ArticlePDF Available

Laparoscopic Pancreas-Sparing Subtotal Duodenectomy

Authors:
Ignasi Poves at Autonomous University of Barcelona
Ignasi Poves
Fernando Burdío at Parc de recerca biomedica de barcelona
Fernando Burdío
Sandra Alonso
Sandra Alonso
Sandra Alonso
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Agustín Seoane at University Pompeu Fabra
Agustín Seoane
Show all 5 authorsHide
Download full-text PDFDownload full-text PDF
Read full-text
Download citation

Abstract and Figures

Primary adenocarcinoma of the duodenum is a rare digestive malignancy which is commonly treated by radical surgical resection, pancreaticoduodenectomy being the technique of choice. Complete tumor resection obtaining free margins should be the standard of treatment for primary adenocarcinoma of the duodenum. Segmental duodenal resection is an appropriate operation for selected cases of primary adenocarcinoma of the duodenum of the 3rd and 4th portions of the duodenum. We present the case of a 67-year-old woman suffering from an infra-ampullary large villous polypoid mass affecting the 3rd portion of the duodenum. Multiple endoscopic biopsies did not disclose any malignancy, and abdominal CT and endoscopic ultrasound found no extraduodenal involvement. A 3rd and 4th portion pancreas-sparing duodenectomy was carried out using a totally laparoscopic approach. Intra-operatory duodenoscopy was done to safeguard the papilla of Vater. Recovery was uneventful and the patient was discharged on the 7th postoperative day. The final diagnosis was primary adenocarcinoma of the duodenum (free resection margins). After forty-five months of follow-up, the patient is free of disease. We recommend this procedure for treatment of an infra-ampullary benign and pre-malignant duodenal pathology; it can also be a treatment option and an alternative to a pancreaticoduodenectomy in very selected cases of tumors confined to the duodenum. Expertise in both pancreatic surgery and laparoscopic techniques is required.
Figures - uploaded by Luis Grande
Author content
All figure content in this area was uploaded by Luis Grande
Content may be subject to copyright.
0780f020-012a-012e-a847-000c293b26
d5.pdf
Content uploaded by Luis Grande
Author content
All content in this area was uploaded by Luis Grande
Content may be subject to copyright.
Laparoscopic Pancreas-Sparing Subtotal Duodenecto
my.pdf
Available via license: CC BY 4.0
Content may be subject to copyright.
JOP. J Pancreas (Online) 2011 Jan 5; 12(1):62-65.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 1 - January 2011. [ISSN 1590-8577] 62
CASE REPORT
Laparoscopic Pancreas-Sparing Subtotal Duodenectomy
Ignasi Poves1, Fernando Burdio1, Sandra Alonso1, Agustín Seoane2, Luís Grande1
Departments of 1General and Digestive Surgery and 2Gastroenterology,
“Hospital del Mar”. Barcelona, Spain
ABSTRACT
Context Primary adenocarcinoma of the duodenum is a rare digestive malignancy which is commonly treated by radical surgical
resection, pancreaticoduodenectomy being the technique of choice. Complete tumor resection obtaining free margins should be the
standard of treatment for primary adenocarcinoma of the duodenum. Segmental duodenal resection is an appropriate operation for
selected cases of primary adenocarcinoma of the duodenum of the 3rd and 4th portions of the duodenum. Case report We present the
case of a 67-year-old woman suffering from an infra-ampullary large villous polypoid mass affecting the 3rd portion of the
duodenum. Multiple endoscopic biopsies did not disclose any malignancy, and abdominal CT and endoscopic ultrasound found no
extraduodenal involvement. A 3rd and 4th portion pancreas-sparing duodenectomy was carried out using a totally laparoscopic
approach. Intra-operatory duodenoscopy was done to safeguard the papilla of Vater. Recovery was uneventful and the patient was
discharged on the 7th postoperative day. The final diagnosis was primary adenocarcinoma of the duodenum (free resection margins).
After forty-five months of follow-up, the patient is free of disease. Conclusions We recommend this procedure for treatment of an
infra-ampullary benign and pre-malignant duodenal pathology; it can also be a treatment option and an alternative to a
pancreaticoduodenectomy in very selected cases of tumors confined to the duodenum. Expertise in both pancreatic surgery and
laparoscopic techniques is required.
INTRODUCTION
Primary adenocarcinoma of the duodenum is a rare
digestive malignancy. Radical surgical resection is
considered the treatment of choice, and a
pancreaticoduodenectomy is the preferred surgical
procedure regardless of the tumor site which is usually
periampullary [1, 2]. Other more limited resection
procedures, such as segmental duodenal resection and
transduodenal excision, are considered only for
selected cases [3, 4, 5, 6, 7]. Endoscopic snare excision
and pancreas-sparing total duodenectomy have been
considered only for the treatment of isolated benign
polyps or in association with familial adenomatous
polyposis [8]. The laparoscopic approach for resection
of the duodenum is still experimental, having only been
used in benign disease [9].
CASE REPORT
A 67-year-old woman with a body mass index of 40
Kg/m2 was admitted to our hospital complaining of
acute upper gastrointestinal bleeding. She had
experienced a syncope episode followed by melenas.
An upper digestive endoscopy revealed a large friable
polypoid mass about 5 cm in diameter, surrounding 3/4
of the internal lumen, coming from the 3rd portion of
the duodenum, about 3 cm distal to the ampulla (Figure
1). There were no other polypoid lesions in the
duodenum. Multiple endoscopic biopsies (five
samples) confirmed a villous adenomatous polyp with
mild-moderate dysplasia. Abdominal CT showed the
mass to be confined to the duodenum. An extension
Received September 16th, 2010 - Accepted December 14th, 2010
Key words Duodenal Neoplasms; Duodenoscopy; Laparoscopy
/surgery; Pancreaticoduodenectomy
Correspondence Ignasi Poves
Hospital Universitari del Mar; Unit of Hepato-Biliary-Pancreatic
Surgery; Department of General and Digestive Surgery; Passeig
Marítim 25-29; 08003 Barcelona; Spain
Phone: +34-932.483.207; Fax: +34.932.483.433
E-mail: ipoves@parcdesalutmar.cat
Document URL http://www.joplink.net/prev/201101/18.html Figure 1. Duodenoscopy revealing a large polypoid mass.
JOP. J Pancreas (Online) 2011 Jan 5; 12(1):62-65.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 1 - January 2011. [ISSN 1590-8577] 63
study was completed via endoscopic ultrasonography
which showed no disruption of any of the muscle
layers of the duodenum (Figure 2) and no penetration
into the pancreas. The pancreatic duct was preserved
and there were no pathological regional lymph nodes.
Tumor markers (CEA and CA 19-9) were negative.
From the day of admission to the day of the surgery,
the patient required transfusion of 7 units of red blood
cells.
A totally laparoscopic approach was used for the entire
procedure using a five-port technique (Figure 3). The
patient was placed in a reverse Trendelenburg position
with the legs spread open. The surgeon stood between
the patient’s legs and the 2 assistants at each side of the
surgeon. The surgical procedure was started with a
complete Kocher’s maneuver, detaching the greater
omentum from the transverse colon along the avascular
plane to the hepatic flexure of the colon. The head of
the pancreas and the plane of the mesocolon were
exposed. The tumor was clearly identified occupying
the 3rd portion of the duodenum but having its origin
near the 2nd portion. The retroduodenal and peri-
pancreatic areas were carefully explored and no
macroscopically pathological lymph nodes were found.
Following dissection of the Treitz ligament, the first
jejunal limb just distal to the duodenojejunal ligament
was sectioned using a 45 mm linear cutter and 2.5 mm
stapler. The sectioned proximal jejunum was then
passed behind the mesenteric vessels. The duodenum
was spared to the pancreas using ultrasound shears
(Harmonic AceTM 5 mm, Ethicon Endo-Surgery,
Guaynabo, Puerto Rico) (Figure 4). By means of
concomitant intraoperative duodenoscopic vision of the
ampulla, the duodenum was sectioned, just infra-
ampullary, above the tumor, obtaining adequate free
margins (Figure 5). The intestinal tract was
Figure 2. Endoscopic ultrasonography revealing the depth o
f
invasion of the tumor into the muscular layers. The serosa was
respected.
Figure 3. Placement of the five ports. Umbilical optic view.
Figure 5. Sectioning of the duodenum infrapapillary unde
r
endoscopic control view.
D II: second portion of the duodenum
Figure 4. 3rd and 4th portions of the duodenum are spared from the
head of the pancreas.
JOP. J Pancreas (Online) 2011 Jan 5; 12(1):62-65.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 1 - January 2011. [ISSN 1590-8577] 64
reconstructed in a transmesocolic side-to-side
duodenojejunostomy (45 mm linear cutter and 2.5 mm
stapler and the enterotomy was closed with interrupted
2-0 polyglactin sutures) (Figure 6). The specimen was
removed through the umbilical trocar and protected in
a bag. The operation lasted 227 minutes.
The patient started oral intake on the 3rd postoperative
day following a swallow control (Figure 7). Recovery
was uneventful and she was discharged on the 7th
postoperative day. Upper digestive endoscopy
performed three months after surgery showed a normal
anastomosis.
Final diagnosis was primary duodenal adenocarcinoma
(moderate differentiation) over a villous adenoma. The
size of the tumor was 75x55x19 mm (Figure 8). The
depth of invasion was 3 mm near the serosa. Proximal
(15 mm), distal and tangential resection margins were
not affected. There was neither perineural nor
microvascular invasion. No lymph nodes were
harvested. One month after the surgical procedure,
adjuvant chemotherapy was given (four cycles with
oxaliplatin and capecitabine). After forty-five months
of follow-up, there is no evidence of either local
recurrence or metastatic disease on abdominal CT and
upper digestive endoscopy.
DISCUSSION
Overall 5-year survival for primary adenocarcinoma of
the duodenum is 23-31% [5, 6], rising to 51-60% [2, 4,
5, 6, 10] in resected patients. The reported experience
from the Memorial Sloan-Kettering Cancer Center [5]
showed that nodal metastases, regardless of their
location, do not have an impact on survival. Only
resectability and the presence of non-nodal metastases
Figure 6. Stapled side-to-side duodenojejunostomy.
D II: second portion of the duodenum
Figure 7. Postoperative swallow control. Figure 8. Resected duodenal specimen showing the size of the tumo
r
and macroscopically free margins.
JOP. J Pancreas (Online) 2011 Jan 5; 12(1):62-65.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 1 - January 2011. [ISSN 1590-8577] 65
predict outcome. In this way, the Mayo Clinic
experience [2] reports that lymph node metastasis,
advanced tumor stage, and positive resection margins
are associated with decreased survival, and hence
recommends pursuing negative resection margins.
These findings are supported by the majority of authors
[3, 10]. When considering oncological benefits,
segmental duodenal resection and wide local excision
instead of a pancreaticoduodenectomy seem to be
appropriate for selected patients, especially for tumors
of the distal duodenum [6, 10]. A pancreatico-
duodenectomy is an aggressive procedure well justified
for the treatment of neoplasms of the head of the
pancreas, periampullary area and duodenum, although
it has considerable morbidity and mortality. For
treatment of distal primary adenocarcinoma of the
duodenum, a pancreaticoduodenectomy is associated
with an increase in postoperative complications when
compared to segmental duodenal resection even though
they have equal outcomes [4, 6]. Primary
adenocarcinoma of the duodenum usually extends to
the pancreas. Direct extension of the tumor into the
pancreas and involvement of pathological lymph nodes
can now be preoperatively well documented by
endoscopic ultrasonography, with subsequent
consideration of segmental duodenal resection as an
alternative treatment option.
The pancreas-sparing duodenectomy technique for the
treatment of infra-ampullary duodenal pathologies was
first described in 1996 [8] for tumors located in the 3rd
and/or 4th portions of the duodenum. In this case, the
difficulty of a successful pancreas-sparing
duodenectomy was that the tumor was located infra-
papillary, thus it was mandatory to perform an intra-
operatory duodenoscopy to preserve the papilla of
Vater while maintaining disease-free margins when
sectioning the duodenum. A laparoscopic pancreas-
sparing duodenectomy has been described once in the
literature, but only for the treatment of a benign peptic
stricture of the 4th portion of a very distended
duodenum [9]. This is the first time that this procedure
has been described for the treatment of duodenal
tumors and for lesions involving the 3rd portion of the
duodenum. Obviously, not only adequate experience in
pancreatic surgery but also expertise in laparoscopy is
mandatory for carrying out this procedure. Due to the
difficulty involved in obtaining a large series of these
rare tumors and since long term follow-up of this case
is not yet available, we recommend this procedure as a
less morbid option than a pancreaticoduodenectomy for
the treatment of benign and pre-malignant infra-
ampullary duodenal pathologies. It can also be a
treatment option for patients suffering from duodenal
gastrointestinal stromal tumors and for patients ruled
out for a pancreaticoduodenectomy if the tumor is
confined to the duodenal wall.
Disclosure statement No competing financial interests
exist
References
1. Bal A, Joshi K, Vaiphei K, Wig JD. Primary duodenal
neoplasms: a retrospective clinico-pathological analysis. World J
Gastroenterol 2007; 13:1108-11. [PMID 17373748]
2. Bakaeen FG, Murr MM, Sarr MG, Thompson GB, Farnell MB,
Nagorney DM, et al. What prognostic factors are important in
duodenal adenocarcinoma? Arch Surg 2000; 135:635-41. [PMID
10843358]
3. Kaklamanos IG, Bathe OF, Franceschi D, Camarda C, Levi J,
Livingstone AS. Extent of resection in the management of duodenal
adenocarcinoma. Am J Surg 2000; 179:37-41. [PMID 10737576]
4. Sohn TA, Lillemoe KD, Cameron JL, Pitt HA, Kaufman HS,
Hruban RH, Yeo CJ. Adenocarcinoma of the duodenum: factors
influencing long term survival. J Gastrointest Surg 1998; 2:79-87.
[PMID 9841972]
5. Rose DM, Hochwald SN, Klimstra DS, Brennan MF. Primary
duodenal adenocarcinoma: a ten-year experience with 79 patients. J
Am Coll Surg 1996; 183:89-96. [PMID 8696551]
6. Tocchi A, Mazzoni G, Puma F, Miccini M, Cassini D, Bettelli E,
Tagliacozzo S. Adenocarcinoma of the third and fourth portions of
the duodenum: results of surgical treatment. Arch Surg 2003; 138:80-
5. [PMID 12511157]
7. Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL.
Pancreas-sparing duodenectomy for infra-ampullary duodenal
pathology. Am J Surg 1996; 171:62-7. [PMID 8554153]
8. Tsiotos GG, Sarr MG. Pancreas-preserving total duodenectomy.
Dig Surg 1998; 15:398-403. [PMID 9845621]
9. Ammori BJ. Laparoscopic pancreas-preserving distal
duodenectomy for duodenal stricture related to nonsteroidal
antiinflammatory drugs (NSAIDs). Surg Endosc 2002; 16:1362-33.
[PMID 12072993]
10. Barnes G Jr, Romero L, Hess KR, Curley SA. Primary
adenocarcinoma of the duodenum: management and survival in 67
patients. Ann Surg Oncol 1994; 1:73-8. [PMID 7834432]
... [6][7][8][9][10] In recent years, there have been some reports of laparoscopic transduodenal and segmental duodenal resections for duodenal tumors, [11][12][13][14] but such approaches are limited by the high level of technical expertise required for resection and reconstruction (especially of the ampulla), limited visualization, and the technical limitations due to lack of articulation of laparoscopic instruments. [11][12][13][14][15] Robotic duodenal surgery (RDS) can combine the benefits of open and laparoscopic approach through better three-dimensional visualization, improved instrument dexterity, and avoidance of larger incisions and can theoretically bridge the gap between endoscopic and surgical treatment strategies for duodenal pathology. [16][17][18] This study is a retrospective review of a single-center experience with robotic surgery (non-PD) for benign and low-grade malignant disease processes of the duodenum. ...
... 7,12 Laparoscopic resection of ampullary and periampullary duodenal diseases initially generated a lot of hype after Rosen et al. first described their experience in 2003 but has not lived up to the promise of providing a safe and less morbid alternate to open resection with reports of experience limited to a handful of case reports and short case series since then. [11][12][13][14][15] Although the complication rates in these articles are comparable or slightly better than those described with open surgery, the technical challenges related to complex anatomy of this region, two-dimensional visualization, and rigidity of nonarticulating instruments has limited reproducibility and restricted use of this approach to the hands of a few highly skilled individuals. [13][14][15][16][17] The robotic platform offers several theoretic advantages specific to duodenal and ampullary anatomy 16, 17 and can combine the minimally invasive benefits of laparoscopy and endoscopy with visualization and resectional advantages of open surgery. ...
... [11][12][13][14][15] Although the complication rates in these articles are comparable or slightly better than those described with open surgery, the technical challenges related to complex anatomy of this region, two-dimensional visualization, and rigidity of nonarticulating instruments has limited reproducibility and restricted use of this approach to the hands of a few highly skilled individuals. [13][14][15][16][17] The robotic platform offers several theoretic advantages specific to duodenal and ampullary anatomy 16, 17 and can combine the minimally invasive benefits of laparoscopy and endoscopy with visualization and resectional advantages of open surgery. [16][17][18] The three-dimensional imaging, higher magnification, and extreme wrist articulation with the robotic platform provides unmatched visualization and instrument dexterity that is not too dissimilar to conventional open surgery. ...
Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum
Article
  • Apr 2019
Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010-2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3-21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.
View
... Pancreas-preserving duodenectomy (PPD) is an alternative for nonampullary duodenal neoplasms, with the rationale of limiting the loss of pancreatic parenchyma and decreasing the risk of exocrine and endocrine pancreatic insufficiency. Both partial and total sleeve resections of the duodenum have been reported [25]. ...
... While technically challenging, the magnification of the surgical site during laparoscopic access facilitates dissection of the duodenum from the pancreas. Moreover, PPD has several advantages over the pancreaticoduodenectomy both in terms of complexity and complications including lower incidence of exocrine and endocrine pancreatic insufficiency and a reduced number of anastomoses [25]. Generally, data on laparoscopic sleeve duodenal resections are limited [25,32]. ...
... Moreover, PPD has several advantages over the pancreaticoduodenectomy both in terms of complexity and complications including lower incidence of exocrine and endocrine pancreatic insufficiency and a reduced number of anastomoses [25]. Generally, data on laparoscopic sleeve duodenal resections are limited [25,32]. Our series demonstrates that the procedure is feasible and has low morbidity when performed in a tertiary care center [32]. ...
Endoscopic and surgical management of nonampullary duodenal neoplasms
Article
Full-text available
  • Jun 2018
  • SURG ENDOSC
Background: Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD). Methods: We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients. Results: Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention. Conclusions: Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.
View
... [5] The next most common presentations are abdominal discomfort, pain and swelling. [6] Diagnosis can be made with upper GI endoscopy. [6] Presentation of a non palpable gastro duodenal stromal tumor is very vague and high likelihood of missed diagnosis persists. ...
... [6] Diagnosis can be made with upper GI endoscopy. [6] Presentation of a non palpable gastro duodenal stromal tumor is very vague and high likelihood of missed diagnosis persists. ...
A Rare Case Report of Gastroduodenal Stromal Tumour: A Diagnostic Dilemma
Article
Full-text available
  • Jan 2015
Gastrointestinal stromal tumors are relatively uncommon mesenchymal tumors affecting the GI tract. Non palpable gastro duodenal are difficult to diagnose. Here is one such case diagnosed on upper GI endoscopy and was evaluated. On evaluation features were suggestive of CA stomach and endoscopic biopsy report was inconclusive. The patient underwent exploratory laparotomy and post operatively histopathology report suggested of Gist. Hence on table surgeons decision of surgical procedure is gold standard in deciding the further outcome of the disease.
View
... Moreover, CGLD does not require complex reconstruction; thus, it does not disrupt PD when it is found to be necessary. CGLD can be performed without intraoperative endoscopy, although local duodenectomy often requires endoscopy, especially when the tumor is limited to the mucosal side [24]. Furthermore, sometimes the whole tumor cannot be observed by intraoperative endoscopy. ...
Clip-guided local duodenectomy for safe and minimal local resection of nonampullary duodenal neoplasms
Article
Full-text available
  • Aug 2022
  • BMC Surg
Background Local duodenectomy and primary closure is a simple option for some nonampullary duodenal neoplasms. Minimizing the resection area while ensuring curability is necessary for safe primary duodenal closure. However, it is often difficult to determine the appropriate resection line from the serosal side. We developed clip-guided local duodenectomy to easily determine the resection range and perform local duodenectomy safely, then performed a retrospective observational study to confirm the safety of clip-guided local duodenectomy. Methods The procedure is as follows: placing endoscopic metal clips at four points on the margin around the tumor within 3 days before surgery, identifying the tumor extent with the clips under X-ray imaging during surgery, making an incision to the duodenum just outside of the clips visualized by X-ray imaging, full-thickness resection of the duodenum with the clips as guides of tumor demarcation, and transversely closure by Gambee suture. We evaluated clinicopathological data and surgical outcomes of patients who underwent clip-guided local duodenectomy at two surgical centers between January 2010 and May 2020. Results Eighteen patients were included. The pathological diagnosis was adenoma (11 cases), adenocarcinoma (6 cases), and GIST (1 case). The mean ± SD tumor size was 18 ± 6 mm, and the tumor was mainly located in the second portion of the duodenum (66%). In all cases, the duodenal defect was closed with primary sutures. The mean operation time and blood loss were 191 min and 79 mL, respectively. The morbidity was 22%, and all complications were Clavien–Dindo grade II. No anastomotic leakage or stenosis was observed. In the 6 adenocarcinoma patients, all were diagnosed with pT1a, and postoperative recurrence was not observed. The 1-year overall and recurrence free survival rate was 100%. Conclusions Clip-guided local duodenectomy is a safe and useful surgical option for minimally local resection of nonampullary duodenal neoplasms such as duodenal adenoma, GIST, and early adenocarcinoma.
View
... Moreover, CGLD does not require complex reconstruction; thus, it does not disrupt PD when it is found to be necessary. CGLD can be performed without intraoperative endoscopy, although local duodenectomy often requires endoscopy, especially when the tumor is limited to the mucosal side [24]. Furthermore, sometimes the whole tumor cannot be observed by intraoperative endoscopy. ...
Clip-Guided Local Duodenectomy for Safe and Minimal Local Resection of Nonampullary Duodenal Neoplasms
Preprint
Full-text available
  • Dec 2021
Background: Local duodenectomy and primary closure is a simple option for some nonampullary duodenal neoplasms. Minimizing the resection area while ensuring curability is necessary for safe primary duodenal closure. However, it is often difficult to determine the appropriate resection line from the serosal side. We developed clip-guided local duodenectomy to easily determine the resection range and perform local duodenectomy safely, then performed a retrospective observational study to confirm the safety of clip-guided local duodenectomy. Methods: The procedure is as follows: placing endoscopic metal clips at four points on the margin around the tumor within 3 days before surgery, identifying the tumor extent with the clips under X-ray imaging during surgery, making an incision to the duodenum just outside of the clips visualized by X-ray imaging, full-thickness resection of the duodenum with the clips as guides of tumor demarcation, and transversely closure by Gambee suture. We evaluated clinicopathological data and surgical outcomes of patients who underwent clip-guided local duodenectomy at two surgical centers between January 2010 and May 2020. Results: Eighteen patients were included. The pathological diagnosis was adenoma (11 cases), adenocarcinoma (6 cases), and GIST (1 case). The mean ± SD tumor size was 18 ± 6 mm, and the tumor was mainly located in the second portion of the duodenum (66%). In all cases, the duodenal defect was closed with primary sutures. The mean operation time and blood loss were 191 minutes and 79 mL, respectively. The morbidity was 22%, and all complications were Clavien-Dindo grade II. No anastomotic leakage or stenosis was observed. In the 6 adenocarcinoma patients, all were diagnosed with pT1a, and postoperative recurrence was not observed. The 1-year overall and recurrence free survival rate was 100%. Conclusions: Clip-guided local duodenectomy is a safe and useful surgical option for minimally local resection of nonampullary duodenal neoplasms such as duodenal adenoma, GIST, and early adenocarcinoma.
View
... Bartel et al. described infra-ampullary distal pancreas-preserving partial duodenectomy as a good surgical option for benign lesions not amenable to endoscopic resection and which preserves the pancreas [11]. Poves et al. reported a patient who underwent laparoscopic PSDD using an approach that began with the complete Kocher's maneuver [12]. However Kocher's maneuver and Cattell-Braasch maneuver make laparoscopic approach difficult under the magnified view by laparoscopy. ...
Two Case of Bilateral Approach in Laparoscopic Pancreas-Sparing Distal Duodenectomy for Duodenal Neoplasms Arising from the Distal Duodenum
Article
Full-text available
  • Feb 2021
Introduction Laparoscopic pancreas-sparing distal duodenectomy is a less invasive surgical therapy; however, the anatomical complexity of the duodenum increases the difficulty of laparoscopic procedures. We introduce our technique for laparoscopic pancreas-sparing distal duodenectomy for distal duodenal tumors. Presentation of cases A first patient was 47-year-old woman who had 30 mm of duodenal tumor which located in third portion of duodenum. A second patient was 66-year-old man who had 35 mm of submucosal tumor which located in the third portion of duodenum. Laparoscopic pancreas-sparing duodenectomy was performed using bilateral approach for both cases. We began by dissecting an avascular area on the right side of the transverse mesocolon to mobilize the second and third portions of the duodenum with the uncinate process of the pancreas. Next, from the left side, the jejunum and the fourth portion of the duodenum were fully mobilized orally from the surrounding tissue, connecting the dissection plane with the right-side area. The jejunum and duodenum were cut with a linear stapler. Intracorporeal reconstruction was performed in an overlapped manner. We performed this procedure in two patients. Operative time was 326 and 370 min, respectively. Patients were discharged on postoperative days 9–12 without postoperative complications. Discussion Duodenal tumors are found increasingly often because of developments in endoscopic technology and techniques; therefore, establishing safe surgical procedures for duodenal tumor excision is imperative. Our surgical approach was simple and safe procedure. Conclusion Laparoscopic pancreas-sparing distal duodenectomy with a bilateral approach is a useful approach without wide mobilization of duodenum.
View
... However, a laparoscopic procedure for this has also been recently reported. 7,8 The artery first approach is designed to decrease the R1 rate for pancreatic cancer, especially for the one located at the uncinate process. This is another procedure, known as the SMA first approach for PD, that was first presented in Korea by myself a few years ago. ...
View
Limited resection vs. pancreaticoduodenectomy for primary duodenal adenocarcinoma: a systematic review and meta-analysis
Article
  • Mar 2021
It is well known that surgery is the mainstay treatment for duodenal adenocarcinoma. However, the optimal extent of surgery is still under debate. We aimed to systematically review and perform a meta-analysis of limited resection (LR) and pancreatoduodenectomy for patients with duodenal adenocarcinoma. A systematic electronic database search of the literature was performed using PubMed and the Cochrane Library. All studies comparing LR and pancreatoduodenectomy for patients with duodenal adenocarcinoma were selected. Long-term overall survival was considered as the primary outcome, and perioperative morbidity and mortality as the secondary outcomes. Fifteen studies with a total of 3166 patients were analyzed; 995 and 1498 patients were treated with limited resection and pancreatoduodenectomy, respectively. Eight and 7 studies scored a low and intermediate risk of publication bias, respectively. The LR group had a more favorable result than the pancreatoduodenectomy group in overall morbidity (odd ratio [OR]: 0.33, 95% confidence interval [CI] 0.17–0.65) and postoperative pancreatic fistula (OR: 0.13, 95% CI 0.04–0.43). Mortality (OR: 0.96, 95% CI 0.70–1.33) and overall survival (OR: 0.61, 95% CI 0.33–1.13) were not significantly different between the two groups, although comparison of the two groups stratified by prognostic factors, such as T categories, was not possible due to a lack of detailed data. LR showed long-term outcomes equivalent to those of pancreatoduodenectomy, while the perioperative morbidity rates were lower. LR could be an option for selected duodenal adenocarcinoma patients with appropriate location or depth of invasion, although further studies are required.
View
Minimally Invasive Small Bowel Cancer Surgery
Article
  • Dec 2018
  • SURG ONCOL CLIN N AM
Small bowel malignancies are extremely rare. Surgical resection is often the mainstay of treatment with the extent of the operation depending on the type of tumor. Whereas neuroendocrine tumors and adenocarcinoma require lymph node resection, gastrointestinal stromal tumors do not typically metastasize to regional nodes and therefore need resection only. Minimally invasive approaches are applicable to small tumors that require a limited resection and reconstruction and have been shown to have equal survival benefits with decreased risk of postoperative complications.
View
Laparoscopic Partial Sleeve Duodenectomy for the Infra-Ampullary Gastrointestinal Stromal Tumors of the Duodenum
Article
  • Jun 2018
Background: Although organ-preserving operations are regarded as effective strategies for duodenal gastrointestinal stromal tumors (GISTs), laparoscopic partial sleeve duodenectomy (lap PSD) has not been fully evaluated. The aims of this study were to evaluate the effectiveness and technical feasibility of lap PSD. Study design: Between January 2011 and March 2016, we reviewed 13 patients who underwent laparoscopic approach among 22 patients who underwent PSD. PSD for the infra-ampullary lesions was defined as infra-ampullary duodenal resection including the first portion of the jejunum. After resection, all patients underwent reconstruction via side-to-side duodenojejunostomy. Results: The total mean operation time was 273 min (range 160-346 min), and estimated mean blood loss was 80 ml (range scanty-200 ml). One patient was converted to open laparotomy because of mesocolonic tumor involvement. The median postoperative hospital stay was 10.5 days (range 4-36 days). There were no postoperative mortalities. Postoperative complications included 2 instances of delayed gastric emptying (DGE), 1 duodenojejunostomy stricture, and 2 intestinal obstructions. No patient was treated with adjuvant therapy. One patient experienced hepatic metastasis 28 months after surgery during a mean follow-up period of 48.6 months. Conclusion: Lap PSD might be an oncologically effective strategy for duodenal GIST, and the laparoscopic approach is a technically feasible and appealing surgical modality in terms of safety and perioperative results. However, DGE and anastomosis strictures are concerns for postoperative complications, which need to be further investigated.
View
Primary duodenal neoplasm: a retrospective clinico-pathological analysis
Article
Full-text available
  • Mar 2007
  • WORLD J GASTROENTERO
To analyze the clinico-pathological spectrum of primary duodenal neoplasms. A total of 55 primary duodenal neoplasms reported in the last 10 years after excluding ampullary and periampullary tumors were included in the study. Clinical details were noted and routine hematoxylin and eosin stained paraffin sections were studied for histological subtyping of the tumors. On histopathological examination primary duodenal neoplasms were categorized as: epithelial tumor in 27 cases (49.0%) including 10 cases of adenoma, 15 cases of adenocarcinoma, and 2 cases of Brunner gland adenoma; mesenchymal tumor in 9 cases (16.3%) consisting of 4 cases of gastrointestinal stromal tumor, 4 cases of smooth muscle tumor and I case of neurofibroma; lymphoproliferative tumor in 12 cases (21.8%), and neuroendocrine tumor in 7 cases (12.7%). Although non-ampullary/periampullary duodenal adenocarcinomas are rare, they constitute the largest group. Histopathological examination of primary duodenal tumors is important for correct histological subtyping.
View
Primary adenocarcinoma of the duodenum: Management and survival in 67 patients
Article
  • Jul 1994
Because of the rarity of primary adenocarcinoma of the duodenum, accumulation of natural history data has been difficult. As a result, debate continues over important treatment issues. We did a retrospective review of 67 patients with nonampullary adenocarcinoma of the duodenum treated at the University of Texas M.D. Anderson Cancer Center between 1967 and 1991. Presenting symptoms and signs, diagnostic studies, operation performed, surgical pathology, and survival were analyzed. A primary duodenal tumor was demonstrated by upper gastrointestinal radiographs (UGI) in 37 of 42 patients (88%), esophagogastroduodenoscopy (EGD) in 49 of 55 (89%), and computerized tomograms (CT) in 21 of 42 (50%). A curative resection was performed in 36 of the 59 patients who underwent operation (61%); 27 had pancreaticoduodenectomies and nine had wide local excisions. Overall 5-year survival was 29%. The 5-year survival difference between resected and unresected patients was 54% versus 0%, respectively (p < 0.0001). No survival difference was noted between patients who underwent pancreaticoduodenectomy rather than wide local excision. Lymph node metastases were significantly related to the occurrence of distant metastases (p = 0.0034). The 5-year survival for patients with stage I or II tumors was 100% and 52%, respectively, compared to 45% and 0% for stage III and IV (p < 0.0001). Our data suggest that UGI and EGD are effective for diagnosing duodenal carcinoma. Survival is improved by curative resection and is not compromised by a wide local excision instead of a pancreaticoduodenectomy for lesions of the third and fourth portion. We recommend that adjuvant chemotherapy be considered for stage III disease, because distant failure is the predominant pattern of failure in this group.
View
Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology
Article
  • Feb 1996
  • AM J SURG
Surgical management of distal duodenal pathology is challenging because of the duodenum's retroperitoneal location and its shared blood supply with the pancreas. For infra-ampullary pathology, surgical treatment may include local excision, pancreaticoduodenectomy, or pancreas-sparing duodenectomy (PSD). We retrospectively reviewed the management of 24 patients with infra-ampullary duodenal pathology treated by PSD between 1985 and 1994 at The Johns Hopkins Hospital. There were 16 men and 8 women with a mean age of 51.2 +/- 4.4 years. The indications for elective PSD in 19 patients were neoplasms (n = 15), Crohn's disease (n = 2), and other (n = 2). Of the neoplasms, 13 were malignant (11 adenocarcinoma, 1 lymphoma, 1 liposarcoma) and 2 were being (1 villous adenoma, 1 benign stromal tumor). Five patients had PSD as an emergency procedure for penetrating trauma. The mean follow-up is 24.2 +/- 5.8 months (range 1 to 122). In the group undergoing elective PSD, the mean length of operation was 5.3 +/- 0.4 hours, and the estimated blood loss was 569 +/- 121 mL. In the entire series, there was 1 postoperative death from an anastomotic leak and 1 reexploration for anastomotic bleeding. Pancreas-sparing duodenectomy in patients with trauma or benign duodenal pathology resulted in a good outcome in all. In those 11 patients with duodenal adenocarcinoma, 7 have died, 2 have had recurrences, and 2 are disease free. Actuarial and disease-free, 2-year survival rates in the 11 patients with duodenal adenocarcinoma were 33% and 14%, respectively. Pancreas-sparing duodenectomy is a safe and effective treatment in patients with distal duodenal benign neoplasms or trauma, and PSD appears to have limited effectiveness for malignant distal duodenal pathology.
View
Primary duodenal adenocarcinoma: A ten-year experience with 79 patients
Article
  • Sep 1996
Duodenal adenocarcinoma is a rare malignancy with a poorly defined natural history and outcome. The factors that affect management and survival of patients with this disease remain controversial. This study analyzed the ten-year experience at one institution with primary duodenal adenocarcinoma to define factors that have an impact on patient survival. In addition, the outcome of patients with resected duodenal adenocarcinoma was compared with that of patients with gastric and pancreatic adenocarcinoma. A retrospective review of the prospective database for patients with peripancreatic lesions treated at Memorial Sloan-Kettering Cancer Center between 1983 and 1994 identified 79 patients with a primary duodenal adenocarcinoma. Demographics, presenting symptoms, operative variables, pathologic findings, and survival data were analyzed. Multivariate comparisons and actuarial survival were calculated using these variables. A curative resection was performed in 42 (53 percent) of the 79 patients, including 38 pancreaticoduodenectomies and four duodenal resections. The overall projected five-year survival rate was 31 percent, with resected and nonresected patient survival rates of 60 and zero percent, respectively (p < 0.0001). Nodal metastases, regardless of location, did not have an impact on survival. While stage was a significant factor in survival on univariate analysis, no survival difference was noted between stages I, II, and III. Only resectability and presence of non-nodal metastases predicted outcome on multivariate analysis. Resectability and presence of distant metastatic disease are the strongest determinants of outcome for patients with duodenal adenocarcinoma. Staging and nodal status offer little prognostic information and nodal positivity should not preclude resection. As patients have symptoms similar to those of pancreatic adenocarcinoma but have an outlook more comparable to gastric adenocarcinoma, a vigorous approach to resection is justified.
View
Adenocarcinoma of the Duodenum: Factors Influencing Long-Term Survival
Article
  • Feb 1998
This single-institution retrospective analysis reviews the management and outcome of patients with surgically treated adenocarcinoma of the duodenum. Between February 1984 and August 1996, fifty-five patients with adenocarcinoma of the duodenum underwent surgery at The Johns Hopkins Hospital. Univariate analysis was performed to identify possible prognostic indicators. Curative resection was performed in 48 patients (87%): 35 of these patients (73%) underwent a pancreaticoduodenectomy (PD), whereas 27% (n = 13) underwent a pancreas-sparing duodenectomy (PSD). Patients undergoing PD were comparable to those undergoing PSD with respect to demographic factors, presenting symptoms, and tumor pathology. The remaining 13% of patients (n = 7) were deemed unresectable at the time of surgery and underwent biopsy and/or palliative bypass. PD was associated with an increase in postoperative complications when compared to PSD (57% vs. 30%), but this difference was not statistically significant. One perioperative death occurred following PD (mortality 2.9%). The overall 5-year survival rate for the 48 patients undergoing potentially curative resection was 53%. Negative resection margins (P <0.001), PD (P <0.005), and tumors in the first and second portions of the duodenum (P <0.05) were favorable predictors of long-term survival by univariate analysis. Nodal status, tumor diameter, degree of differentiation, and the use of adjuvant chemoradiation therapy did not influence survival. These data support an aggressive role for resection in patients with adenocarcinoma of the dueodenum
View
Pancreas-Preserving Total Duodenectomy
Article
  • Feb 1998
  • DIGEST SURG
The concept of operations to be 'as resective as necessary and as organ-preserving as possible' has led to the novel technique of resection of the entire duodenum, with complete preservation of the head of the pancreas, as a better alternative to the classic pancreaticoduodenectomy. This operation requires meticulous technique and precise knowledge of pancreatic and peripancreatic anatomy. Indications include benign or premalignant conditions confined to the duodenal mucosa, usually familial adenomatous polyposis. When appropriately performed, pancreas-preserving total duodenectomy leads to shorter operative time, requires less and safer anastomoses, and optimizes postoperative endoscopic surveillance. The available long-term results are encouraging.
View
Extent of resection in the management of duodenal adenocarcinoma
Article
  • Feb 2000
  • AM J SURG
It has been postulated that segmental duodenal resection (SR) is not an adequate operation for patients with adenocarcinoma of the duodenum and that pancreaticoduodenectomy (PD) is the procedure of choice, regardless of the tumor site. However, data from previous studies do not clearly support this position. We reviewed the records of 63 patients treated for duodenal adenocarcinoma from 1979 through 1998. Perioperative outcome, patient survival, and extent of lymphadenectomy were compared in patients who underwent PD and SR. The overall morbidity for PD and SR was 27% and 18%, respectively (not significant [NS]). Patients who underwent SR had a 5-year survival of 60% versus 30% for patients who underwent PD (NS). Lymph node status was a prognostic factor for survival (P = 0.014). The mean number of lymph nodes in the specimens was 9.9 +/- 2.1 for PD and 8.3 +/- 4.4 for SR (NS). Segmental duodenal resection for patients with duodenal adenocarcinoma is associated with acceptable postoperative morbidity and long-term survival. The procedure is especially well suited for distal duodenal tumors. Clearance of lymph nodes and outcome are comparable to PD.
View
What prognostic factors are important in duodenal adenocarcinoma? Arch Surg. 135(6):635-641; discussion 641-2
Article
  • Jul 2000
  • ARCH SURG-CHICAGO
Survival of patients with adenocarcinoma of the duodenum depends on the ability to perform a complete resection and the tumor stage Retrospective case series. Tertiary care referral center. A cohort of 101 consecutive patients (mean age, 62 years), undergoing surgery for duodenal adenocarcinoma from January 1, 1976, through December 31, 1996. Patients with ampullary carcinoma were specifically excluded. Mean duration of follow-up was 4 years. Surgery was curative in 68 patients (67%) and palliative in 33 patients (33%). Of the curative group, 50 patients (74%) underwent radical surgery, ie, 30 (60%), pancreaticoduodenectomy; 15 (30%), pylorus-preserving pancreaticoduodenectomy; and 5 (10%), total pancreatectomy. A more limited resection procedure was used in 18 patients (26%) involving a segmental duodenal resection in 15 (83%) and a transduodenal excision in 3 (17%). patient survival, and correlation with patient and tumor variables using univariate and multivariate analysis. Actuarial 5-year survival for the curative group was 54%. Only 1 patient in the unresected group survived beyond 3 years. Nodal metastasis (P = .002), advanced tumor stage (P<.001), positive resection margin (P = .02), and weight loss (P<.001) had a significant negative impact on survival in multivariate analysis. Tumor grade, size, and location within the duodenum had no impact on survival. Patient age and tumor depth of invasion influenced survival in univariate analysis, but lost their prognostic significance in multivariate analysis. Metastasis to lymph nodes, advanced tumor stage, and positive resection margins are associated with decreased survival in patients with duodenal adenocarcinoma. An aggressive surgical approach that achieves complete tumor resection with negative margins should be pursued. Pancreaticoduodenectomy is usually required for cancers of the first and second portion of the duodenum. Segmental resection may be appropriate for selected patients, especially for tumors of the distal duodenum.
View
Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs)
Article
  • Oct 2002
  • SURG ENDOSC
Chronic ingestion of nonsteroidal antiinflammatory drugs (NSAIDs) has rarely been associated with the development of intestinal diaphragm-like strictures. We have explored the role of laparoscopic surgery for the management of NSAID-related long distal duodenal strictures. A 49-year-old woman had been on NSAID therapy (ibuprofen) for backache more than 2 years. She showed symptoms of gastric outlet obstruction and gastrointestinal blood loss, and investigations showed a long stricture in the third and fourth parts of the duodenum. She underwent a laparoscopic pancreas-preserving distal duodenectomy with duodenojejunal anastomosis. Relaparoscopy on postoperative day 1 for bleeding showed no active source of bleeding. The patient's subsequent recovery was uneventful, and she was discharged on postoperative day 4. Further symptomatic strictures developed 2 months later at the previously ulcerated pylorus and distal duodenal bulb and were managed by a laparoscopic Roux-en-Y gastrojejunostomy. The patient was discharged on postoperative day 3, but represented 2 months later with symptomatic stenosis at the gastrojejunostomy which was managed by a laparoscopic revision gastrojejunostomy. Discharged on the postoperative day 2, she had regained weight and remained symptom free at follow-up assessment 3 months later. Laparoscopic pancreas-preserving distal duodenectomy for the management of benign duodenal strictures is feasible and safe. Moreover, we have demonstrated the beneficial role of relaparoscopy for the management of postoperative complications and for revision surgical procedures.
View
Adenocarcinoma of the Third and Fourth Portions of the Duodenum Results of Surgical Treatment
Article
  • Feb 2003
  • ARCH SURG-CHICAGO
To verify the adequacy of duodenal segmentectomy after intestinal derotation in the treatment of primary adenocarcinoma of the third and fourth portions of the duodenum. A retrospective review of the surgical management of patients who underwent derotation of the third and fourth portions of the duodenum was undertaken to determine long-term outcome. Departments of surgery in 3 university hospitals. Between January 1, 1980, and December 31, 2000, 47 patients with primary adenocarcinoma of the third and fourth portions of the duodenum were surgically treated at 3 different institutions. Details of primary surgery were abstracted from clinical records of the original hospital referral. Postoperative clinical course and long-term outcome were evaluated by a review of the hospital records and follow-up. The results of a barium swallow test series was positive in 38 cases (80.8%) and esophagogastroduodenoscopy was primarily diagnostic in 30 patients (63.8%). In all cases duodenal segmentectomy was attempted. Twenty-two patients underwent palliative gastrojejunal bypass and in 9 patients pancreaticoduodenectomy was performed. In 16 cases duodenal segmentectomy was performed after intestinal derotation. Anastomoses were performed manually in all cases. Fifteen of the resected patients died of recurrent disease. A median (SD) disease-free survival of 36 (23.6) months (range, 6-85 months) was observed. The median (SD) overall survival was 37.5 (23.9) months (range, 11-85 months), the overall 5-year survival rate was 23% (11 patients), and the actuarial 5-year survival rate was 51% (24 patients). Duodenal segmentectomy associated with intestinal derotation was shown to be a straightforward, safe procedure for the treatment of the primary adenocarcinoma of the third and fourth portions of the duodenum. This surgical procedure should be preferred to pancreaticoduodenectomy because it is associated with negligible rates of morbidity and mortality, while allowing for satisfactory margin clearance and adequate lymphadenectomy.
View