Ann Hepatobiliary Pancreat Surg.  2022 May;26(2):149-158. 10.14701/ahbps.21-124.

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

• Sharma A
• Nagar A
• Varshney P
• Tomar M
• Sarin S
• Choubey RP
• Kapoor VK

• KMID: 2530094
• DOI: http://doi.org/10.14701/ahbps.21-124

Abstract

Backgrounds/Aims
Pancreaticoduodenectomy is the most common procedure for the management of duodenal pathologies. However, it is associated with substantial morbidity and a low risk of mortality. Pancreas-preserving limited duodenal resection (PPLDR) can be performed under specific scenarios. We share our experience with PPLDR and its outcome.
Methods
We retrospectively analyzed a prospectively maintained database of patients undergoing limited duodenal resection in the form of wedge (sleeve) resection or segmental resection of one or more duodenal segments from March 2016 to March 2021 at a tertiary care center in North India.
Results
During the study period, 10 patients (including 9 males) underwent PPLDR. Five of these 10 patients showed primary duodenal or proximal jejunal pathology, while the remaining five had duodenal pathology involving an adjacent organ tumor. Four patients underwent wedge (sleeve) resection, while the remaining six underwent segmental duodenal resection of one or more duodenal segments. Mean hospital stay was 6 days (range, 3–11 days) without 30-day mortality. Morbidity occurred in 4 patients (Grade I–II, n = 3; Grade III, n = 1). All patients were alive and disease-free at the time of last follow-up. The mean follow-up duration was 23 months (range, 2–48 months).
Conclusions
PPLDR is a safe and effective alternative for pancreaticoduodenectomy when selected carefully for specific tumor types and location.

Keyword

Duodenal neoplasms; Pancreaticoduodenectomy

Figure

• 

  Fig. 1 Diagrammatic representation of surgical procedures. (A) Primary repair of a minor defect in duodenal wall. (B) Jejunal serosal (loop) patch repair of large defect in the duodenal wall. (C) End-toend duodenojejunostomy. (D) Side-to-side duodenojejunostomy.

• 

  Fig. 2 (A, B) Computed tomography image of primary jejunal adenocarcinoma (arrows). (C) Intra-operative image showing jejunal tumor after mobilization of duodeno-jejunal flexure. (D, E) Resected specimen showing jejunal tumor.

• 

  Fig. 3 (A, B) Computed tomography images of large retroperitoneal sarcoma. (C, D) Intra-operative image showing large retroperitoneal sarcoma with focal duodenal involvement (arrows).

• 

  Fig. 4 (A) Computed tomography (CT) image showing hepatic flexure growth with colo-duodenal fistula (arrow). (B) Coronal section of CT scan showing colo-duodenal fistula (arrow). (C) Intra-operative image showing duodenal involvement (specimen retracted by the first assistant). (D) Jejunal patch in progress (side-to-side loop). (E) Resected specimen showing hepatic flexure colonic growth with duodenal fistula.

• 

  Fig. 5 Algorithm for management of duodenal pathologies requiring pancreas-preserving limited duodenal resection (PPLDR).

• 

  Fig. 6 Intra-operative image showing completed side-to-side duodenojejunal anastomosis.

Reference

1. Dindo D, Demartines N, Clavien PA. 2004; Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 240:205–213. DOI: 10.1097/01.sla.0000133083.54934.ae. PMID: 15273542. PMCID: PMC1360123.

2. Nakayama Y, Konishi M, Gotohda N, Kato Y, Aizawa H, Kudo M, et al. 2017; Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy. Surg Today. 47:705–711. DOI: 10.1007/s00595-016-1418-1. PMID: 27654454.

3. Nagai H, Hyodo M, Kurihara K, Ohki J, Yasuda T, Kasahara K, et al. 1999; Pancreas-sparing duodenectomy: classification, indication and procedures. Hepatogastroenterology. 46:1953–1958. PMID: 10430376.

4. Eisenberger CF, Knoefel WT, Peiper M, Yekebas EF, Hosch SB, Busch C, et al. 2004; Pancreas-sparing duodenectomy in duodenal pathology: indications and results. Hepatogastroenterology. 51:727–731. PMID: 15143902.

5. Burasakarn P, Higuchi R, Nunobe S, Kanaji S, Eguchi H, Okada KI, et al. 2021; Limited resection vs. pancreaticoduodenectomy for primary duodenal adenocarcinoma: a systematic review and meta-analysis. Int J Clin Oncol. 26:450–460. DOI: 10.1007/s10147-020-01840-5. PMID: 33386555.

6. Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL. 1996; Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg. 171:62–67. DOI: 10.1016/S0002-9610(99)80075-0. PMID: 8554153.

7. Golhar A, Mangla V, Mehrotra S, Lalwani S, Mehta N, Nundy S. 2018; Limited distal duodenal resection: surgical approach and outcomes. A case series. Ann Med Surg (Lond). 30:36–41. DOI: 10.1016/j.amsu.2018.04.005. PMID: 30013770. PMCID: PMC6019849.

8. Konishi M, Kinoshita T, Nakagohri T, Takahashi S, Gotohda N, Ryu M. 2007; Pancreas-sparing duodenectomy for duodenal neoplasms including malignancies. Hepatogastroenterology. 54:753–757. PMID: 17591055.

9. Dorcaratto D, Heneghan HM, Fiore B, Awan F, Maguire D, Geoghegan J, et al. 2015; Segmental duodenal resection: indications, surgical techniques and postoperative outcomes. J Gastrointest Surg. 19:736–742. DOI: 10.1007/s11605-015-2744-0. PMID: 25595309.

10. Zhou B, Zhang M, Wu J, Yan S, Zhou J, Zheng S. 2013; Pancreaticoduodenectomy versus local resection in the treatment of gastrointestinal stromal tumors of the duodenum. World J Surg Oncol. 11:196. DOI: 10.1186/1477-7819-11-196. PMID: 23945012. PMCID: PMC3751193.

11. Chung JC, Chu CW, Cho GS, Shin EJ, Lim CW, Kim HC, et al. 2010; Management and outcome of gastrointestinal stromal tumors of the duodenum. J Gastrointest Surg. 14:880–883. DOI: 10.1007/s11605-010-1170-6. PMID: 20140534.

12. Liang X, Yu H, Zhu LH, Wang XF, Cai XJ. 2013; Gastrointestinal stromal tumors of the duodenum: surgical management and survival results. World J Gastroenterol. 19:6000–6010. DOI: 10.3748/wjg.v19.i36.6000. PMID: 24106400. PMCID: PMC3785621.

13. Koea JB, Conlon K, Paty PB, Guillem JG, Cohen AM. 2000; Pancreatic or duodenal resection or both for advanced carcinoma of the right colon: is it justified? Dis Colon Rectum. 43:460–465. DOI: 10.1007/BF02237187. PMID: 10789739.

14. Hakimi AN, Rosing DK, Stabile BE, Petrie BA. 2007; En bloc resection of the duodenum for locally advanced right colon adenocarcinoma. Am Surg. 73:1063–1066. DOI: 10.1177/000313480707301031. PMID: 17983082.

15. Kamath AS, Iqbal CW, Pham TH, Wolff BG, Chua HK, Donohue JH, et al. 2011; Management and outcomes of primary coloduodenal fistulas. J Gastrointest Surg. 15:1706–1711. DOI: 10.1007/s11605-011-1630-7. PMID: 21826549.

16. Lianwen Y, Jianping Z, Guoshun S, Dongcai L, Jiapeng Z. 2009; Surgical treatment for right colon cancer directly invading the duodenum. Am Surg. 75:385–388. DOI: 10.1177/000313480907500507. PMID: 19445288.

17. Gupta V, Kurdia KC, Kumar P, Yadav TD, Gulati A, Sinha SK, et al. 2018; Malignant colo-duodenal fistula: management based on proposed classification. Updates Surg. 70:449–458. DOI: 10.1007/s13304-018-0570-0. PMID: 30054817.

18. Agarwal AK, Mandal S, Singh S, Sakhuja P, Puri S. 2007; Gallbladder cancer with duodenal infiltration: is it still resectable? J Gastrointest Surg. 11:1722–1727. DOI: 10.1007/s11605-007-0320-y. PMID: 17906907.

19. Cananzi FCM, Ruspi L, Samà L, Sicoli F, Gentile D, Minerva EM, et al. 2019; Short-term outcomes after duodenal surgery for mesenchymal tumors: a retrospective analysis from a single tertiary referral center. Updates Surg. 71:451–456. DOI: 10.1007/s13304-019-00667-8. PMID: 31270684.

20. Bakaeen FG, Murr MM, Sarr MG, Thompson GB, Farnell MB, Nagorney DM, et al. 2000; What prognostic factors are important in duodenal adenocarcinoma? Arch Surg. 135:635–641. discussion 641–642. DOI: 10.1001/archsurg.135.6.635. PMID: 10843358.

21. Mitchell WK, Thomas PF, Zaitoun AM, Brooks AJ, Lobo DN. 2017; Pancreas preserving distal duodenectomy: a versatile operation for a range of infra-papillary pathologies. World J Gastroenterol. 23:4252–4261. DOI: 10.3748/wjg.v23.i23.4252. PMID: 28694665. PMCID: PMC5483499.

22. Platoff RM, Kellish AS, Hakim A, Gaughan JP, Atabek UM, Spitz FR, et al. 2021; Simple versus radical resection for duodenal adenocarcinoma: a propensity score matched analysis of National Cancer Database. Am Surg. 87:266–275. DOI: 10.1177/0003134820951432. PMID: 32927979.