Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies

Abstract

AIMTo investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up.METHODSNeoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed.RESULTSTwenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively).CONCLUSIONPPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Treatment Strategy of Pancreas‐Sparing Distal Duodenectomy for Distal Duodenal Malignancies with Adjustable Dissection Levels According to Disease Progression (with Video)

“…DGE after PSDD in the current study occurred in 42% of patients, which was higher than previous reports for PD (12–46%) [37–41] and PSDD (0–16%) [20, 25, 42]. The cause of DGE in PSDD was reported to be ischemia or edema of the stump or gastric‐duodenal atony due to reduced circulating levels of motilin secreted from the duodenum, which is associated with the interdigestive migrating motor complex [13, 37, 43, 44].…”

“…However, we should carefully determine the surgical indications of this procedure because it is still challenging for tumors located on the 4th part or distal side of the 3rd part of the duodenum. DGE after PSDD in the current study occurred in 42% of patients, which was higher than previous reports for PD (12-46%) [37][38][39][40][41] and PSDD (0-16%) [20,25,42]. The cause of DGE in PSDD was reported to be ischemia or edema of the stump or gastric-duodenal atony due to reduced circulating levels of motilin secreted from the duodenum, which is associated with the interdigestive migrating motor complex [13,37,43,44].…”

Pancreas-preserving limited duodenal resection: Minimizing morbidity without compromising oncological adequacy

“…Primary adenocarcinoma of the fourth segment of the duodenum and the proximal jejunum can also be safely resected with limited (distal) duodenal resection, especially when the tumor is small and the small bowel mesentery and the head of the pancreas/uncinate process are not involved. Many studies comparing pancreaticoduodenectomy with limited duodenal resection have reported equivalent long-term outcome and overall survival with less morbidity [ 20 , 21 ]. A recent propensity-matched analysis of 2,487 patients comparing radical resection with partial resection for duodenal adenocarcinoma concluded that adjuvant therapy in addition to surgery improved survival regardless of the type of surgery and played a significant role in survival [ 22 ].…”

Duodenaladenome und -karzinome: chirurgische Therapiekonzepte

“…Insbesondere bei der FAP führt dieses Verfahren zu einer Entfernung möglicher weiterer Prädilektionsstellen. Die pankreaserhaltende Duodenektomie stellt entsprechend bei gutartigen Befunden das Pendant zur Pankreaskopfresektion dar und wird in den Händen erfahrener Pankreaschirurgen als gleichwertig hinsichtlich der Komplikationsrate bewertet 23 , 31 . In Analogie zur transduodenalen Papillektomie wird auch die pankreaserhaltende Duodenektomie von einigen Autoren für das Früh- bzw.…”