Pancreas-sparing total duodenectomy for ampullary duodenal neoplasms

Multi-Institutional Analysis of Pancreaticoduodenectomy for Nonfamilial Periampullary Adenoma: A Novel Risk Score to Guide Shared Decision-Making

BACKGROUND

Pancreaticoduodenectomy (PD) may occasionally be indicated for complete removal of periampullary (duodenal and ampullary) adenomas (PAs). As compared with malignant indications, PD for benign or premalignant disease is often associated with increased morbidity. Although the Spigelman classification assesses malignancy risk for familial adenomatous polyposis (FAP)-related duodenal adenomas, no malignancy risk score (MRS) exists for non-FAP-related PAs. We developed an MRS for non-FAP-related PAs undergoing PD to weigh the risk of malignancy and postoperative morbidity.

STUDY DESIGN

We retrospectively analyzed patients with non-FAP-related PA who underwent PD at 8 institutions (2010 to 2022). Patient and lesion factors associated with final malignant pathology were identified using multivariable logistic regression to create MRS. Postoperative complications were assessed according to MRS.

RESULTS

Of 127 patients, 59 (46.5%) had evidence of malignancy on final pathology. The odds of malignancy were higher in patients aged 65 years or older (odds ratio [OR] 3.2, p = 0.01), having bile duct 9 mm or more (OR 3.3, p = 0.009), having preoperative symptoms (OR 7.7, p = 0.002), and having high-grade dysplasia (OR 7.5, p < 0.001). A MRS was derived ranging from 0 to 6: age 65 years or older = 1, bile duct 9 mm or more = 1, symptomatic = 2, and high-grade dysplasia = 2. Patients were stratified into low-risk (MRS 1 to 2, n = 26), intermediate-risk (MRS 3 to 4, n = 59), and high-risk groups (MRS 5 to 6, n = 26), with malignancy rates increasing with MRS (10.3%, 44.1%, and 88.2%, p < 0.001). Patients in the no- or low-risk group (MRS 0 to 2) had higher odds of major postoperative complications compared with patients in the intermediate- or high-risk group (MRS 3 or higher, OR 2.9, p = 0.047).

CONCLUSIONS

This novel MRS stratifies the risk of malignancy in non-FAP-related PAs managed with PD. This score can be used to counsel patients who may require PD for complete tumor removal about their risk of harboring malignancy and their risk of major postoperative complications.

Laparoscopic pancreas-preserving near total duodenectomy for large villous adenoma in patients with total colectomy for familial adenomatous polyposis

Most familial adenomatous polyposis (FAP) patients undergo total colectomy, but duodenal polyposis develops in up to 90% of patients with FAP and a 4% to 18% risk of duodenal and ampullary cancer remains. Laparoscopic pancreas-preserving near total duodenectomy is thought to be a potential option and can be an effective approach to preserve the pancreas. A 48-year-old male patient, who underwent laparoscopic total colectomy with end ileostomy because of FAP with colorectal cancer, was diagnosed with a 20 mm-sized duodenal adenoma in the second to the third portion. The operation was performed on December 27, 2021. Near total duodenectomy was done and type II Billroth gastrojejunostomy was done. Laparoscopic pancreas-sparing duodenectomy is shown to be safe, with favorable short-term oncologic outcome compared to laparoscopic pancreatoduodenectomy in terms of less blood loss, faster recovery time, and much less total cost.

Surgical strategies for duodenal gastrointestinal stromal tumors

PURPOSE

Duodenal gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract. For localized or potentially resectable GISTs, surgery is the first choice. But the important and complex anatomical structure adjacent to the duodenum makes surgical management for duodenal GISTs challenging and few comprehensive surgical strategies have been described. This study aims to provide new comprehensive surgical strategies for duodenal GISTs by summarizing the surgical approaches and outcomes of duodenal GISTs in different locations in our center in the past 11 years.

METHODS

Information from patients who underwent surgical resection for duodenal GISTs at our facility during the past 11 years was retrospectively analyzed.

RESULTS

Ninety-two patients have received surgical procedures in the facility. Twenty-three, 31, 3, and 35 patients underwent wedge resection, segmental resection, pancreatic head-preserving duodenectomy, and pancreaticoduodenectomy, respectively. The mean operative times were 212.6 (150-270), 260 (180-370), 323 (300-350), and 354.9 (290-490) min; the mean blood loss was 226.1 (100-400), 303.2 (100-600), 500 (400-600), and 582.9 (200-1300) ml, respectively. R0 margins were obtained in 21, 29, 3, and 32 patients, respectively.

CONCLUSIONS

For duodenal GISTs without invasion of the ampulla of Vater or the pancreatic head, a limited resection (such as wedge resection, segmental resection, or pancreatic head-preserving duodenectomy) is feasible. For duodenal GISTs with an invasion of the ampulla of Vater or the pancreatic head, a pancreaticoduodenectomy is still necessary.

First Report of Treatment with Pancreas-Sparing Duodenectomy in a Child with Primary Intestinal Lymphangiectasia

Pancreas-sparing duodenectomy (PSD) is a known surgical technique used in patients with duodenal pathologies in the adult age group. We present a 3-year-old female patient with intestinal lymphangiectasia who underwent PSD. This is the first case in which this surgical technique was used in childhood. We believe that PSD can be used in the pediatric age group for benign pathologies. Introducing a stent to the common bile duct and the main pancreatic duct is not a requirement, especially if the ampulla is preserved as a “button” duodenal patch.

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.

Acute obstructive pancreatitis after pancreas-sparing total duodenectomy in a patient with pancreas divisum: a case report

Background

Pancreas-sparing total duodenectomy (PSTD) is an ideal recommended procedure for patients with multiple duodenal adenomas or early duodenal cancer. We herein report a rare but serious complication of PSTD.

Case presentation

A 20-year-old woman with duodenal adenocarcinoma underwent PSTD. On postoperative day one, she complained of severe abdominal pains. Her serum amylase and serum pancreatic amylase levels were extremely elevated (Amy, 1296 IU/L; P-Amy, 1273 IU/L). With contrast enhanced CT, acute obstructive pancreatitis with pancreas divisum due to the ligation of the dorsal pancreatic duct was highly suspected. An emergency operation was performed to relieve the pancreatic duct obstruction, and an additional anastomosis between the dorsal pancreatic duct and jejunum was performed. The patient’s postoperative course was mostly uneventful, and her discomfort improved immediately.

Conclusion

When we perform pancreas-sparing total duodenectomy, some form of pancreatography is necessary to exclude pancreas divisum.

Recent advances in diagnosis and treatment of primary duodenal tumors

Compared to tumors from other parts of the gastrointestinal tract, primary tumors of the duodenum are uncommon. Both benign tumors and malignancies are possible, although the majority are malignancies. The treatment of choice is surgical resection, mostly pancreaticoduodenectomy. With the development of endoscopy microsurgery and medical imaging technology, especially the advent of gastroduodenal fiberscopy, capsule endoscopy, endoscopic ultrasonography (EUS), endoscopic retrograde cholangio-pancreatography (ERCP) and laparoscopy, more duodenal neoplasms have been detected in recent years. Some advances have been achieved in the diagnosis and treatment of duodenal tumors. Endoscopic and segmental resections play a more and more important role in the management of duodenal tumors. In this paper, we describe the clinical features, pathological patterns, diagnosis and treatment of primary duodenal tumors.