Severe Duodenal Involvement in Familial Adenomatous Polyposis Treated by Pylorus-Preserving Pancreaticoduodenectomy

Caillié, Frédéric; Paye, François; Desaint, B.; Bennis, Malika; Lefèvre, Jérémie H.; Parc, Yann; Svrcek, Magali; Balladur, Pierre; Tiret, Emmanuel

doi:10.1245/s10434-012-2221-x

Cited by 22 publications

(24 citation statements)

References 48 publications

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“…Some have advocated for mucosectomy of the duodenal cuff to further minimize the risk of cancer, 26,28 although there are fears that this may impair healing of the anastomosis. 22 To our knowledge, this is the first report of duodenal bulb polyps after pylorus-sparing surgery in FAP patients. The risk of duodenal bulb polyposis may make resection of the pylorus a reasonable option in patients without a J-pouch and good bowel function and continence.…”

Section: Duodenal Bulb Polypsmentioning

confidence: 73%

The Prevalence and Significance of Jejunal and Duodenal Bulb Polyposis After Duodenectomy in Familial Adenomatous Polyposis

et al. 2019

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Objective: To evaluate the prevalence, natural history, and severity of polyposis of the duodenal bulb and jejunum after duodenectomy in patients with FAP. Summary of Background Data: Advanced duodenal polyposis stage in FAP requires consideration of duodenal resection to prevent cancer; pyloruspreserving 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. Methods: 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). Results: 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 ¼ 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. Conclusions: 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.

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Section: Duodenal Bulb Polypsmentioning

confidence: 73%

The Prevalence and Significance of Jejunal and Duodenal Bulb Polyposis After Duodenectomy in Familial Adenomatous Polyposis

et al. 2019

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“…The restorative procedure after PD was always standardized for the indication of duodenal or ampullary polyposis in FAP patients according to the modified Imanaga procedure. 16 After pylorus preserving PD, the remnant pancreas was anastomosed to the posterior wall of the stomach by an end-toside duct-to-mucosa anastomosis, then an end-to-end duodenojejunal anastomosis was made, followed by a hepaticojejunal end-to-side anastomosis 10 cm downstream 17 Thanks to this reconstruction, postoperative endoscopic explorations of the upper gastrointestinal tract to assess recurrence of polyposis in the jejunum is easier than after the Child's reconstruction. 18 Moreover, this reconstruction conserves more length of functional small bowel for digestion which is probably useful in these patients without colon and rectum.…”

Section: Patient Selectionmentioning

confidence: 99%

“…Pathological examinations of the operative specimens are exposed in Table 1. In patients with a duodenal invasive adenocarcinoma, the median number of lymph nodes analyzed in the operative specimen was 14.5 (12)(13)(14)(15)(16)(17). 75% of patients with an invasive adenocarcinoma (3/4) were not diagnosed preoperatively as invasive cancer but as duodenal dysplasia.…”

Section: Population Surgical Procedures and Outcomesmentioning

confidence: 99%

Ten-year impact of pancreaticoduodenectomy on bowel function and quality of life of patients with ileal pouch-anal anastomosis for familial adenomatous polyposis

Collard

Lefèvre

Ahmed

et al. 2020

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Background: Patients with familial adenomatous polyposis (FAP) carry a risk of duodenal adenocarcinoma. These patients, who already have an ileal pouch-anal anastomosis (IPAA), sometimes require pancreaticoduodenectomy (PD). This work aims to evaluate the long-term consequences of the combination of PD + IPAA.Methods: All patients with IPAA due to FAP who underwent PD from 1991 to 2017 were included (PD + IPAA group). Patients were matched 1:1 according to age, sex, ASA score and presence of colorectal cancer. Fecal continence and quality of life (QoL) were assessed using the Wexner score and the EORTC-QLQ-C30 questionnaire. Results: Thirty-two PD + IPAA patients were matched with thirty-two IPAA-only patients. In each group, the response rate to the questionnaire was 78% (25/32). No differences were noted between PD + IPAA and IPAA-only groups in terms of daytime fecal frequency (6.0 vs 6.0; p = 0.362), Wexner score (3/20 vs 4/20; p = 0.984) and global QoL score (83.3/100 vs 83.3/100; p = 0.401). In the PD + IPAA group, 26% of patients developed diabetes a median period of 10.0 years after PD. The global QoL for these patients was significantly altered (p = 0.011), while daytime fecal frequency was unaffected (p = 0.092) as fecal continence (p = 0.475). Conclusion:In FAP patients with IPAA, PD does not affect bowel function or QoL.

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“…Important considerations of the operation type chosen are endoscopic access to the postsurgical neo‐duodenum as the prevalence of duodenal bulb and jejunal polyposis can be as high as 80% and postsurgical adverse events can arise. 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 Endoscopic access in PSD compared to PD anatomy is facilitated by the lack of an afferent limb and a single ductal anastomosis (Figures 1 and 2 ). Complications of duodenectomy which may be managed endoscopically include anastomotic strictures, recurrent pancreatitis, adenomatous involvement of the neo‐papilla, or cholangitis.…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4][5] Prophylactic surgery to prevent duodenal cancer in patients with advanced-stage duodenal polyposis includes pancreas-sparing duodenectomy (PSD) or pancreaticoduodenectomy (PD) with or without a pylorus-sparing approach (Figure 1). 6,7,[16][17][18][8][9][10][11][12][13][14][15] PSD involves resection of the duodenum with resection of the native ampulla and the creation of two anastomoses, an end-to-side duodenal stump to the jejunal anastomosis and a single-layer anastomosis between the pancreatic duct and bile duct and the advanced loop of jejunum thus recreating a neo-ampulla (Figures 1a and 2). PD results in resection of the duodenum and pancreatic head with reconstruction requiring three anastomoses.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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Objectives Familial 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). Methods A 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. Results Of 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. Conclusions ERCP 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.

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Severe Duodenal Involvement in Familial Adenomatous Polyposis Treated by Pylorus-Preserving Pancreaticoduodenectomy

Abstract: PPPD remains a safe and efficient therapeutic option for severe duodenal polyposis in familial adenomatous polyposis patients.

Cited by 22 publications

References 48 publications

The Prevalence and Significance of Jejunal and Duodenal Bulb Polyposis After Duodenectomy in Familial Adenomatous Polyposis

The Prevalence and Significance of Jejunal and Duodenal Bulb Polyposis After Duodenectomy in Familial Adenomatous Polyposis

Ten-year impact of pancreaticoduodenectomy on bowel function and quality of life of patients with ileal pouch-anal anastomosis for familial adenomatous polyposis

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

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