Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report

A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.

Pancreas-preserving total duodenectomy for advanced duodenal polyposis in patients with familial adenomatous polyposis: short and long-term outcomes

BACKGROUND

In patients with familial adenomatous polyposis (FAP), extensive nonmalignant duodenal polyposis not amenable to endoscopic management demands surgical resection for which pancreas-preserving total duodenectomy (PPTD) offers a pancreatic parenchyma sparing approach.

METHODS

This is a retrospective cohort study including consecutive patients who underwent PPTD for FAP. Reconstruction involved a Billroth II anastomosis with a short isolated jejunal limb to facilitate future endoscopic surveillance. Short and long-term outcomes were evaluated.

RESULTS

Overall, 30 patients underwent PPTD for Spigelman stage III (n = 6) or IV (n = 24). Sixteen patients experienced a severe complication (Clavien-Dindo grade III/IV) including postoperative pancreatic fistula (ISGPS grade B/C) in twelve. There was no all cause in-hospital and 90-day mortality. During follow-up (median 125 months), five patients developed acute pancreatitis, one new-onset diabetes and one exocrine pancreatic insufficiency. During endoscopic surveillance in 27 patients, jejunal adenomas were detected in 22 and advanced adenomas in 11. An additional surgical resection was required in four patients with extensive jejunal polyposis. None developed jejunal cancer. The 10-year overall survival rate was 93.3%.

CONCLUSION

Postoperative morbidity after PPTD is substantial but on the long-term, rates of pancreatic insufficiencies are low. Most patients develop jejunal adenomas at follow-up, highlighting the need for endoscopic surveillance.

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

Objectives

Familial adenomatous polyposis (FAP) patients with Spigelman stage IV polyposis should be considered for prophylactic duodenectomy. Post‐surgical pancreaticobiliary complications occur and may require management via endoscopic retrograde cholangiopancreatography (ERCP). We aimed to assess the success and adverse events of ERCP in FAP patients after pancreas‐sparing duodenectomy (PSD) and pancreaticoduodenectomy (PD).

Methods

A retrospective review of FAP patients who underwent ERCP after PSD or PD from 1992 to 2020 at a quaternary referral center was completed. The technical success of ERCP was defined as the ability to identify the anastomosis and cannulate the duct. Post‐procedural adverse events were defined by bleeding, perforation, pancreatitis, or cholangitis. Clinical outcomes included the need for surgical intervention and recurrent pancreatitis after ERCP were assessed.

Results

Of 84 FAP patients with duodenectomy, 12 patients with PSD and two patients with PD underwent 17 ERCPs for pancreatic indications and five for biliary indications. The technical success of ERCP in patients with PSD and a single neoampullary complex for pancreatic (n = 6) and biliary (n = 5) indications was 100% but for those with PD (n = 2) or PSD reconstruction with pancreatic divisum or separate anastomoses (n = 3), it was 0%. Surgical intervention was required in 50% of patients with technically failed ERCP after PSD (2/4) and PD (1/2). There were no adverse events.

Conclusions

ERCP is expected to be therapeutically successful for biliary complications following PSD. Assessment and potential therapy for pancreatitis post‐PSD are best in the setting of a single neo‐ampullary complex rather than in PD or PSD with pancreatic divisum.

Management of familial adenomatous polyposis and MUTYH-associated polyposis; new insights

Familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP) are rare inherited polyposis syndromes with a high colorectal cancer (CRC) risk. Therefore, frequent endoscopic surveillance including polypectomy of relevant premalignant lesions from a young age is warranted in patients. In FAP and less often in MAP, prophylactic colectomy is indicated followed by lifelong endoscopic surveillance of the retained rectum after (sub)total colectomy and ileal pouch after proctocolectomy to prevent CRC. No consensus is reached on the right type and timing of colectomy. As patients with FAP and MAP nowadays have an almost normal life-expectancy due to adequate treatment of colorectal polyposis, challenges in the management of FAP and MAP have shifted towards the treatment of duodenal and gastric adenomas as well as desmoid treatment in FAP. Whereas up until recently upper gastrointestinal surveillance was mostly diagnostic and patients were referred for surgery once duodenal or gastric polyposis was advanced, nowadays endoscopic treatment of premalignant lesions is widely performed. Aiming to reduce polyp burden in the colorectum as well as in the upper gastrointestinal tract, several chemopreventive agents are currently being studied.

Endoscopic management of non-ampullary duodenal adenomas

Duodenal polyps are found in 0.1 % to 0.8 % of all upper endoscopies. Duodenal adenomas account for 10 % to 20 % of these lesions. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis. Endoscopy is the cornerstone of management of duodenal adenomas, allowing for diagnosis and treatment, primarily by endoscopic mucosal resection. The endoscopic treatment of duodenal adenomas has a high morbidity, reaching 15 % in a prospective study, consisting of bleeding and perforations, and should therefore be performed in expert centers. The local recurrence rate ranges from 9 % to 37 %, and is maximal for piecemeal resections of lesions > 20 mm. Surgical resection of the duodenum is flawed with major morbidity and considered a rescue procedure in cases of endoscopic treatment failures or severe endoscopic complications such as duodenal perforations. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of non-ampullary duodenal adenomas.

Long-Term Outcomes of Pancreas-Sparing Duodenectomy for Duodenal Polyposis in Familial Adenomatous Polyposis Syndrome

BACKGROUND

Pancreas-sparing duodenectomy (PSD) offers definitive therapy for duodenal polyposis associated with familial adenomatous polyposis (FAP). We reviewed the long-term complications of PSD and evaluated the incidence of high-grade dysplasia (HGD) and cancer in the remaining upper gastrointestinal tract.

METHODS

Forty-seven FAP patients with duodenal polyposis undergoing PSD from 1992 to 2019 were reviewed. Long-term was defined as > 30 days from PSD.

RESULTS

All patients were treated with an open technique, and 43 (91.5%) had Spigelman stage III or IV duodenal polyposis. Median follow-up was 107 months (IQR, 26-147). There was no 90-day mortality. Seven patients died at a median of 10.5 years (IQR, 5.4-13.3) after PSD, with one attributed to gastric cancer. Pancreatitis occurred in 10 patients (21.3%), and two required surgical intervention. Seven patients (14.9%) developed an incisional hernia, and all underwent definitive repair. Forty-one patients (87.2%) had postoperative surveillance endoscopy over a median follow-up of 111 months (IQR, 42-138). Three patients (6.4%) developed adenocarcinoma (two gastric, one jejunal), and four (8.5%) had adenomas with HGD (two gastric, two jejunal) with a median of 15 years (IQR, 9-16) from PSD. One patient with gastric adenocarcinoma and all patients with HGD or adenocarcinoma of the jejunum required surgical intervention.

CONCLUSION

PSD can be performed with a low but definable risk of long-term morbidity. Risk of gastric and jejunal carcinoma rarely occurs and was diagnosed decades after PSD. This demonstrates the need for lifelong endoscopic surveillance and educates us on the risk of carcinoma in the remaining gastrointestinal tract.

Parenchymal Sparing Resection: Options in Duodenal and Pancreatic Surgery

Parenchymal sparing duodenal and pancreatic resection are safe procedures in selected patients with the aim to reduce endocrine and exocrine long-term dysfunction. When the tumor is benign or borderline malignant, this appears to be a good option for the surgeon, associated with low rates of severe surgery-related early postoperative complications and low in-hospital mortality. This mini review offers comments, tips and tricks, and a review of literature concerning those different options with specific illustrations in order to clarify their indication.

Hybrid laparoscopic pancreas-preserving subtotal duodenectomy for suspected early duodenal cancer: A case report

INTRODUCTION

Non-ampullary duodenal adenomas rarely show malignant potential. However, such adenomas located in the periampullary area are suspected of being malignant and require surgical treatment.

PRESENTATION OF CASE

A 75-year-old man presented with a 30-mm wide, endoscopically-unresectable laterally spreading tumor in the periampullary area. Biopsy showed a tubular adenoma; however, the size and color of the tumor strongly suggested malignancy. Therefore, a hybrid laparoscopic pancreas-preserving subtotal duodenectomy (HLPPSD) was performed. Laparoscopically, a Kocher maneuver was performed. The jejunum was divided 10 cm distal to the ligament of Treitz, and the duodenum was also divided at the supraduodenal-angle. The Shuriken method was applied, and the surgery converted to an open procedure. The common bile and pancreatic ducts were divided, and the subtotal duodenum and 10 cm of the jejunum were removed. Thereafter, the jejunal stump was hand-sutured to the duodenal stump. Cholangiojejunostomy and pancreatojejunostomy were performed under direct vision. Finally, an umbilicoplasty was performed. The histology revealed that the tumor was a carcinoma in situ.

DISCUSSION

Endoscopic resection is the first-choice for duodenal adenoma suspected of malignant potential. When the endoscopically-unresectable tumor is located in periampullary area, pancreatoduodenectomy is generally selected because ampulla cannot be preserved. However, HLPPSD is an alternative option.

CONCLUSIONS

Non-ampullary duodenal adenomas can be malignant when the tumor is large and red. In these cases, HLPPSD can be useful; less invasive than conventional pancreaticoduodenectomy; leaves only a 3-cm, round scar, in addition to the laparoscopic port scars; and combines the benefits of both open and laparoscopic surgeries.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

INTRODUCTION

There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection.

METHODS

Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre.

RESULTS

There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant.

CONCLUSION

Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.

Surveillance of Duodenal Polyposis in Familial Adenomatous Polyposis: Should the Spigelman Score Be Modified?

BACKGROUND

Duodenal polyposis is a manifestation of adenomatous polyposis that predisposes to duodenal or ampullary adenocarcinoma. Duodenal polyposis is monitored by upper GI endoscopies and may require iterative resections and prophylactic radical surgical treatment when malignancy is threatening.

OBJECTIVE

The purpose of this study was to evaluate severity scoring for surveillance and treatment in a large series of duodenal polyposis.

DESIGN

From 1982 to 2014, every patient surveyed by upper GI endoscopies for duodenal polyposis was included.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

We performed 1912 upper GI endoscopies in 437 patients (median = 3; interquartile range, 2-6 endoscopies).

MAIN OUTCOME MEASURES

Conservative treatment was performed in 103 patients (159 endoscopic and 17 surgical resections), whereas radical surgical treatment (Whipple procedure or duodenectomy) was required in 52 (median age, 47.5 y; range, 43.0-57.3 y) because of high-grade dysplasia or unresectable lesions.

RESULTS

Genes involved were APC (n = 274; 62.7%) and MUTYH (n = 21; 4.8%). First upper GI endoscopies (median age, 32 y; range, 21-44 y) revealed duodenal polyposis in 190 (43.5%). Rates of low-grade dysplasia, high-grade dysplasia, and duodenal or ampulary adenocarcinoma at 5 years were 65% (range, 61.7%-66.9%), 12.1% (range, 10.3%-13.9%), and 2.4% (range, 1.5%-3.3%), whereas 10-year rates were 75.8% (range, 73.1%-78.5%), 20.8% (range, 18.2%-23.4%), and 5.4% (range, 3.8%-7.0%). The rate of ampullary abnormalities rose during surveillance from 18.3% at the first upper GI endoscopies to 47.4% at the fourth. Predictive factors for high-grade dysplasia were age at first upper GI endoscopy, type and age of colorectal surgery, Spigelman score, presence of an ampullary abnormality, and number of endoscopic treatments. In multivariate analysis, only age at first upper GI endoscopy and presence of an ampullary abnormality were independent predictive factors. Histologic analysis after radical surgical treatment showed high-grade dysplasia in 30 patients and duodenal or ampulary adenocarcinoma in 11 (4 patients had lymph node involvement).

LIMITATIONS

The study was limited by its retrospective analysis of a prospective database.

CONCLUSIONS

More than 20% of patients developed high-grade dysplasia with duodenal polyposis after 10 years. Iterative endoscopic resections allowed extended control, but surgery remained necessary in 12% of the patients and happened too late in many cases; 20% of those operated had developed duodenal or ampulary adenocarcinoma, whereas 8% exhibited malignancy with lymph node involvement. The trigger for prophylactic surgery required a more accurate predictive score leading to closer endoscopic surveillance. Modifying the Spigelman score by accounting for ampullary abnormalities should be considered as a means to increase compliance with closer endoscopic follow-up in high-risk patients. See Video Abstract at http://links.lww.com/DCR/A430.

Postoperative outcome and quality of life after surgery for FAP-associated duodenal adenomatosis

INTRODUCTION

Prophylactic colon surgery has increased life expectancy of familial adenomatous polyposis patients. Extracolonic manifestations are life limiting, above all duodenal adenomas. Severe duodenal adenomatosis or cancer may necessitate pancreas-preserving total duodenectomy or partial pancreatico-duodenectomy, mostly after previous proctocolectomy and often after limited local resections of duodenal adenomas. Scarce information on long-term postoperative outcome and quality of life after surgery for duodenal adenomatosis is available. Aim of the present study was to analyze perioperative and long-term outcome after PD and PPTD for FAP-associated duodenal adenomatosis, including QoL and recurrence of adenomas in the neoduodenum after PPTD.

MATERIAL, METHODS AND PATIENTS

Thirty-eight patients, 27 after pancreas-preserving duodenectomy and 11 after partial pancreaticoduodenectomy, were included.

RESULTS

Pancreas-preserving total duodenectomy was associated with shorter operation time and less blood loss than partial pancreatico-duodenectomy. Clinically relevant pancreatic fistula occurred in 31.5%. In-hospital mortality was 5.3%. Long-term follow-up revealed recurrent pancreatitis after pancreas-preserving total duodenectomy in 22% of patients, two (7.4%) required re-operation. Recurrent adenomatosis was detected in 26% of patients. Quality of life was comparable to the German normal population after both surgical procedures. Patients with postoperative complications showed worse results than those without complications. Disease-specific 10-year survival rate with respect to duodenal adenomatosis was 100%.

CONCLUSION

Surgery for FAP-associated duodenal adenomatosis and cancer can be carried out with reasonable morbidity rates despite previous proctocolectomy. Long-term outcome, quality of life, and survival rates are favorable.

Pancreas-sparing total duodenectomy for Spigelman stage IV duodenal polyposis associated with familial adenomatous polyposis: experience of 10 cases at a single institution

Duodenal cancer is a leading cause of death in patients with familial adenomatous polyposis (FAP). In patients with Spigelman's classification (SC) stage IV duodenal polyposis (DP), careful endoscopic surveillance by specialists or surgical intervention is mandatory. We herein report the surgical and pathological outcomes of FAP patients with SC stage duodenal polyposis undergoing pancreas-sparing total duodenectomy (PSTD), which has been rarely reported but seems optimal in such patients. PSTD and distal gastrectomy with Billroth-I type reconstruction in ten consecutive FAP patients with SC stage IV DP are reported. The median duration of surgery was 396 min (range 314-571 min) and the median estimated blood loss was 480 mL (range 100-975 mL). Significant postoperative complications included wound infection in 1 patient, pancreatic fistula [International Study Group on Pancreatic Fistula definition (ISGPF) grade B] in 4 patients. Histopathologic examinations revealed a well-differentiated carcinoma in situ in 3 patients and others were all adenomas. Over a median follow-up period of 15 months (range 9-29 months), 1 patient developed a stomal ulcer which improved with medical treatment. There were no patients with a body weight loss of ≥10 % relative to the preoperative body weight. No recurrence were experienced during the follow up period. Patients were free from postoperative diabetes mellitus. PSTD is a feasible and acceptable procedure in FAP patients with SC stage IV DP, in terms of surgical, pathological and clinical outcome. However, accumulation of the patients and long-term follow up study is necessary.

Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies

AIM

To investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up.

METHODS

Neoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed.

RESULTS

Twenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively).

CONCLUSION

PPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Pancreas-sparing duodenectomy with regional lymph node dissection for early-stage ampullary carcinoma: A case control study using propensity scoring methods

AIM: To investigate the outcomes of pancreas-sparing duodenectomy (PSD) with regional lymph node dissection vs pancreaticoduodenectomy (PD).

METHODS: Between August 2001 and June 2014, 228 patients with early-stage ampullary carcinoma (Amp Ca) underwent surgical treatment (PD, n = 159; PSD with regional lymph node dissection, n = 69). The patients were divided into two groups: the PD group and the PSD group. Propensity scoring methods were used to select patients with similar disease statuses. A total of 138 matched cases, with 69 patients in each group, were included in the final analysis.

RESULTS: The median operative time was shorter among the patients in the PSD group (435 min) compared with those in the PD group (481 min, P = 0.048). The median blood loss in the PSD group was significantly less than that in the PD group. The median length of hospital stay was shorter for patients in the PSD group vs the PD group. The incidence of pancreatic fistula was higher among patients in the PD group vs the PSD group. The 1-, 3-, and 5-year overall survival and disease-free survival rates for patients in the PSD group were 83%, 70%, 44% and 73%, 61%, 39%, respectively, and these values were not different than compared with those in the PD group (P = 0.625).

CONCLUSION: PSD with regional lymph node dissection presents an acceptable morbidity in addition to its advantages over PD. PSD may be a safe and feasible alternative to PD in the treatment of early-stage Amp Ca.

"High rate of recurrent adenomatosis during endoscopic surveillance after duodenectomy in patients with familial adenomatous polyposis"

Advanced duodenal adenomatosis in patients with familial adenomatous polyposis (FAP) is associated with a significant risk of duodenal carcinoma. Duodenectomy is sometimes indicated to prevent malignant transformation or to resect established carcinomas. Advanced recurrent adenomatosis and cancer formation in the neo-duodenum after duodenectomy in FAP have been reported. The aim of this study was to describe findings during endoscopic follow-up in a cohort of FAP patients after duodenectomy, to assess the indication and whether recommendations can be made for endoscopic surveillance. All FAP patients with a history of duodenectomy performed at a single tertiary referral centre between January 2000 and July 2011 were identified. Patient characteristics and postoperative upper endoscopic procedures were reviewed retrospectively. 19 patients, with a mean age of 49 years at the time of duodenectomy were identified. One patient was lost to follow-up. The majority of patients underwent prophylactic pancreas preserving duodenectomy (95%). Mean duration of postoperative follow-up in 18 patients was 78 months with 4 postoperative endoscopies on average. An increase in neo-Spigelman stage was seen in 9 patients, after an average interval of 35 months. Overall, newly formed adenomas in the neo-duodenum were found in 14 of 18 patients (78%), after a mean of 46 months after duodenectomy. Recurrent adenomas were mostly located in close proximity to the neo-papilla. This included advanced adenomas in 7 patients, warranting enteric re-resection in 2 patients. Continued intensive endoscopic surveillance is indicated after duodenectomy in FAP, especially of the area around the bilio- and pancreatico-enteric anastomoses.

Pancreas-sparing total duodenectomy for ampullary duodenal neoplasms

BACKGROUND

Ampullary and extensive periampullary lesions can be difficult to treat and often require pancreaticoduodenectomy (PD) for complete removal, even if benign. However, PD may be overtreatment for noninvasive lesions, and pancreas-sparing total duodenectomy (PSTD) is an emerging valid surgical option for selected cases.

METHODS

We reviewed patients undergoing PSTD at our institution over 16 months and a comparison group who had undergone PD for benign duodenal disease over the past 15 years. We also reviewed cases in the English-language literature and performed a meta-analysis of those patients who had undergone PSTD.

RESULTS

PSTD had been performed in four patients, who had an average hospital length of stay (LOS) of 13 days; two of them experienced complications. None required conversion to PD, experienced a postoperative fistula or endocrine or exocrine insufficiency, or required intensive care. Two of the PSTDs were performed laparoscopically. Open PD for benign duodenal disease was performed in 22 patients, with overall morbidity and pancreas fistula rates of 82 and 27 %, respectively. The meta-analysis found 128 unique cases of PSTD with morbidity and mortality rates of 46.4 and 2.3 %, respectively. Pancreaticobiliary leak was seen in 20 %, with an average LOS of 17 days.

CONCLUSIONS

Although PSTD can be used to avoid PD and can be performed laparoscopically, it is technically challenging and still associated with morbidity.

The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies

INTRODUCTION

Tube decompression of the duodenum is an old but underutilized technique known to decrease morbidity and mortality in patients with difficult to manage duodenal injuries. Broad arrays of techniques have been described in the literature and are reviewed, but most are complex procedures not appropriate for the management of an unstable patient.

PRESENTATION OF CASE

In this paper we describe the technique of tube duodenostomy and the successful application in three cases of large defects (>3cm) which two of these cases had failed previous repair attempts. The defects were caused by very different etiologies, including blunt trauma, peptic ulcer disease and erosion from cancer. All were finally managed by application of tube duodenostomy with success.

DISCUSSION

Patients with "difficult to manage duodenum" usually present with hemodynamic instability with hostile abdomen. Complex procedures in an unstable patient are associated with adverse outcomes. In patients with significant comorbidities and instability the damage control principle of trauma surgery is gaining popularity. Tube duodenostomy technique described in this paper fits in well with that principle.

CONCLUSION

Application of tube duodenostomy instead of a complex procedure in an unstable patient provides an opportunity to stabilize the patient, converting an impending catastrophe to a future scheduled surgery.

Laparoscopic pancreas-preserving total duodenectomy for familial adenomatous polyposis

Patients with duodenal polyps associated with familial adenomatous polyposis (FAP) have a considerable risk of developing duodenal carcinoma. Prophylactic resection of the duodenum for Spigelman stage III disease is the treatment of choice to prevent progression to cancer. Pancreaticoduodenectomy and pancreas-preserving total duodenectomy (PPTD) are the techniques that have been described for the surgical treatment of duodenal polyposis. We report the first case of laparoscopic PPTD in a patient with previous total colectomy for FAP and Spigelman stage III duodenal polyposis. A laparoscopic total dissection of the duodenum was carried out and the restoration was achieved performing pancreatico-biliary-jejunostomy and gastrojejunostomy. The postoperative period was uneventful. Laparoscopic PPTD can be performed safely in selected cases for the management of FAP.

Severe duodenal involvement in familial adenomatous polyposis treated by pylorus-preserving pancreaticoduodenectomy

PURPOSE

Pancreaticoduodenectomy is an alternative to pancreas-sparing duodenectomy for radical treatment of duodenal lesions. The aims of this study were to assess the results of pylorus-preserving pancreaticoduodenectomy (PPPD) for severe duodenal polyposis in familial adenomatous polyposis in terms of morbidity, long-term influence on functional results, the recurrence rate of cancer or jejunal polyps, and survival.

METHODS

All patients operated on for a PPPD between 1992 and 2009 were included. Clinical data, endoscopic findings, and pathologic examinations were evaluated.

RESULTS

A total of 19 patients underwent PPPD for severe duodenal polyposis (17 Spigelman IV, 1 Spigelman III, and 1 invasive carcinoma). Postoperative mortality was nil. The postoperative morbidity rate was 42%, including 4 pancreatic fistulae (21%) and 2 delayed gastric emptying (11%). Pathologic examination found 7 invasive carcinomas, of which only 1 was known before resection. One third of patients operated on without a preoperative diagnosis of malignancy already had an invasive duodenal carcinoma. After a mean follow-up of 58 months, 16 patients were alive. Thirteen patients underwent endoscopic follow-up, and new adenomas were found in 4 (31%). All were treated successfully during the same endoscopic procedure. PPPD did not modify the functional result after coloproctectomy.

CONCLUSIONS

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

[Pancreas-preserving duodenectomy in acute situations. Surgical treatment of an iatrogenic hemorrhage in the duodenal wall]

We report the case of a 24-year-old patient who underwent a duodenal biopsy due to the suspicion of graft-versus-host disease following allogeneic stem cell transplantation 3 months previously. The patient developed severe upper abdominal pain after the biopsy. A computed tomography scan revealed diffuse hemorrhaging in the duodenal wall and mesenteric root. Following supraselective angioembolization to stop the bleeding a control computed tomography scan was carried out the following day and revealed increasing destruction of the duodenal wall due to a dissecting aneurysm. A pancreas-preserving duodectomy was carried out.