Pancreas-preserving duodenectomy

Di Saverio S, et al. Pancreas-sparing, ampulla-preserving duodenectomy for major duodenal (D1-D2) perforations. Br J Surg. 2018 Oct;105(11):1487-1492.

Results: Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65-84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170-377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1-11) days), and the overall mean hospital stay was 17·8 (range 10-32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications.

Surgical technique. a Kocher manoeuvre with medial mobilization of the duodenum, evacuation of retroperitoneal collection, and full visualization of the location and extension of the lesion. b Cholecystectomy and insertion of a transcystic tube in the common bile duct, pushed further until its transpapillary exit to identify and precisely locate the ampulla. c Division of the gastric antrum and gastric distal resection. d Dissection of the first part of the duodenum and the superior duodenal flexure from the head of the pancreas on the plane between the duodenum and the pancreatic gland. e Placement of an articulating flexible endostapler tangentially across healthy margins of the mid-duodenum, just above the ampulla, and completion of resection of D1 and proximal D2. f Gastrointestinal continuity is finally restored by performing a Roux-en-Y gastrojejunostomy. The ampulla is preserved and the normal flow of bile and pancreatic juices into D3 and D4 is preserved

Conclusion: Pancreas-sparing, ampulla-preserving D1-D2 duodenectomy for emergency treatment of major duodenal perforations is feasible and associated with satisfactory outcomes.

Busquets J, et al. Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement. Hepatobiliary Pancreat Dis Int. 2021 Mar 9:S1499-3872(21)00039-4.

Results: We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35).

Conclusions: Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

More PubMed results on pancreas-preserving duodenectomy.

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