation. Histology demonstrated gastrointestinal stromal tumour in three patients, low-grade dysplasia in one, moderate-grade dysplasia in eight and duodenal intramucosal adenocarcinoma in one. During a median follow-up of 20 (i.q.r. 8-41) months one patient experienced recurrent acute pancreatitis (due to hypertriglyceridaemia) and one developed a jejunal adenocarcinoma in the neoduodenum. The morbidity of PPTD is similar to that of partial pancreatoduodenectomy, but PPTD preserves the whole pancreas and reduces the number of anastomoses.

Pancreas-preserving total duodenectomy versus standard pancreatoduodenectomy for patients with familial adenomatous polyposis and polyps in the duodenum

Pancreas-preserving total duodenectomy (PPTD) was introduced as a replacement for pancreatoduodenectomy (PD) for familial adenomatous polyposis (FAP). This study analysed the results of PPTD in the Netherlands and reviewed the relevant literature. All 26 patients who underwent PPTD for FAP in four centres in the Netherlands between January 2000 and January 2007 were compared with a group of 77 patients who had PD for ampulla of Vater adenocarcinoma at one centre during the same interval. Morbidity rates were similar after PPTD for FAP (16 patients, 62 per cent) and PD for ampulla of Vater adenocarcinoma (44 patients, 57 per cent) (P = 0.694). One patient (4 per cent) died after PPTD and two (3 per cent) after PD. A review of the literature, including patients from the present study, found that 71 patients had PPTD, with postoperative morbidity in 36 (51 per cent) and one death (1 per cent). In publications containing a total of 94 patients who underwent PD for FAP, 43 (46 per cent) developed complications and three (3 per cent) died. PPTD has similar short-term results to PD in terms of morbidity and mortality.

Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis?

Background Duodenal adenomatosis is a premalignant condition often not treatable by local resection or endoscopy. An option for treatment is a pylorus-preserving (pp)-Whipple resection. Since the introduction of pancreas-preserving total duodenectomy (PPTD), the question has arisen whether a pp-Whipple resection is still needed to treat duodenal adenomatosis. Patients and methods In a 5-year period 23 PPTDs were performed for duodenal adenomatosis. In a matched-pairs analysis the outcome following PPTD (16 patients with a follow-up longer than 12 months) was compared with pp-Whipple. Results Hospital mortality in all 23 patients was 4.3% and total morbidity 30% after PPTD. Operation time, intensive care and hospital stay, morbidity, and mortality were comparable between the matched paired groups (16 patients). Patients with PPTD had significantly lower intraoperative blood loss. No PPTD patient required pancreatic enzyme substitution, compared with 12 patients after pp-Whipple. Quality-of-life analysis in PPTD patients revealed no difference compared to a normal control population and the pp-Whipple group. Conclusions PPTD is a safe surgical procedure for duodenal adenomatosis that avoids pancreatic head resection, provides high quality of life, and shows advantages over the pp-Whipple procedure.

Radiation-associated Synovial Sarcoma Arising in the Digestive Tract: A Case Report and Literature Review

DOI: http://dx.doi.org/10.5915/40-1-5285 Synovial sarcoma of the digestive tract is an extremely rare tumor. Only 12 cases were reported; none of these was in the gastroduodenal region. Radiation therapy is well known for its long-term carcinogenesis, especially of soft tissue sarcomas. Only four cases of radiation-associated synovial sarcoma have been reported. We report a case of primary gastroduodenal synovial sarcoma in a 54-year-old woman who was treated for Hodgkin’s lymphoma at age 35, using external radiation to the mantle field and the paraortic strip (including abdominal paraaortic nodes). She presented with epigastric pain and sensation of fullness, associated with loss of appetite and weight. An upper endoscopy showed a distal gastric mass extending to the post-pulpal duodenum; a tissue biopsy of the mass showed monophasic synovial sarcoma with positive epithelial membrane antigen (EMA). The diagnosis was confirmed when reverse transcriptase-polymerase chain reaction (RT-PCR) demonstrated the presence of a SYT-SSX fusion transcript. She underwent total duodenectomy and partial gastrectomy and gastrojejunostomy. After surgery she regained her appetite and started gaining weight. She has been symptom-free for 7 months after the surgery.

Large Duodenal Villous Adenoma Requiring Head of the Pancreas and Pylorus-Preserving Total Duodenectomy

Villous adenomas of the duodenum (VAD) are infrequent lesions of the gastrointestinal tract but have a high risk of recurrence and malignancy. For these reasons and its specific topographic location, the surgical treatment of VAD is still controversial. Herein we present a case of large VAD located in the second duodenal portion that was successfully treated with a head of the pancreas, pylorus-preserving total duodenectomy (PPTD). PPTD should be an excellent option in patients with large adenomas because it allows preservation of the pancreas, gastrointestinal function is maintained, the possibility of a recurrence and of an invasive carcinoma of the ampulla is eliminated, and finally because it permits an adequate endoscopic follow-up. PPTD should not be used in the presence of malignancy and/or high-grade dysplasia.

Role of the Duodenum on Sphincter of Oddi Motility in Conscious Dogs

目的 通过观察清醒状态下十二指肠切除后狗奥狄氏括约肌(SO)运动的变化,检验十二指肠对SO运动的调节作用.方法对照组(n=6)于十二指肠乳头对侧植入测量用套管.十二指肠切除组(n=6)保留十二指肠乳头切除十二指肠,将近端空肠(重建十二指肠)与胃吻合,原十二指肠乳头与重建十二指肠行端侧吻合,再于吻合后的十二指肠乳头对侧植入测量用套管.经套管插入测压管,通过压力变化来观测SO及十二指肠运动变化.结果十二指肠切除后,SO周期性运动消失,SO呈持续性强收缩状态.结论十二指肠对消化间期SO运动有重要的调节作用。

New Pancreas‐preserving Total Duodenectomy Technique

Pancreas-preserving total duodenectomy (PPTD) was first described by Chung et al. in 1994. Since then, several surgeons have used PPTD to treat diseases that involve the duodenum diffusely but not the head of the pancreas, mostly familial adenomatous polyposis (FAP). The PPTD method has been changed in each report and seems to have improved over time. We performed PPTD on three patients with different diseases--one with intestinal hemorrhage due to small intestinal amyloidosis; another with numerous duodenal gastrinomas in a patient with multiple endocrine neoplasia type 1 (MEN-1) and Zollinger-Ellison syndrome (ZES); and the third with numerous duodenal polyposis and FAP--using a new method that is simpler and safer than those previously reported. When resecting the whole duodenum, we performed mucosectomy of the major papillar portion and saved the structure of the major papilla. After an approximately 8 mm long sphincteropapillotomy, the opened major papilla was anastomosed to an incisional opening of the small intestine. The orifice of the main pancreatic duct (MPD) was stented by a catheter, and the MPD was kept intact under direct vision during the operative procedures. The head of the pancreas was fixed with the small intestine by interrupted 4-0 silk sutures. Reconstruction of the alimentary tract was performed after either the Billroth I or the Billroth II method. This is the first report of PPTD in which the entire MPD was preserved to simplify the biliopancreatic-ductal reconstruction.

Total duodenectomy: Effects of choecystokinin on the Sphincter of oddi motility in conscious dogs

Total duodenectomy: Effects of choecystokinin on the Sphincter of oddi motility in conscious dogs

Role of duodenum on sphincter of Oddi motility in conscious dogs.

Our aim was to determine the role of the duodenum in controlling sphincter of Oddi motility using conscious dogs after total duodenectomy. In a control group (N = 6), a cannula was implanted into the duodenum opposite to the papilla to allow retrograde sphincter manometry. In a duodenectomy group (N = 6), the papillae were preserved at total duodenectomy and sutured to thejejunum anastomosed to the stomach (neoduodenum). The cannula was implanted opposite to the implanted papillae. Interdigestive and postprandial sphincter and duodental or neoduodenal motility were recorded by manometric and myoelectric methods. Duodenectomy disrupted sphincter cyclic motility associated with the intestinal migrating motor complex and increased sphincter activity throughout the cycle. Sphincter activity increased immediately after feeding and did not differ between the two groups. In conclusion, during the interdigestive period, the duodenum has a distinct role in regulating sphincter cyclic motility. The initiation of the fed pattern of sphincter motility does not need the duodenum.

Postprandial plasma secretin response in Whipple-treated patients

We hypothesize that the presence of a few secretin-releasing cells sited in the upper jejunum may provoke a postprandial secretin response to meal loading in patients who have undergone the Whipple procedure. This procedure involves gastrectomy and total duodenectomy and requires gastrointestinal tract reconstruction by one of three methods: (i) choledocho-pancreatico-gastro alignment (PD-1), (ii) pancreatico-choledocho-gastro alignment (PD-2) (both these methods excluding the upper jejunum from the route of food passage), or (iii) gastro-pancreatico-choledocho alignment (PD-3), in which food passes through the upper jejunum. Fasting and postprandial plasma secretin and gastrin response were measured in 47 Whipple-treated patients, 16 given a PD-1, 15 given a PD-2, and 16 given a PD-3, and in 15 healthy controls. Plasma secretin response and integrated secretin release were higher, but not significantly, in the PD-3 group, and lower in all three Whipple-treated groups than in the control (P<0.05). Plasma gastrin concentration showed no significant increase in any of the three treated groups and was significantly lower than in the controls (P<0.05). The integrated gastrin release also did not differ among the treated groups and was lower than in the controls (P<0.05). Twenty-four-h monitoring showed that the gastric pH was neutral or alkaline in all three treated groups. The failure to prove our hypothesis may be due to the presence of too few secretin-releasing cells in the upper jejunum to respond to the meal loading and/or to the intragastric pH not being sufficiently acidic to stimulate those secretin-releasing cells present in the upper jejunum.

Total duodenectomy: Effect on canine gastrointestinal motility

Motor activity of the upper gastrointestinal tract undergoes a cyclic pattern during fasting called the migrating motor complex (MMC). The role of the duodenum in controlling this cyclic activity was studied in the dog. Five dogs served as controls. In four other dogs, the entire duodenum and the proximal 20 cm of jejunum were resected. The ostia of the bile duct and pancreatic duct were preserved as “mucosal buttons” and reimplanted in situ into the jejunum after gastrojejunostomy. All dogs had manometry catheters placed into the stomach and serosal electrodes implanted onto the small intestine to monitor gastrointestinal motility. All control dogs showed the characteristic MMC in the stomach and small intestine, the period being 112 ± 16 min (mean ± SEM). After total duodenectomy, an irregular, noncyclic pattern of contractions occurred in the stomach in two of the four dogs during fasting. The other two dogs had a cyclic pattern of gastric motility; however, the overall characteristics of these cyclic patterns of gastric motility differed from that of controls. A variable proportion of the phases of cyclic gastric activity did not fit the criterion for temporal coordination with the jejunum as defined from study of control dogs. In contrast, jejunal motility in all four dogs after total duodenectomy continued to exhibit the characteristic MMC, but the period of the cycle (58 ± 7 min) was shorter than in controls ( P < 0.05). “Ectopic” jejunal activity fronts with no preceding gastric contractions were frequent. After total duodenectomy, plasma concentration of motilin remained lower than normal and showed no cyclic variation with the jejunal MMC. After total duodenectomy, feeding interrupted the fasting motor pattern of the stomach as in controls, but did not disrupt the MMC in the jejunum. We concluded that the duodenum has an important role in initiating cyclic gastric motor activity and in coordinating motor activity between the stomach and the small intestine.

The Continuing Challenge of Duodenal Injuries

Thirty-four cases of duodenal trauma, 23 caused by gunshot wounds, are reviewed. All but three patients had associated major organ injuries, a total of 97 injuries. Postoperative mortality was 14% for injuries into the duodenal lumen. Techniques for operative repair included simple primary closure, use of omental or serosal patches, controlled fistula with a duodenostomy tube, decompressive and feeding ostomies, "diverticulization", segmental duodenal resection and anastomosis, and total duodenectomy and pancreatectomy. It is emphasized that the surgeon finding duodenal injury must be familiar with all of these techniques, each of which has its indications. Treatment of duodenal injuries perhaps more than any other bowel trauma must be individualized.

Case 3-1962

Presentation of Case A sixty-three-year-old man was admitted to the hospital because of vomiting and pain in the abdomen. Eleven years previously because of a three-month history of severe periumbilical pain and the radiologic demonstration of calculi in the region of the pancreas and swelling of the ampulla of Vater a Whipple operation (partial pancreatectomy, total duodenectomy, choledochojejunostomy, pancreaticojejunostomy and gastrojejunostomy) was performed (Fig. 1). Pathological examination of the surgical specimen revealed pancreatic lithiasis with chronic inflammation and fibrosis. He recovered from the operation promptly and was improved, but because of repeated episodes of similar abdominal pain a bilateral lower . . .

EFFICIENCY OF GASTROINTESTINAL TRACT AFTER RESECTION OF HEAD OF PANCREAS

When resection of the head of the pancreas is carried out, partial gastrectomy, total duodenectomy and some sort of anastomosis between the biliary tract and the stomach or small intestine are integral parts of the operative procedure. Such extensive surgical operations cannot be done without interfering to some degree with the normal functioning of the gastrointestional tract. It was the purpose of this study to assess the degree of impairment of the digestive and absorptive functions of the gastrointestinal tract brought about by this operation and to evaluate ways by which such impairment of function could be reduced. This was done by means of intake-excretion studies with standard test diets. Similar studies of normal persons had previously been carried out with two of the same test diets for control purposes. SUBJECTS STUDIED Ten patients who had undergone resection of the head of the pancreas consented to be studied. Two of