Pancreas-sparing duodenectomy for a huge leiomyosarcoma in the third portion of the duodenum

Abstract

A duodenal leiomyosarcoma which was resected by pancreas-sparing duodenectomy is reported. The tumor arose in the third portion of the duodenum and grew in an extraluminal direction. The tumor was huge (13 cm x 9 cm x 8 cm) but did not involve the pancreas, and there were no findings of periduodenal lymph node metastases. Because the possibility of metastasis to the lymph nodes around the root of the superior mesenteric artery (which are removed only in a pancreatoduodenectomy) was judged to be low, pancreas-sparing duodenectomy was performed, with dissection of the pancreaticoduodenal lymph nodes. The proximal duodenum was transected between the second and third portions of the duodenum, and the distal end was cut in the jejunum at the portion of the first jejunal artery. Reconstruction was performed by end-to-side anastomosis between the duodenum and jejunum, using an end-to-end anastomosis instrument. Since the incidence of lymph node metastasis of leiomyosarcoma is low, resection of the head of the pancreas for extensive lymph node dissection does not always seem necessary. Pancreas-sparing duodenectomy can be a good option for a leiomyosarcoma in the third and fourth portions of the duodenum which does not invade the pancreas and is not accompanied by any apparent periduodenal lymph node metastases.

Pancreas-Sparing Distal Duodenectomy for Infrapapillary Neoplasms

“…27,30 Although reported figures are limited, times given for PSTD range between 217-360 min, 8,12,16 whilst those for PSDD range between 300-330 min. 19,21,23 Median blood loss of 1197 ml in this series was similar to that previously reported for PD (970 ml 27 ), PSTD (690 ml 16 ) and PSDD (1347 ml 19 ). Blood loss was noted to be greater among the malignant cases (1500m l) than the benign cases (700 ml), especially when concomitant partial colectomy was needed (2350 ml).…”

“…40 The reports of duodenal GISTs that have been resected completely with PSDD have shown freedom of recurrence at 12-156 months. 18,21,22,24 Tw o of our 4 patients with stromal tumours had incomplete resections, and each of them was submitted to radical radiotherapy thereafter. Three of the 4 are alive and well with no evidence of recurrence at 36, 120 and 179 months, while one died during radiotherapy secondary to dehiscence of an ileocolic anastomosis that had previously healed.…”

“…[18][19][20][21][22][23][24] For neoplasms that arise in the third and fourth parts of the duodenum (D 3 , D 4 ), a conservative duodenectomy that preserves the pancreas and papilla can provide adequate tumour clearance while avoiding the additional dissection and risk associated with the biliary and pancreatic anastomoses implicit in the common alternative PD (or PSTD). Other advantages of this procedure include a shorter operative time and the preservation of more normal anatomy and function allowing postoperative endoscopic surveillance.…”

Leiomyosarcoma of the Duodeno-Jejunal Angle: Two Case Reports and Literature Review

“…Indeed, on one hand the anatomical complexity of the duodenum imposes different procedures adapted to the location of the tumor, and on the other hand, the rarity of lymph node metastases arouses debate for the need for node dissection. Among the published cases, only 52 cases had a curative surgery [2][3][4][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. The review of the various procedures carried out (Table 1) found that the choice of surgical procedure depended much more on the location and the size of the tumor that on the need for node dissection.…”

End‐to‐end anastomosis using a surgical instrument after a segmental resection of the distal duodenum

“…When performing surgery for this disease, selecting the most appropriate procedure is very important because of the complex anatomical characteristics of the duodenum including the pancreas, superior mesenteric vessels, portal vein, and extrahepatic biliary system [2][3][4]. While a pancreatoduodenectomy (PD) is unavoidable in cases with direct invasion to the pancreas, no standard surgical procedure has yet been established in cases without direct invasion.…”