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Review Article
Dig Surg
Pancreas-Preserving Total
Duodenectomy: A Systematic Review
Miguel Cantalejo-Díaz a José Manuel Ramia-Ángel b Ana Palomares-Cano a
Mario Serradilla-Martín c
aDepartment of Surgery, Miguel Servet University Hospital, Zaragoza, Spain; bDepartment of Surgery, Instituto de
Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital, Alicante, Spain; cDepartment
of Surgery, Instituto de Investigación Sanitaria Aragón, Miguel Servet University Hospital, Zaragoza, Spain
Received: September 2, 2020
Accepted: February 15, 2021
Published online: May 17, 2021
Correspondence to:
José Manuel Ramia-Ángel, jose_ramia @ hotmail.com
© 2021 S. Karger AG, Basel
karger@karger.com
www.karger.com/dsu
DOI: 10.1159/000515718
Keywords
Total duodenectomy · Pancreas-preserving ·
Familial adenomatous polyposis · Pancreatic trauma ·
Pancreas-sparing
Abstract
Background: The management of the pancreas in patients
with duodenal trauma or duodenal tumors remains a con-
troversial issue. Pancreas-preserving total duodenectomy
(PPTD) requires a meticulous surgical technique. The most
common indication is familial duodenal adenomatous pol-
yposis (FAP). The aims of this study are to carry out a system-
atic review of the literature on the indications for PPTD and
to highlight the risks and benefits compared with other
more aggressive procedures. Summary: A systematic litera-
ture review was performed following PRISMA recommenda-
tions of studies published in PubMed, Embase, and Cochrane
library until May 2019. Thirty articles describing 211 patients
were chosen. The mean age was 48 years. The surgical indi-
cation in 75% of patients was FAP. The mean operating time
was 329 min and mean intraoperative bleeding 412 mL.
Postoperative morbidity rate was 49.7% (76% Clavien-Dindo
<IIIa), and mortality rate was 1.4%. The mean hospital stay
was 22 days. Overall survival at 1–3–5 years was >97.8%. Key
Messages: PPTD is indicated for patients with benign and
premalignant duodenal lesions without involvement of the
pancreatic head. It is a feasible procedure offering an alter-
native to other more aggressive procedures in selected pa-
tients. Mortality is below 1.5%. © 2021 S. Karger AG, Basel
Introduction
The management of the pancreas in patients with duo-
denal trauma or duodenal tumors remains a controver-
sial issue. Until a few years ago, patients with duodenal
tumors underwent pancreatoduodenectomy (PD). The
centralization of pancreatic procedures in high-volume
services, the improvement of surgical techniques, and the
refinement in perioperative management have reduced
the postoperative mortality rate to below 5% in special-
ized centers [1, 2]. However, morbidity after pancreatic
surgery is still high (30–50%) [2]. Postoperative pancre-
atic fistula (POPF) is the most common complication.
Despite all the advances and technical modifications de-
veloped to prevent POPF, the incidence still ranges be-
Cantalejo-Díaz/Ramia-Ángel/
Palomares-Cano/Serradilla-Martín
Dig Surg
2
DOI: 10.1159/000515718
tween 3 and 45% at high-volume centers according to the
International Study Group of Pancreatic Surgery [3].
The modification of the surgical concept has led to a
change from a radical approach to a conservative one that
aims to preserve all possible organs [4]. In 1995, Chung et
al. [2] described the first pancreas-preserving total duode-
nectomy (PPTD), which offers certain advantages over
PD [1, 5, 6]. However, as of 2010, only about 100 cases of
PPTD had been published [5–11]. PPTD requires a me-
ticulous surgical technique, as well as a detailed knowl-
edge of the peripancreatic anatomy. It consists of the re-
section of the entire duodenum with preservation of the
pancreatic head [1, 8]. Despite possible technical prob-
lems that may arise, such as reconstruction with 1 or 2
jejunal loops, details of ampullary anastomosis, to leave or
not a duodenal cuff, ligation or not of duct of Santorini,
etc., when performed for the correct indications, PPTD
can offer many advantages over more classical techniques.
PPTD is indicated in neoplastic or preneoplastic le-
sions that diffusely affect the duodenal mucosa but do not
have the potential to spread to regional lymph nodes [5–
7]. The most common indication for PPTD is familial du-
odenal adenomatous polyposis (FAP) [1, 7, 9]. Other pos-
sible indications for PPTD are carcinoid tumors, the pres-
ence of a broad-based villous adenoma in the duodenum,
large supra-ampullary adenomas, multiple duodenal gas-
trinomas in patients with MEN-1 syndrome, duodenal
trauma, ischemic phenomena, mucosa-associated lym-
phoid tissue lymphoma, Crohn’s disease, intestinal amy-
loidosis, and duodenal gastrointestinal stromal tumors
(GISTs) [2, 4]. The main objectives of this study are (a) to
carry out a regulated systematic literature review of the
indications of PPTD, through the correct application of
evidence-based medicine; (b) to highlight the risks and
benefits of PPTD in contrast to other more aggressive sur-
gical techniques; (c) and to assess the morbidity and mor-
tality rates in patients undergoing PPTD compared to PD.
Material and Methods
This systematic review was based on the PICO [12] strategies
and was performed following the recommendations of the pre-
ferred reporting elements for systematic reviews (PRISMA, online
suppl. Material 1; see www.karger.com/doi/10.1159/000515718
for all online suppl. material) [13]. The data from each study were
classified according to the Oxford Centre for Evidence-Based
Medicine levels of evidence [14].
Literature Review
A systematic literature review of all studies published in
PubMed, Embase, and the Cochrane library was conducted of pa-
tients with both benign and malignant diseases, and duodenal
trauma undergoing PPTD. The search was performed in English
using the terms “((pancreas-sparing)) OR (pancreas)) AND ((sav-
er) OR (preserving) OR (preservation))] and (duodenectomy).”
Bibliographical references were checked manually for additional
studies. Three independent authors reviewed all the studies re-
trieved that met the inclusion and exclusion criteria. Discrepancies
between the 3 authors were resolved by discussion and consensus.
Inclusion Criteria
All articles written in English without any limit on the year of
initial publication up to and including May 31, 2019, were includ-
ed, covering: (a) articles presenting data on pancreatic preserva-
tion in patients undergoing total duodenectomy (excluding partial
duodenectomy); (b) original published data; and (c) available
long-term outcomes.
Variables Studied
Two data compilation tables were created, including the fol-
lowing variables for study:
− Demographic variables and characteristics of the population,
the country of the origin, number of patients included, mean
age in years, and sex; preoperative diagnosis, Spigelman stage
in patients with FAP, the percentage of patients undergoing
scheduled versus emergency PPTD, the percentage of patients
with FAP diagnosis who underwent prophylactic colectomy
prior to PPTD, as well as perioperative morbidity and mortal-
ity recorded in percentages.
− The surgical outcome variables included operative time, surgi-
cal bleeding, the number of complications and their causes, as
well as severity according to the Clavien-Dindo classification
[15], hospital stay, percentage of recurrence of polyps in pa-
tients with FAP, overall survival of patients at 1, 3, and 5 years,
postoperative histology, and survival in patients with histolog-
ical postoperative diagnosis of adenocarcinoma localized to the
mucosa.
Results
A total of 371 papers were identified in the initial search.
After screening and duplicate removal, 67 papers were re-
vised. Six of them were rejected because they were not writ-
ten in English and 13 were not relevant publications. A total
of 48 articles were selected for reading, of which 16 pre-
sented cases of partial duodenectomies and 2 did not pre-
sent long-term results. Finally, thirty papers were finally se-
lected describing a total of 211 patients meeting the inclu-
sion criteria [1, 2, 4–6, 8, 9, 16–38]. All these studies were
observational and classified as level 4 evidence. The charac-
teristics of the populations studied are detailed in Table1.
The mean age was 48 years (range 11–71). Ninety-four
men and 87 women were included (30 patients included in
3 studies did not specify the sex). One hundred and sixty
patients presented initial surgery for FAP (75.8%); of these
104 (65%) were classified as Spigelman stage IV, 23
Total Duodenectomy: A Systematic
Review
3
Dig Surg
DOI: 10.1159/000515718
Table 1. Characteristics of the study population
Study [Ref.] Country NP Age,
years
M/F Indication SPIGELMAN PROG,
%
PC,
%
OT,
min
Bleeding, mL MB,
%
MT,
%
Chung
et al. [2]
USA 5 48.4 5/0 4 FAP 1 trauma NK 80 NK NK NK 60 0
Tsiotos and
Sarr [8]
USA 4 44 2/2 2 FAP 2 unresectable adenoma NK 100 NK 217 Scarce/
Nontransfusion
25 0
Lundell
et al. [16]
Sweden 4 61.7 2/2 2 FAP 1 MGAD 1 giant lipoma NK 100 NK NK NK 25 0
Kalady
et al. [17]
USA 3 38 1/2 3 FAP NK 100 100 279 Scarce/
Nontransfusion
33 0
Sarmiento
et al. [9]
USA 8 54 2/6 5 FAP 3 unresectable adenoma NK 100 63 366 340 62.5 0
Takagi
et al. [18]
Japan 1 59 1/0 1 carcinoid tumor – 100 0 360 690 0 0
De Vos tot Neverdeen
et al. [19]
Holland 6 43 NK 6 FAP 4 S. IV 2 S. III 100 NK NK NK 50 0
Eisenberger
et al. [20]
Germany 3 54.6 1/2 1 gardner SD. LGAD 2 broad-base adenoma – 100 100 NK NK 66 0
Imamura
et al. [6]
Japan 3 52.3 2/1 1 FAP 1 amyloidosis bleeding 1 Zollinger-Edison
MEN-1 gastrinoma
NK 66 NK NK NK 0 0
Kimura
et al. [21]
Japan 1 71 0/1 1 liposarcoma – 100 – NK NK 100 0
Mackey
et al. [22]
USA 21 57.7 15/6 21 FAP 19 S. IV 1 S. III 1 S. II 100 100 327 503 38 0
Koshariya
et al. [23]
Greece 3 62.6 1/2 2 non-FAP diffuse polyposis
1 polyp recurrence
– 100 – 175 400 33 0
Al-Sarieh
et al. [5]
England 12 59 7/5 6 FAP 3 GIST 3 unresectable adenoma 4 S. IV 1 S. III 1 S. II 100 100 NK Scarce/
Nontransfusion
50 0
De Castro
et al. [24]
The
Netherlands
26 51 16/10 26 FAP 25 S. IV 1 S. III 100 100 336 NK 61.5 4
Müller
et al. [4]
Germany 23 49 8/15 13 FAP 1 duodenum NET
9 no-FAP DP
13 S. IV 100 52 335 334 30 4.3
Wig
et al. [25]
India 2 21 2/O Perforation + peritonitis – 0 – NK NK 50 0
Benetatos
et al. [26]
England 1 22 1/0 1 FAP 1 S. III 100 100 450 Scarce/
Nontransfusion
0 0
Drini
et al. [27]
Australia 4 66 NK 4 FAP 4 S. IV 100 NK NK NK 50 0
Cantalejo-Díaz/Ramia-Ángel/
Palomares-Cano/Serradilla-Martín
Dig Surg
4
DOI: 10.1159/000515718
Study [Ref.] Country NP Age,
years
M/F Indication SPIGELMAN PROG,
%
PC,
%
OT,
min
Bleeding, mL MB,
%
MT,
%
Penninga and
Svendsen [28]
Denmark 13 50 6/7 10 FAP 2 unresectable adenoma 1 GIST 10 S. IV 100 NK NK NK 46 0
Stauffer
et al. [29]
USA 4 60.7 2/2 2 FAP 2 unresectable adenoma NK 100 NK 423 NK 50 0
Beamish
et al. [30]
England 1 34 1/0 1 FAP NK 100 100 NK NK 0 0
Ramia-Angel
et al. [1]
Spain 1 46 0/1 1 FAP 1 S. IV 100 100 NK NK 0 0
Ravoire
et al. [31]
France 1 56 1/0 1 GIST – 100 – NK NK 100 0
Qadan
et al. [32]
USA 1 49 1/0 1 giant polyp – 100 – NK NK 100 0
Rangelova
et al. [33]
Sweden 20 50 NK 13 FAP 5 MGAD 1 duodenum NET 1 GIST 13 S. IV 100 NK 319 128 55 0
Otsuka
et al. [34]
Japan 1 20 0/1 1 FAP + adenoca 1 S. IV 100 0 NK NK 100 0
Watanabe
et al. [35]
Japan 10 52 4/6 10 FAP 10 S. IV 100 90 369 480 60 0
Ganschow
et al. [36]
Germany 27 48 12/15 27 FAP 17 S. III 10 S. Not
known
100 100 322.8 428 55.5 3.7
Vincenzi
et al. [37]
Brazil 1 11 1/0 1 bleeding CMV ulcers post-Kasai IQ biliary atresia – 0 0 NK NK 100 0
Jiménez Cubedo
et al. [38]
Spain 1 47 0/1 1 FAP NK 100 100 NK NK 0 0
NP, number of patients; M/F, Male/Female; PROG, programmed; PC, prophylactic colectomy; OT, operating time, min; MB, morbidity; MT, mortality; FAP, familiar adenomatous polypo-
sis; GIST, gastrointestinal stroma tumor; HGAD, high-grade adenomatous dysplasia; MGAD, moderate-grade adenomatous dysplasia; LGAD, low-grade adenomatous dysplasia; CMV, cyto-
megalovirus; NET, neuroendocrine tumor.
Table 1 (continued)
Total Duodenectomy: A Systematic
Review
5
Dig Surg
DOI: 10.1159/000515718
(14.37%) stage III, and 2 (1.25%) stage II, and in as many
as 31 patients, the stage was not recorded or their descrip-
tion was unknown. Only 16 studies (with a total of 120 pa-
tients with FAP) recorded the number of patients undergo-
ing prophylactic total colectomy on a scheduled basis (109
patients, 90.8%) prior to PPTD. Surgery was scheduled in
almost all cases (97.63%). Emergency surgery was per-
formed in only 5 patients: one due to trauma, 2 for duode-
nal bleeding, and 2 for perforation (2.73%). The mean op-
erative time was 329 min and mean intraoperative bleeding
(not including 4 papers with a total of 20 patients in which
“scarce/no transfusion” was evident) was 412.9 mL. Post-
operative morbidity was 49.7%. Mortality was 1.4%.
Surgical Results
Surgical results are summarized in Table2. The mean
hospital stay in 23 of the 30 articles was 22.2 days. In 95
of the 211 patients (45.1%), a known postoperative com-
plication was reported, a figure that rose to 49.7% after
including 10 patients with complications that were re-
corded but not specified. The most common complica-
tions reported in 105 of the 211 patients were POPF
(36.0%), delayed gastric emptying (DGE) (15.7%), wound
infection (10.5%), postoperative bleeding (8.4%), acute
pancreatitis (8.4%), and intra-abdominal abscess (8.4%).
Three patients died during the immediate postoperative
period. Seventy-five of the 98 patients with postoperative
complications Clavien-Dindo <IIIa (76.5%) were man-
aged conservatively. The remaining 23 patients (23.4%)
presented major complications. 13.1% of the patients
with initial surgery for FAP (21/160) presented polyposis
recurrence in the neoduodenum in the follow-up. Post-
operative histologies reported were 100 cases of adenoma
with dysplasia (40 high-degree dysplasia, 10 moderate-
degree dysplasia, and 50 low-degree dysplasia), 35 cases
of adenoma without dysplasia, and 15 adenomas with
carcinoma in situ. Other reported cases were: 5 GIST, 2
duodenal perforations, 2 liposarcomas, 1 lipoma, 1 carci-
noid tumor, and 1 neuroendocrine tumor. In 49, cases,
histology was nor reported. The overall survival rates in
the first, third, and fifth year were 99.6, 98.7, and 97.8%,
respectively.
Discussion
Until a few years ago, the standard treatment for duo-
denal tumors was PD. One of the basics of oncological
surgery is the requirement of a block resection of organs
potentially invaded by cancer. That is why, in the pres-
ence of nonmalignant pathology, the surgical philosophy
tends to be “less is more,” in which pancreatic preserva-
tion with total duodenal exeresis allows better intestinal
function, saves pancreatic tissue, and avoids the need for
a hepaticojejunostomy in an undilated bile duct. In 1995,
Chung et al. [2] described the technique, indications, and
results of PPTD performed in 5 patients with FAP, and
reported a significant decrease in mortality figures com-
pared to PD [5, 9].
The most common indication for PPTD is FAP [1, 7,
9]. Extracolonic manifestations of FAP show that 70–90%
of patients develop adenomas in the duodenum. Their
severity is classified using the Spigelman score [10], which
assesses the number, size, histological type, and dysplasia
of the adenomas. Several therapeutic modalities can be
applied for these lesions: endoscopic excision, local surgi-
cal resection, and, in some cases, removal of the duode-
num [2–5]. A high degree of dysplasia develops in 32% of
adenomas, and approximately 43% of polyps are Spigel-
man stage IV [3]. Initially, after diagnosis of FAP, patients
tend to present low stages, but progress to higher stages
during the course of the disease [10].
Wallace and Phillips [11] proposed that patients with
stage I or II disease should be evaluated every 3 years, while
patients with stage III or IV disease should undergo an-
nual endoscopy and biopsy. Endoscopic findings requiring
treatment include lesions >1 cm, severe dysplasia, villous
histology, and carcinoma. Polyps that cause symptomatic
diseases such as pancreatitis, pain, or bleeding from ulcer-
ation also require intervention [5, 11]. According to inter-
national guidelines, Spigelman stages III and IV, high-
grade dysplasia, and duodenal carcinomas are indications
for surgery [8, 39]. Several types of surgery have been used
for the treatment of duodenal FAP including ampullecto-
my, partial or total duodenectomy, duodenotomy with as-
sociated polypectomy, and PD. PPTD should not be per-
formed in patients with cancer confirmed to be derived
from FAP in the sample, which is evaluated by the com-
plete extent of involvement of the rest of the gastrointesti-
nal tract, before and at the time of surgery [3, 4].
Other indications for PPTD are listed in the intro-
duction. Concerning carcinoid tumor is characteristi-
cally slow growing and has a low potential for metasta-
sis, features that indicate a less aggressive behavior than
common carcinomas [6–8]. Patients with multiple tu-
mors, <1 cm in size, should undergo PPTD. Duodenal
GIST constitutes the most challenging location for treat-
ment. Duodenal GIST is uncommon, accounting for
only 5–7% of all surgical GISTs. The surgical treatment
depends on the duodenal size and location; PPTD is
Cantalejo-Díaz/Ramia-Ángel/
Palomares-Cano/Serradilla-Martín
Dig Surg
6
DOI: 10.1159/000515718
Table 2. Surgical results of PPTD
Study [Ref.] Complication C-D R-R-R HS,
days
PR
(FAP), %
1 yr
OS, %
3 yr
OS, %
5 yr
OS, %
Cancer
survival, %
Histology
Chung
et al. [2]
1 wound infection 1 PF
1 DGE
I
II
II
0/5 13.8 0 100 NK NK No cancer NK
Tsiotos and Sarr
[8]
1 PF I 0/4 12 0 100 NK NK NK NK
Lundell
et al. [16]
1 biliar fistula III b 1/4
Biliar fistula
12.25 0 100 NK NK 100 1 lipoma 1 HGAD 2 AFA
Kalady
et al. [17]
1 biliar fistula II 0/3 11 33 100 100 100 No cancer 2 HGAD 1 NDA
Sarmiento
et al. [9]
1 bleeding 1 wound infection 3 PF III b II 3 III a 1/8 bleeding 17.8 25 100 100 100 No cancer 3 HGAD 5 LGAD
Takagi
et al. [18]
– – – 48 – 100 NK NK NK 1 carcinoid tumor
De Vos tot Neverdeen
et al. [19]
NK – – NC 0 100 NK NK No cancer NK
Eisenberger
et al. [20]
1 wound infection 1 AP I III b 1/3 lavage for AP 57 0 100 NK NK 100 1 HGAD and AFA 2 LGAD
Imamura
et al. [6]
– – – NC 0 100 NK NK No cancer NK
Kimura
et al. [21]
1 DGE II 0/1 67 – 100 NK NK 100 Liposarcoma
Mackey
et al. [22]
4 DGE
4 PF
4 II
3 II- 1 IIIa
0/21 14.6 9.50 100 100 100 100 20 HGAD 1 AFA
Koshariya
et al. [23]
1 AP III a 0/3 10 0 100 NK NK No cancer NK
Al-Sarieh
et al. [5]
1 AP
1 PF
2 intra-abdominal abscess
1 wound infection
1 DGE
III b
III a
2 III a
I
II
1/12
AP peritonitis
21 0 100 NK NK 100 3 GIST 1 LGAD 7 MGAD 1
AFA
De Castro
et al. [24]
7 PF
2 DGE
1 bleeding 2 intra-abdominal abscess
3 wound infection
1 UTI
5 II- 2 III a
2 II
III b
1 II- 1 III a
3 I
II
1/26
Bleeding
14 15 96 NK NK 100 NK
Total Duodenectomy: A Systematic
Review
7
Dig Surg
DOI: 10.1159/000515718
Study [Ref.] Complication C-D R-R-R HS,
days
PR
(FAP), %
1 yr
OS, %
3 yr
OS, %
5 yr
OS, %
Cancer
survival, %
Histology
Müller
et al. [4]
2 PF
1 bleeding 1 AP
1 biliar fistula 1 DGE
1 pneumonia
2 II
III b
I
III b
II
II
2/23
Biliar fistula and
bleeding
14.6 NK 95.60 NK NK 100 3 AFA 1 NET 19 NDA
Wig
et al. [25]
1 bleeding III b 1/2 bleeding NK – 100 NK NK No cancer 2 perforation
(nonpathology)
Benetatos
et al. [26]
– – – 16 0 100 NK NK No cancer 1 LGAD
Drini
et al. [27]
1 wound infection 1 intra-abdominal
abscess
II
III a
0/4 NK 25 100 100 100 100 3 MGAD 1 AFA
Penninga and
Svendsen [28]
3 PF
1 AP
1 Cholangitis 1 pneumonia
3 II
I
III a II
0/13 19 30 100 100 100 No cancer 12 LGAD 1 GIST
Stauffer
et al. [29]
2 DGE 2 III a 0/4 13.25 0 100 NK NK No cancer 2 NDA 2 HGAD
Beamish
et al. [30]
– – – NK 0 100 NK NK 100 1 HGAD and AFA
Ramia-Angel
et al. [1]
– – – 10 0 100 NK NK No cancer 1 LGAD
Ravoire
et al. [31]
1 intra-abdominal abscess III a 20 – 100 NK NK No cancer 1 GIST
Qadan
et al. [32]
1 P.F III a 0/1 12 – 100 NK NK NK 1 HGAD
Rangelova
et al. [33]
2 DGE
2 bleeding 3 PF
1 II- 1 IV a
2 III b
2 II- 1 III a
2/20 2 bleeding 17 7.69 100 NK NK No cancer 13 NDA 5 HGAD 1
duodenum NET 1 GIST
Otsuka
et al. [34]
1 AP III b 1/1 AP lavage 28 0 100% NK NK NK 1 AFA
Watanabe
et al. [35]
1 Cholangitis 4 PF
1 wound infection
II 4 II
I
0/10 NK 0 100 NK NK 100 6 LGAD 4 AFA
Ganschow
et al. [36]
8 PF
1 bleeding 2 intra-abdominal abscess
2 AP
1 wound infection 1 DGE
II- IIIa- 6 III b
III b 2 II
2 II
III b II
8/27
6 PF (1 of this with
bleeding)
1 wound infection 1
C.S
26.6 26.30 96.30 92.40 87.10 No cancer 7 HGAD 20 LGAD
Vincenzi
et al. [37]
1 bleeding III a 0/1 35 – 100 NK NK No cancer 1 CMV ulcerative
duodenitis
Table 2 (continued)
Cantalejo-Díaz/Ramia-Ángel/
Palomares-Cano/Serradilla-Martín
Dig Surg
8
DOI: 10.1159/000515718
indicated in large tumors located away from the pancre-
atic head [5].
PPTD offers several advantages over PD: greater pres-
ervation of intestinal function and pancreatic tissue,
which allows the maintenance of endo-function and
postoperative pancreatic exocrine and the reduction of
the administration of oral pancreatic enzymes from 75%
to 0 [7, 8]; the performance of 2 anastomoses (compared
with 3 or 4 in PD) thus avoiding the need for a hepatico-
jejunostomy in an undilated bile duct, or a pancreatoje-
junostomy or pancreatogastrostomy with a usually soft
pancreas and an undilated pancreatic duct; shorter surgi-
cal time, and less intraoperative bleeding, allowing better
endoscopic postoperative follow-up of the neoduodenum
since it is not anatomically affected [4–6, 9].
The mean morbidity rate published is 60% (25% minor
complications and 35% major) [2, 39]. The complications
described are DGE, fistula of pylorojejunal or ampullo-
jejunal anastomosis, intra-abdominal abscess, acute pan-
creatitis, and surgical wound infection. The mortality rate
associated with this procedure is below 1.5%. The recur-
rence rate of polyps after PPTD is 9%, either in the small
postpyloric duodenal cuff or in the mucosa surrounding
the papilla [39].
Although an assessment of the role of endoscopy for the
removal of ampullary and duodenal lesions is beyond the
limit of this article, we stress that endoscopic management
of small localized lesions is useful, especially in patients who
would otherwise not tolerate duodenal resection [31]. Le-
sions that are too large, are found in unfavorable anatomical
sites, or associated with a polyposis syndrome require com-
plete removal of the duodenum with the periampullary re-
gion definitive treatment [15]. Pancreatic surgery for be-
nign duodenal disease is more difficult for several reasons.
First, almost all patients have a soft, unaffected pancreas
with high rates of POPF. In our review, a 38% of POPF was
reported. In addition, almost all patients with FAP (90.8%)
underwent previous prophylactic proctocolectomy with
anal anastomosis and ileal reservoir. These intra-abdomi-
nal adhesions may complicate surgery and delay the recov-
ery of bowel function. On the other hand, as shown by Wig
et al. [25], severe duodenal injury is rare and remains a chal-
lenging problem. The major concern is failure of the repair,
with the resulting abdominal septic complications and fis-
tula formation. Duodenal fistula rates range from 0 to 16.2%
and mortality rates from 10 to 29%. Successful management
depends on an appropriately selected procedure. Duode-
num-related morbidity ranges from 12 to 63% and mortal-
ity rates from 6 to 29%. The surgical management of duo-
denal injury is complex: options vary from external drain-
Study [Ref.] Complication C-D R-R-R HS,
days
PR
(FAP), %
1 yr
OS, %
3 yr
OS, %
5 yr
OS, %
Cancer
survival, %
Histology
Jiménez Cubedo
et al. [38]
– – 0/1 NK 0 100 NK NK No cancer 1 LGAD
C-D, Clavien-Dindo; PR (FAP), polyps recurrence in familiar polyposis adenomatous patients; DGE, delayed gastric emptying; HS, hospital stay; 1–3–5 yr OS, 1–3–5 year overall survival;
PF, pancreatic fistula; AP, acute pancreatitis; NDA, nondysplastic adenoma; AFA, adenoma with focus of adenocarcinoma; R-R-R, rate and reasons for reintervention; CS, compartment syndrome;
PPTD, preserving total duodenectomy; GIST, gastrointestinal stromal tum; DP, duodenal polyposis.
Table 2 (continued)
Total Duodenectomy: A Systematic
Review
9
Dig Surg
DOI: 10.1159/000515718
age to complex reconstruction procedures to PD. We
recorded fewer than 5 trauma patients undergoing PPTD.
According to Rangelova et al. [33], in patients with
premalignant or low-malignant nonmucosal tumors re-
stricted to the duodenum, PPTD is a safe and valid alter-
native to PD; it achieves comparable or better short-term
results, with lower hospital costs. In addition, PPTD is
potentially useful for preventing the postoperative onset
of diabetes and exocrine insufficiency and facilitates an
endoscopic follow-up of patients at risk for new polyps.
Another controversial issue is PPTD with/without py-
loric preservation for patients with FAP. Pre-pyloric gas-
tric section has been recommended due to the appearance
of duodenal cancer arising from the duodenal remnant af-
ter conservative intervention of the pylorus [16]. Duodenal
cancer occurs in as many as 5% of cases of duodenal pol-
yposis (DP) in FAP, a figure that rises to 36% in patients
with advanced DP [1]. In these patients, there has also been
an increase in the incidence of patients with DGE.
As described in Fernández-Cruz et al. [40], DGE was
first described by Warshaw and Torchiana in 1985 as a
complication associated with DP with pyloric preserva-
tion, presenting an incidence in that series of 70%. Later,
the decrease in serum motiline due to duodenal resec-
tion as well as the existence of a pyloro-spasm due to
denervation and revascularization during the surgical
procedure was proposed as causal factors [41]. Howev-
er, in most cases, DGE is a consequence of inflammation
of the gastric wall in the resection site owing to the de-
velopment of a PF. In our study, 14.2% of patients pre-
sented DGE.
Although pancreas divisum was not the central theme
of the bibliographic review, the article by Otsuka et al.
[34] deserves special mention. Pancreas divisum is the
most common congenital variant of the development of
the pancreatic duct, with rates between 0.5 and 17.6%. In
these patients, the dorsal pancreatic duct secretes most of
the pancreatic juice, and its occlusion leads to obstructive
pancreatitis. Therefore, when planning PPTD, surgeons
should be alert to the presence of pancreas divisum; if it
is recognized, double duct-mucosal anastomotic or in-
vagination anastomosis is required [33].
In relation to the surgical technique, a wide Kocher
maneuver and dissection of the Treitz ligament should be
performed to achieve total duodenal mobilization. Cho-
lecystectomy with cystic duct tutoring would facilitate the
location of the papilla and ampulla of Vater [1]. The prox-
imal section is performed by stapling at duodenal level
0.3–1 cm distal to the pylorus in most articles [1, 33] al-
though, as described by Penniga and Svendsen [28], it
could be performed at gastric level at 5 cm from the pylo-
rus depending on the nature and extent of the disease.
The infra-ampullary duodenum, head of the pancreas,
and uncinate process is dissected, sectioning the multiple
pancreaticoduodenal branches. Subsequently, the same
maneuver is performed at the supra-ampullary level. Ac-
cording to Kalady et al. [17] after having ruled out the
preoperative presence of pancreas divisum, the minor
pancreatic duct of Santorini in case it is located should be
ligated or obliterated (oscillating fistula rates of 4 and 8%,
respectively). In cases of pancreas divisum, the location
of both pancreatic ducts is mandatory and 2 anastomoses
must be performed. Finally, we achieve that the pancreas
and duodenum are only joined by the ampulla of Vater.
An oval is made in the duodenum of small size around the
papilla which allows us to complete the duodenectomy [1,
8]. There is controversy in relation to the duodenal sec-
tion of the pancreas in this step, as some articles recom-
mend section at the level of the papilla [4, 17] and others
recommend section at about 2–3 mm from the same, ver-
ifying the absence of disease in the surrounding duodenal
mucosa [1]. In terms of reconstruction, Tsotios and Sarr
[8] recommend performing the pylorojejunostomy first
for 2 reasons: the best evaluation of the appropriate length
and tension of the neoduodenum and the site for the re-
implantation of the ampulla with correct positioning of
the retropancreatic mesentery and to avoid improper ma-
nipulation of the higher risk suture (ampullo-jejunosto-
my). All the surgical techniques described in the articles
call for reconstruction in 1 single jejunal handle, with the
exception of Vincenzi et al. [37] whose patient underwent
DTPP after living donor liver transplantation for invasive
cytomegalovirus disease using 2 handles. In general, most
patients underwent pylorojejunal/gastrojejunal (neoduo-
denum) anastomosis according to Billroth I, although
Imamura et al. [6], Kalady et al. [17], Wig et al. [25], and
Benetatos et al. [26] performed Billroth II. No functional
complications derived from each type of anastomosis in
the short, medium, and long term are described (dump-
ing syndrome, afferent loop syndrome, alterations in gas-
tric motility, or metabolic sequelae). As regards ampullo-
jejunostomy, there is variability in relation to the size of
the suture used, although all of them perform the untu-
tored anastomosis by means of loose monofilament
stitches monoplane mucosal-mucosal [1, 4, 6, 17, 28, 33].
The limitations of our study in relation to the surgical
technique are the preservation of the duodenal cuff in cer-
tain articles, the thickness of the suture used for ampullo-
jejunostomy, and the reconstruction of the neoduode-
num according to Billroth I or II.
Cantalejo-Díaz/Ramia-Ángel/
Palomares-Cano/Serradilla-Martín
Dig Surg
10
DOI: 10.1159/000515718
In relation to follow-up, small bowel cancer in a pa-
tient with FAP is an unlikely finding [42]. Murakami et
al. [43] reported a case of FAP with duodenal cancer aris-
ing from the duodenal remnant after PPTD. Although the
cancer was successfully resected endoscopically, they
concluded that resection of the entire duodenum is es-
sential in patients with FAP who present duodenal neo-
plasms so as to prevent any recurrence. Our data collect-
ed include extensive follow-ups at 1–3–5 years, with over-
all survival rates exceeding 98% in all cases.
According to long-term functional outcomes, almost
all articles focus on postoperative survival follow-up.
Only Müller et al. [4] carry out an analysis of the func-
tional, metabolic and quality of life follow-up patients af-
ter the intervention; obtaining as a statistical significance
the nonuse of pancreatic replacement enzymes after
PPTD. On the other hand, Mackey et al. [22] and Al-Sari-
reh et al. [5] describe in their follow-ups 2 patients with
subocclusive pictures of the small intestine managed in a
conservative way. Other long-term functional data re-
garding the nutritional status, DGE, presence of reflux
and terms of quality of life of these patients are not de-
scribed.
While it is true that the tendency is to perform less
radical surgery, the recurrence rate of endoscopic resec-
tion in patients with FAP is higher than in cases of spo-
radic adenoma. Irani et al. [44] reported a recurrence rate
of 17% in patients with FAP, but only 6% in patients with
sporadic adenoma. Catalano et al. [45] published recur-
rence rates of 23 and 4%, respectively. Gluck et al. [46]
suggested the following criteria for resection: overall tu-
mor size of 10 mm, villous structure of the adenoma, and
presence of severe atypia. However, most ampullary ad-
enomas are slow growing and show no significant patho-
logical differences, making it difficult to reduce adeno-
mas that would require resection [47]. Based on the data
compiled, we conclude that PPTD is a safe surgical tech-
nique that achieves total resection of the duodenal mu-
cosa with shorter surgical time, less bleeding, and lower
mortality rates than other surgical techniques.
A brief comparison in terms of morbimortality with
the main alternative and more aggressive and radical in-
tervention, PD, should be highlighted. In terms of mor-
bidity, according to the evidence in the literature, PD car-
ried out in high-volume reference centers, presents rates
of PF between 15 and 45% [48, 49], being slightly higher
than those described in our review. Biliary fistula rates are
clearly higher in patients undergoing PD reaching up to
12% [49]. On the other hand, 4.6–12% of patients present
postoperative bleeding similar to PPTD [48, 50]. In rela-
tion to DGE, the results are similar ranging from 13 to
14%, with a greater tendency in male patients over 75
years old, with pyloric preservation and a surgical dura-
tion of >5 h [49]. The results of wound infection rates are
more than double in patients subjected to PD, reaching
rates of up to 23.5% [50]. In terms of mortality, PPTD is
presented as a safe intervention with values below 2%,
slightly lower than PD (3–5%) [48, 49].
The analysis has several limitations. First, all studies
were retrospective, with an inherent risk of bias; differ-
ences in some variables, including the experience of the
institution, the number of patients undergoing the inter-
vention, perioperative management, study populations,
surgical procedures, and reconstructions may have influ-
enced survival outcomes. Second, as the studies spanned
a period of >3 decades, the results may have been influ-
enced by the time when the surgery was performed. Third,
in FAP, there is a risk of missing lymph node involvement
since the duodenal submucosa is involved; since histolo-
gy was not reported in 49 patients, it is possible that some
FAP patients had this operation inappropriately. Fourth,
survival rates in patients with duodenal pathology have
risen in recent decades, not only because of advances in
surgical technique but also because of the development of
new instruments and endoscopic techniques that allow
better control of the disease. The main limitation of the
study is the lack of homogeneity of the articles collected
to carry out the review, which makes it impossible to per-
form a subsequent meta-analysis.
Conclusions
Despite the difficulty of PPTD surgery, the technical
advances in recent decades have allowed the resection of
patients with duodenal pathology in the absence of pan-
creatic disease. PPTD is the technique of choice for pa-
tients with noninvasive adenomatous disease or lesions
with little or nonmalignant potential that do not affect the
pancreatic head. The studies published are retrospective,
and in many of them, the case series are small. However,
the risks involved in PPTD are clearly falling, and both
the exocrine and endocrine benefits of total pancreatic
preservation are increasingly being recognized. PPTD
prevents the development of diabetic pathology and pre-
sents a mortality rate of <2%. We stress that a complete
preoperative pancreatic anatomical study is necessary to
rule out the presence of a pancreas divisum.
To conclude, in the absence of prospective random-
ized studies and despite the fact that several centers pre-
Total Duodenectomy: A Systematic
Review
11
Dig Surg
DOI: 10.1159/000515718
sent isolated cases of PPDT, especially in relation to those
centers with larger patient series the results show that
PPDT is a safe, viable, and feasible surgical technique for
patients with benign and premalignant duodenal lesions
at high-volume centers with proven experience featuring
overall survival rates at 5 years were upper than 97.5% and
the possibility of conservative management of postopera-
tive complications in up to 76% of patients with postop-
erative adverse effects.
Statement of Ethics
This study complies with the guidelines for human studies. The
research was conducted ethically in accordance with the World
Medical Association Declaration of Helsinki. Because it is a sys-
tematic review of the literature, the paper is exempt from Ethical
Committee approval.
Conflict of Interest Statement
No conflicts of interest.
Funding Sources
No financial support has been received for the realization of
this paper.
Author Contributions
José Manuel Ramia and Mario Serradilla-Martín designed the
work. Miguel Cantalejo-Díaz and Ana Palomares-Cano partici-
pated in the acquisition and analysis of the data. José Manuel
Ramia and Mario Serradilla-Martín interpreted the data for the
work. Miguel Cantalejo-Díaz and Ana Palomares-Cano wrote the
work. José Manuel Ramia and Mario Serradilla-Martín revised the
content and gave the final approval of the version to be published.
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