Robotic distal pancreas-sparing duodenectomy (duodenal sleeve resection) with transmesenteric approach: robotic approach for tumors in the third and fourth parts of the duodenum.

BACKGROUND: Minimally invasive resection of the retroperitoneal duodenum is complicated because of its anatomical location, and the proximity of the ampulla of Vater and vascular structures. Benign or indolent pathology can add complexity to operative decision-making for these already challenging surgeries, and operations associated with lower morbidity may be considered. This study describes a novel robotic transmesenteric approach to duodenal sleeve resection for non-malignant lesions. METHODS: A retrospective review was performed on a prospectively maintained institutional database between 2011 and 2021. The Da Vinci XI or SI platform (Intuitive Surgical, Sunnyvale, CA) was used in all cases. RESULTS: Critical steps in robotic sleeve duodenectomy include the following: (1) techniques for avoiding damage to the ampulla; (2) Kocherization and reverse Kocherization; and (3) A transmesenteric approach for further mobilization of the duodenum. Nineteen patients were referred by experienced gastrointestinal endoscopists after endoscopic management was deemed unsuitable or their resections were incomplete. The histological diagnoses were either symptomatic benign or indolent duodenal pathology. All 19 patients underwent robotic duodenal sleeve resection during the study period. Lesions were located in the third to fourth parts of the duodenum. The median operative time was 216 min (IQR: 199-225), and the estimated intraoperative blood loss was 50 ml (IQR: 50.0-93.7). The 90 day readmission rate was 15.7% (3/19), and no 90-day mortality was observed. CONCLUSION: This small case series of a transmesenteric approach for robotic sleeve duodenectomy demonstrates its feasibility and safety in this potentially challenging operation.

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-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.

Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy.

PURPOSE: Pancreas-sparing duodenectomy (PSD) represents an alternative procedure to pancreatoduodenectomy (PD) for patients with duodenal neoplasms. METHODS: The postoperative early and late complications of 21 patients who underwent PSD between 1992 and 2014 were compared with those of 44 patients with soft pancreatic parenchyma who underwent PD between 2009 and 2014. RESULTS: The median operation time and blood loss were less in the PSD group than in the PD group (P < 0.001). The overall incidence of early complications was less in the PSD group than in the PD group (PSD with ampullectomy vs. PSD without ampullectomy vs. PD; 45.5 vs. 20.0 vs. 56.8 %). The incidence of pancreatic fistula formation and overall incidence of late complications were also less in the PSD group than in the PD group (P = 0.031, 0.020). There were no complications related to the pancreatic endocrine or exocrine functions in the PSD group. CONCLUSION: PSD is a less-invasive procedure and has the advantage over PD of preserving the pancreas.

Well-concealed advanced duodenal carcinoma with Muir-Torre syndrome: a case report and review of literature.

BACKGROUND: Muir-Torre syndrome is an autosomal-dominant mutation in mismatch repair genes that gives rise to sebaceous tumors and visceral malignancies over time. Because colorectal and genitourinary cancers are common in Muir-Torre syndrome, duodenal carcinoma diagnoses are often delayed. CASE PRESENTATION: A 58-year-old woman presented with severe emaciation, anorexia, and upper abdominal pain. She had a history of rectal carcinoma, ascending colon carcinoma, and a right shoulder sebaceous carcinoma. Upper gastrointestinal endoscopy and computed tomography examinations suggested duodenal obstruction due to superior mesenteric artery syndrome, leading to long-term observation. Seven months later, she was finally diagnosed with duodenal carcinoma of the third portion. As the papilla of Vater was preservable due to tumor location, she received a partial duodenectomy in lieu of a pancreatoduodenectomy. Pathologically, the tumor was a well-differentiated adenocarcinoma with a classification of T3N0M0 Stage IIA (UICC, 8th edition). The postoperative course was uneventful and her appetite returned. A mutation in mismatch repair gene MSH2 confirmed the diagnosis of Muir-Torre syndrome genetically. Three years later, her nutritional status has fully recovered and she is free from both recurrence and metastasis. CONCLUSION: In patients with comorbid skin sebaceous tumors and gastrointestinal malignancies, genetic screening is strongly recommended. Patients with Muir-Torre syndrome require long-term follow-up, and function-preserving treatment is desirable.

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.

Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy?

BACKGROUND: Gastrointestinal stromal tumors (GIST) of the duodenum are rarely reported and optimal minimally invasive management has not been well proposed. Pancreaticoduodenectomy and different types of pancreas-sparing duodenectomy can be chosen; however, which to choose and its corresponding clinical outcomes and oncological concerns remain controversial. PATIENTS AND METHODS: Patients diagnosed with GIST of duodenum underwent laparoscopic pancreaticoduodenectomy (L-PD) or pancreas-sparing duodenectomy (L-PSD) in Zhejiang Provincial People's Hospital were enrolled. All prospectively maintained data were analyzed retrospectively. Patients were grouped into the L-PD group or the L-PSD group, and the clinical outcomes and oncological outcomes were analyzed. RESULTS: Between June 2013 and March 2019, a total of 22 patients (11 males/11 females) underwent surgical management, including 13 L-PDs and 9 L-PSDs. The average age was 58.2±9.5 year-old (median 60.5 year-old). The most common presentations were GI bleeding (54.5%) and abdominal discomfort (27.2%), and the dominant lesion located in the second portion of duodenum (59.1%). Compared with L-PD group, L-PSD group showed much shorter operation time (364.2±58.7min vs. 230.0±12.3min, P<0.001), less blood loss (176.9±85.7mL vs. 61.1±18.2min, P<0.001), faster recovery to off-bed (2.6±1.3d vs. 1.1±0.3d, P=0.003), anus flatus (4.5±1.0d vs. 2.4±0.5d, P<0.001) and liquid intake (4.9±1.3d vs. 2.3±0.5d, P<0.001). Lymph node retrieval was much less in L-PSD, but no lymph node metastasis was observed in any patients. L-PSD had much Lower morbidity of both minor (Grade I/II) and major (III/IV/V) complications than that of L-PD (11.1% vs. 61.6%, P=0.02), resulting in shorter hospital stays (10.9±3.8d vs. 20.6±11.1d, P=0.021) and less total cost (76,972.4±11,614.8yuan vs 125,628.7±46,356.8yuan, P=0.006). The median follow-up was 42 months (range from 12 to 82months) without loss. Only 1 L-PD patient suffered hepatic metastasis 36months after surgery, and given sunitinib to stabilize the disease, none of the rest observed recurrence or metastasis. CONCLUSION: For GIST located opposite the major papilla, L-PSD showed comparable safety and oncological benefits when compared to L-PD, with shorter operation time, less blood loss and much faster recovery time, resulting in much less total cost. L-PSD should be applied in selected patients with experienced hands.

Pancreas- and Pylorus-Preserving Duodenectomy for Advanced Familial Duodenal Polyposis.

Most patients with familial adenomatous polyposis (FAP) will develop duodenal polyps and 5% progress to cancer. Those with Spigelman stage IV have a 36% risk of cancer at 10 years. Endoscopic surveillance is necessary with local ablation for early disease. Unresectable duodenal disease and severe dysplasia are an indication for prophylactic radical surgery by pancreaticoduodenectomy or pancreas-sparing duodenectomy. Some preliminary results have shown better outcomes with duodenectomy. A 45-year-old female with FAP had restorative proctocolectomy at 24 years, desmoid of the mesentery with regression after sulindac, two pregnancies, and at the age of 37 years had duodenal polyposis stage III carpeting the periampullary region. Endoscopic papillectomy and extensive piecemeal mucosectomy was performed but was unsuccessful due to recurrence. After 7 years of regular endoscopic surveillance, focal high-grade dysplasia was diagnosed at the last evaluation. Some diminutive polyps were seen in the small-bowel capsule endoscopy. MRCP showed a normal biliary and pancreatic duct without visualization of the Santorini duct. A pancreas and pylorus-preserving duodenectomy was performed with 3 main steps: (1) duodenectomy with preservation of the pancreas and the pylorus; (2) reconstruction with an advanced jejunal limb and duodenojejunostomy; (3) reimplantation of the biliary and pancreatic duct in the jejunal loop. The patient was discharged on the 11th postoperative day without complications. In conclusion, pancreas- and pylorus-preserving duodenectomy is a promising alternative to pancreaticoduodenectomy for advanced duodenal polyposis that allows complete endoscopic surveillance.

A maioria dos doentes portadores de polipose adenomatosa familiar (FAP) vem a desenvolver pólipos duodenais que poderão degenerar em 5% dos casos. Os casos que apresentem um estádio IV de Spigelman têm um risco de degenerescência de 36% ao fim de 10 anos. É necessária vigilância endoscópica e excisão das lesões iniciais. Os pólipos considerados irressecáveis e com displasia de alto grau têm indicação para exérese cirúrgica radical através de duodenopancreatectomia ou de duodenectomia com conservação do pâncreas. Existem alguns resultados preliminares a revelar melhores resultados com a duodenectomia. Uma doente de 45 anos portadora de FAP efetuou proctocolectomia reconstrutiva aos 24 anos. Desenvolveu tumor desmoide mesentérico após um ano e que regrediu com sulindac, teve dois filhos e aos 37 anos apresentou polipose duodenal, em toalha periampular, com estádio III. Foi submetida a papilectomia endoscópica e mucosectomia fragmentada da lesão circundante tendose verificado recorrência. Durante 7 anos procedeu-se a vigilância endoscópica regular com presença de displasia de alto grau focal na última avaliação. Na cápsula endoscópica foram observados alguns pólipos diminutos no intestino delgado. A CPRM revelou normalidade nos canais pancreático e biliar, sem evidência do Santorini. Foi efetuada uma duodenectomia com conservação do pâncreas e do piloro cujos passos cirúrgicos principais foram: (a) duodenectomia com conservação do pâncreas e do piloro; (b) reconstrução com ansa jejunal e duodenojejunostomia; (c) reimplantação dos canais biliar e pancreático à ansa jejunal. A doente teve alta ao 11o dia pós-operatório sem complicaçõs. Em conclusão, a duodenectomia com conservação do pâncreas e do piloro constitui uma boa alternativa à duodenopancreatectomia permitindo vigilância endoscópica completa.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy.

A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.

Surgical approach for tumours of the third and fourth part of the duodenum. Distal pancreas-sparing duodenectomy.

The anatomic complexity of the duodenum makes surgical resection challenging. We describe our experience with distal pancreas-sparing duodenectomy (PSD) for tumours that arise in the third and fourth parts of the duodenum. Between July 2008 and January 2012 eight patients underwent surgical resection for tumours in the distal parts of the duodenum. Short and long-term outcomes of treatment are retrospectively analyzed. We used the Cattell and Braash surgical approach in six patients. Seven patients underwent a segmental resection of the distal duodenum with a duodenojejunal anastomosis and in one case we performed a wedge local excision with primary closure. There were 5 gastrointestinal stromal tumours (GIST), 1 primary duodenal adenocarcinoma, 1 metastasis of a lung adenocarcinoma and 1 patient with malignant duodenocolic fistula caused by advanced sigmoid colon carcinoma. Median operating time was 200 min and median intraoperatory blood loss 162 mL. Three patients showed postoperative complications and one of them died. There was no reoperation. Median hospital stay was 10 days (range, 7-28 days). The patient with primary adenocarcinoma died after 12 months due to hepatic metastases. All of five patients with GIST are alive without recurrence (mean follow up of 65.6 months), as well as the patient with metastatic duodenal infiltration (45 months after surgery). Segmental resection of the third and fourth portions of the duodenum is reliable and feasible. The Cattell and Braash manoeuvre provides a good exposure and makes this kind of resection easier.

Pancreas-sparing duodenectomy for gastrointestinal stromal tumor.

BACKGROUND: Pancreas-sparing duodenectomy (PSD) is a promising alternative procedure to pancreaticoduodenectomy for the treatment of duodenal tumors with low-grade malignant behavior. METHODS: Between March 2003 and September 2012, PSD was performed in 7 patients with a gastrointestinal stromal tumor (GIST) in the second (n = 5) or third (n = 2) portions of the duodenum. The short- and long-term outcomes of treatment were analyzed in all patients. RESULTS: The median blood loss was 160 mL, and the median operative time was 315 minutes. No pancreatic leakage or perioperative mortality occurred. Surgical margins were negative in all cases. All patients were alive at the median follow-up time of 42 months after PSD. The recurrence-free 5-year survival rate was 53% in all patients. Hepatic metastases developed in 2 of the 5 patients with high- or intermediate-grade risks at the time of diagnosis. Hepatic resection was performed, and imatinib mesylate was administered in the 2 cases. CONCLUSIONS: Good short- and long-term outcomes and surgical curability were observed in patients treated with PSD for duodenal GIST.

Adenocarcinoma of the minor duodenal papilla treated with pancreas-sparing segmental duodenectomy: case report and review of the literature.

Carcinoma of the minor duodenal papilla is extremely rare. We present the case of a 69-year-old man diagnosed with a tumor of the second portion of the duodenum by upper gastrointestinal endoscopy, which revealed a 1.5-cm elevated tumor with slight ulceration at the minor duodenal papilla. Biopsy revealed adenocarcinoma, and a computed tomography scan showed an enhanced tumor in the duodenum, with no abnormality in the pancreatic head. A pancreas-sparing segmental duodenectomy was performed, and the duodenum reconstructed with an end-to-end anastomosis. Microscopically, the tumor was a well-differentiated adenocarcinoma, with no infiltration at the cut end of the accessory pancreatic duct. The postoperative course was uneventful and the patient discharged on postoperative day 11. We reviewed previously reported cases of carcinoma of the minor duodenal papilla. Early and exact preoperative diagnosis of duodenal neoplasms makes it possible to select a less invasive treatment, which also maintains curability.