Pancreas preserving duodenectomy (PPrD).

BACKGROUND: Pancreaticoduodenectomy has been the standard of care for managing duodenal neoplasms, but recent studies show similar overall and disease-specific survival after pancreas-preserving duodenectomy (PPrD) with potentially less morbidity. METHODS: Retrospective cohort of all adult (age >18) patients who underwent PPrD with curative intent of a neoplasm in or invading into the duodenum at our institution from 2011 to 2022 (n â€‹= â€‹29), excluding tumors involving the Ampulla of Vater or the pancreas. Statistical analyses were performed using STATA. RESULTS: R0 resection was achieved in 93 â€‹% patients. Ten (34.4 â€‹%) experienced postoperative complications (13.7 â€‹% within Clavien-Dindo III-V). PPrD patients had lower rates of pancreatic leak, delayed gastric emptying, and deep surgical site infection. CONCLUSIONS: In this case series, we demonstrate PPrD is safe and effective, with a high rate of complete resection and lower complication rate than that seen in pancreaticoduodenectomy.

Indocyanine green-fluorescent imaging for a detection of accessory pancreatic duct in pancreas-preserving duodenectomy.

Pancreas-preserving duodenectomy is indicated for select patients with a duodenal tumor in the second portion. In this procedure, identification and closure of the accessory pancreatic duct is important to prevent postoperative pancreatic fistula. A 63-y-old man was diagnosed with duodenal mucosal carcinoma in the second portion, with invasion of the major ampullary. We performed pancreas-preserving duodenectomy. Intraoperatively, indocyanine green-fluorescent imaging identified the accessory pancreatic duct clearly and it was successfully closed. Postoperative pancreatic fistula did not occur. Indocyanine green-fluorescent imaging is effective in identifying the accessory pancreatic duct in pancreas-preserving duodenectomy.

Pancreas-preserving partial duodenectomy for non-ampullary duodenal neoplasms: three case reports.

BACKGROUND: There are multiple surgical procedures for resecting non-ampullary duodenal neoplasms (NADNs), and the appropriate method is selected depending on the tumor location and diagnosis. We herein report 3 cases of NADNs that were resected using pancreas-preserving partial duodenectomy (PPD). CASE REPORTS: The first patient, a 73-year-old woman with a circumferential duodenal adenoma in the supra-ampullary duodenum, underwent surgery. After laparotomy, the duodenum proximal to the tumor was confirmed using intraoperative endoscopy and dissected. The duodenum distal to the tumor was dissected under direct visualization, and the specimen was removed. The distal stump of the duodenum was closed, and duodenojejunostomy was performed as described by Billroth II. The tumor was diagnosed as an adenoma 75 mm in size. She was discharged 12 days after surgery without any complications. The second patient, a 48-year-old man, was diagnosed with a neuroendocrine neoplasm (NEN) with a diameter of 14 mm in the supra-ampullary duodenum. Laparoscopic PPD was performed. He was diagnosed with NEN G1 and discharged the 11th day after surgery. The third patient, a 71-year-old man with a 0-Is + IIa lesion in the horizontal duodenum, underwent surgery. After laparotomy, the horizontal duodenum and proximal jejunum were resected, and duodenojejunostomy was performed. The patient was diagnosed with stage I adenocarcinoma and discharged on the 15th day after surgery. CONCLUSION: PPD is useful for avoiding the morbidity of pancreatoduodenectomy in the management of NADNs without invasion to the ampulla of Vater or pancreas.

Mesenteric approach in pancreas-preserving partial duodenectomy for aortic graft-duodenal fistula: a case report.

An aortic graft-duodenal fistula commonly requires graft replacement and duodenectomy. However, the appropriate surgical approach to the duodenum with aortic graft fistula remains unclear. Herein, we describe the case of an 85-year-old male patient who underwent a pancreas-preserving partial duodenectomy using the mesenteric approach for aortic graft-duodenal fistula. The patient presented with hemorrhagic shock and duodenal bleeding 2 years after undergoing open aortic graft replacement. He first underwent emergent endovascular aortic repair with an artificial vascular graft to achieve hemostasis. Although his general condition stabilized following endovascular treatment, duodenal endoscopy revealed an aortic graft-duodenal fistula, exposing the artificial vascular graft via the third portion of the duodenum. As the radical treatment for aortic graft-duodenal fistula, open graft replacement and pancreas-preserving partial duodenectomy were performed using the mesenteric approach which helps to divide the pancreas and duodenum. The patient recovered without any major complications, such as postoperative pancreatic fistula, and was discharged. In conclusion, the mesenteric approach in partial duodenectomy for aortic graft-duodenal fistula could be safely performed. This procedure is useful to approach the duodenum fixed by fistula formation, which may help reduce intraoperative blood loss, operative time, and surgical invasiveness.

Pancreas-preserving duodenectomy for treatment of a duodenal papillary tumor: A case report.

BACKGROUND: Duodenal papillary tumor is a rare tumor of the digestive tract, accounting for about 0.2% of gastrointestinal tumors and 7% of periampullary tumors. The clinical manifestations of biliary obstruction are most common. Some benign tumors or small malignant tumors are often not easily found because they have no obvious symptoms in the early stage. Surgical resection is the only treatment for duodenal papillary tumors. At present, the methods of operation for duodenal papillary tumors include pancreatoduodenectomy, duodenectomy, ampullectomy, and endoscopic resection. CASE SUMMARY: A 47-year-old man was admitted to because of a duodenal mass that had been discovered 2 mo previously. Electronic gastroscopy at another hospital revealed a duodenal papillary mass that had been considered to be a high-grade intraepithelial neoplasia. Therefore, we conducted a multidisciplinary group discussion and decided to perform a pancreas-preserving duodenectomy and a R0 resection was successfully performed. After surgery, the patient underwent a follow-up period of 5 yr. No recurrence or metastasis occurred. CONCLUSION: According to our experience with a duodenal papillary tumor, compared with pancreaticoduodenectomy, the use of pancreas-preserving duodenectomy can preserve pancreatic function, maintain gastrointestinal structure and function, reduce tissue damage and complications, and render the postoperative recovery faster. Pancreas-preserving duodenectomy for treatment of a duodenal papillary tumor is feasible under strict control of surgical indications.

Pancreas-preserving duodenal resections vs pancreatoduodenectomy for groove pancreatitis. Should we revisit treatment algorithm for groove pancreatitis?

BACKGROUND: The management of cystic dystrophy of the duodenal wall (CDDW), or groove pancreatitis (GP), remains controversial. Although pancreatoduodenectomy (PD) is considered the most suitable operation for CDDW, pancreas-preserving duodenal resection (PPDR) has also been suggested as an alternative for the pure form of GP (isolated CDDW). There are no studies comparing PD and PPDR for this disease. AIM: To compare the safety, efficacy, and short- and long-term results of PD and PPDR in patients with CDDW. METHODS: A retrospective analysis of the clinical, radiologic, pathologic, and intra- and postoperative data of 84 patients with CDDW (2004-2020) and a comparison of the safety and efficacy of PD and PPDR. RESULTS: Symptoms included abdominal pain (100%), weight loss (76%), vomiting (30%) and jaundice (18%) and data from computed tomography, magnetic resonance imaging, and endoUS led to the correct preoperative diagnosis in 98.8% of cases. Twelve patients were treated conservatively with pancreaticoenterostomy (n = 8), duodenum-preserving pancreatic head resection (n = 6), PD (n = 44) and PPDR (n = 15) without mortality. Weight gain was significantly higher after PD and PPDR and complete pain control was achieved significantly more often after PPDR (93%) and PD (84%) compared to the other treatment modalities (18%). New onset diabetes mellitus and severe exocrine insufficiency occurred after PD (31% and 14%), but not after PPDR. CONCLUSION: PPDR has similar safety and better efficacy than PD in patients with CDDW and may be the optimal procedure for the isolated form of CDDW. The pure form of GP is a duodenal disease and PD may be an overtreatment for this disease. Early detection of CDDW provides an opportunity for pancreas-preserving surgery.

Pancreas-preserving duodenectomy after living donor liver transplantation for invasive cytomegalovirus disease.

CMV infection plays an important role in the postoperative course following solid organ transplantation. We present the case of an 11-year-old male patient who underwent LDLT due to severe hepatopulmonary syndrome and biliary cirrhosis. Four weeks after LDLT, he developed persistent GI bleeding and was subjected to repeated endoscopic treatment and radiological arterial embolization to stop the bleeding from duodenal ulcers. Diagnostic workup was negative for CMV disease. Because the bleeding persisted, surgical treatment was indicated, and a pancreas-preserving duodenectomy was performed. Immunohistochemical staining of the surgical specimen demonstrated diffuse endothelial infiltration by CMV. Despite ganciclovir treatment, the patient developed new erosions in the jejunal mucosa and melena; ganciclovir was discontinued, and foscarnet was started, resulting in clinical improvement and the cessation of bleeding. This case highlights the technical aspects of performing a complex upper GI resection in a patient recently subjected to LDLT, taking care to avoid injury to the previous liver graft anastomosis and restore GI continuity. Moreover, CMV tissue-invasive disease compartmentalized in the GI tract may be difficult to diagnose, as indicated by the negative results of antigenemia and PCR assays and endoscopic superficial mucosal biopsies.

Non-Whipple Operations in the Management of Benign, Premalignant and Early Cancerous Duodenal Lesions.

AIM: We reviewed our 20-year experience with non-Whipple operations (pancreas-preserving duodenectomy and transduodenal ampullectomy) for the treatment of benign, premalignant or early-stage malignant duodenal lesions. PATIENTS AND METHODS: Twenty-four patients who underwent non-Whipple operations between January 1996 and December 2015 were identified from an institutional database and retrospectively analyzed. RESULTS: Between 1996 and 2015, 10 patients underwent pancreas-preserving duodenectomy and 14 patients underwent transduodenal ampullectomy. The mean follow-up was 25.8 months (range=6-54 months) and no patient was lost to follow-up. Eighteen patients had preoperative diagnosis of duodenal adenomatosis, three patients had preoperative diagnosis of duodenal adenocarcinoma, one had a bleeding polyp and two had localized inflammation. Average operative time was 145 min (range=127-168 min) for transduodenal ampullectomy and 183 min (range=173-200 min) for pancreas-preserving duodenectomy (p<0.05). The estimated blood loss for transduodenal ampullectomy was 85 vs. 125 ml for pancreas-preserving duodenectomy (p<0.05). Early postoperative complications were noted in 13 cases (54.17%). There were no postoperative (90-day) deaths observed in this series and there were no recurrences during follow-up for the patients operated on with neoplastic lesions. CONCLUSION: For carefully selected patients, transduodenal ampullectomy and pancreas-preserving duodenectomy may be used in place of the Whipple operation for benign and occasionally early-stage malignant (Tis and T1) duodenal and ampullary disease.