Surg Today DOI 10.1007/s00595-014-0868-6
CASE REPORT
Pancreas-preserving partial duodenectomy of the distal region for large duodenal adenoma: report of a case Kenji Shimizu • Daisuke Hashimoto • Shinya Abe • Akira Chikamoto • Hideo Baba
Received: 20 August 2013 / Accepted: 20 November 2013 Ó Springer Japan 2014
Abstract For neoplasms in the third and fourth parts of the duodenum, a duodenectomy that preserves the pancreas may provide feasible tumor clearance while avoiding the additional dissection and pancreaticoduodenectomy. We herein describe the case of a 40-year-old male patient with an adenoma in the third part of the duodenum. The patient underwent a partial duodenectomy of the distal region, preserving the pancreas and Vater’s papilla. The residual duodenum and jejunum were successfully reconstructed by an end-to-side anastomosis. We also present a review of the English literature regarding pancreas-preserving partial duodenectomy of the distal region.
points and pitfalls of this operation have not been sufficiently discussed. We herein describe the case of a patient with an adenoma in the third part of the duodenum, in whom partial duodenectomy was performed. The technique used for the partial duodenectomy of the distal region, preserving the pancreas and Vater’s papilla, is described in detail below. Additionally, we herein present a review of the English literature regarding partial duodenectomy of the distal region, describing the indications, reconstruction and postoperative complications associated with this procedure.
Keywords Duodenal adenoma Operation Duodenectomy
Case report
Introduction Tumors that arise in the duodenum are relatively rare (only 1 % of gastrointestinal tumors) [1]. The surgical management of duodenal pathology is challenging because of its retroperitoneal position and shared blood supply with the pancreas [2]. Most pancreas-preserving duodenectomy procedures, although technically demanding, eliminate the need for pancreatic resection [3–8]. However, there have been few reports in which a partial duodenectomy of the distal region was described specifically, and the technical
K. Shimizu D. Hashimoto S. Abe A. Chikamoto H. Baba (&) Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan e-mail: [email protected]
A large polypoid lesion with a diameter of 4.0 cm was accidentally discovered in the duodenum of a 40-year-old male by esophago-gastro-duodenoscopy (Fig. 1a). The patient had no symptoms. Hypotonic duodenography confirmed that the tumor existed in the third part of the duodenum (Fig. 1b). An endoscopic biopsy revealed tubular adenoma, but it was considered that endoscopic mucosal resection would be difficult due to the location of the tumor. Therefore, the patient underwent a planned partial resection of the duodenum after providing written informed consent. Before the operation, a clip was left by endoscopy near the Vater’s papilla as a palpable guide (Fig. 1b). After Kocher’s mobilization, the duodenum was cut using a PROXIMATEÒ Linear Cutter (Ethicon Endo-Surgery, Johnson & Johnson, Inc.) 5.0 cm distal from the Treitz ligament (Fig. 2a). The third part of the duodenum was divided from the Treitz ligament, and then from the uncinate process of the pancreas. The duodenum was then cut 2.0 cm below Vater’s papilla, and it was confirmed that the clip was left in the proximal residual duodenum
123
Surg Today Fig. 1 The preoperative findings. Upper gastrointestinal endoscopy (a) and hypotonic duodenography (b) indicated the presence of a 3-cm polypoid lesion (arrowheads) in the third part of the duodenum. A clip (b, circle) was left using the endoscope near Vater’s papilla
Fig. 2 Resection of the distal duodenum. The duodenum was cut 5.0 cm distal from the Treitz ligament (a, solid arrow). The third part of the duodenum (b, arrowheads) was divided from the pancreas 2 cm below Vater’s papilla (a and b, dotted arrow), and was resected
Fig. 3 The reconstruction by an end-to-side anastomosis. The residual duodenum and jejunum were reconstructed (a and b, solid arrow) by an end-to-side anastomosis
(Fig. 2a, b). Thus, pancreas-preserving partial duodenectomy of the distal region was archived, and the residual duodenum and jejunum were reconstructed by a retrocolic end-to-side anastomosis (Fig. 3a, b). An abdominal drain
123
was placed behind the anastomosis, and was later removed without any postoperative complications. Macroscopically, the tumor was 4.0 9 2.5 cm, and the oral margin was 2.5 cm (Fig. 4). A postoperative
Surg Today
Fig. 4 The postoperative findings. Macroscopically, the tumor was 4.0 9 2.5 cm, and the oral margin was 2.5 cm
histological examination confirmed that it was a duodenal adenoma.
Discussion Larger duodenal lesions involve a significant portion of the circumference, and those in an unfavorable location, like the presented case, are usually not amenable to endoscopic mucosal resection or wedge resection [9]. For such lesions, the most commonly practiced approach has been to perform a pancreaticoduodenectomy (PD) [9]. However, PD
may be too aggressive for benign lesions that would not require PD for oncological reasons. Pancreas-sparing duodenectomy is an attractive option for selected cases with isolated duodenal pathology [10], as it shortens the length of the operation, avoids resection of the distal bile duct and pancreas and obviates the need for the biliary– enteric and pancreatic–enteric anastomoses required for a pancreaticoduodenectomy [3, 9]. We reviewed the English literature, in which 55 cases were reported that have undergone pancreas-preserving partial duodenectomy of the distal region, including the present case [2, 5, 7, 9–16] (Table 1). The procedure was performed for 18 patients with duodenal adenocarcinoma [2, 9, 10, 12], four with adenoma (including the present case) [9], nine with gastrointestinal stromal tumors [5, 7, 11, 13, 16], and for other tumors in the other cases. In spite of the benefits of the procedure, two patients died due to gangrenous cholecystitis and anastomotic leakage [2, 10]. Additionally, postoperative complications, such as a pancreatic fistula, anastomotic stenosis and delayed gastric emptying, were reported for 13 other cases [2, 9, 10, 12– 14]. These high mortality and morbidity rates have not been emphasized in the previous literature, although some cases were performed as laparoscopic surgery [9]. Therefore, in terms of safety, the best technique for this operation has not been discussed, and there is currently no established method that provides an optimal outcome.
Table 1 A summary of the cases treated by pancreas-preserving partial duodenectomy of the distal region Author Stauffer [9]
No. of cases 7
Histopathology
Anastomosis
Complication(s)
3 adenoma
7 side-to-side
1 DGE and pancreatic fistula
2 adenocarcinoma 2 others Waisberg [15]
1
Carcinoid
NA
NA
Cavaniglia [16]
1
GIST
End-to-end
NA
5 adenocarcinoma
14 end-to-end
1 death (cholecystitis)
Spalding [2]
14
4 GIST 5 others
1 anastomotic stenosis 1 DGE 1 anastomotic hemorrhage
Eisenberger [5]
1
GIST
NA
none
Ammori [14]
1
Benign stricture
NA
Abdominal hemorrhage
Orda [7]
1
GIST
NA
None
Suzuki [13]
1
GIST
End-to-side
DGE
Sohn [12]
2
2 adenocarcinoma
NA
2 cholangitis
Maher [10]
24
11 adenocarcinoma
10 end-to-end
1 death (anastomotic leak)
4 other tumors
8 end-to-side
2 pancreatic fistula
2 Crohn’s disease
3 side-to-end
2 DGE
7 others
3 side-to-side
2 anastomotic hemorrhage
Kawano [11]
1
GIST
End-to-side
None
Present case
1
Adenoma
End-to-side
None
DGE delayed gastric emptying, GIST gastrointestinal stromal tumor
123
Surg Today
End-to-end duodenojejunostomy was often performed [2, 10, 16], followed by end-to-side anastomosis [10, 11, 13]. Although Spalding et al. [2] reported one late reoperation for delayed gastric emptying secondary to anastomotic stenosis after end-to-end duodenojejunostomy; end-to-end anastomosis can better replicate the physiological continuity. End-to-side anastomosis, keeping the regional blood supply, especially at the anal side of the anastomosis, was adopted for the present case, and was performed successfully. Further studies should thus be planned that include more patients to compare the safety of these different reconstructions. In conclusion, a careful surgical technique and perioperative management are necessary for pancreas-preserving partial duodenectomy of the distal region because of the high morbidity rate. However, it appears to represent an effective treatment for patients with distal duodenal neoplasms. Conflict of interest Kenji Shimizu and co-authors have no conflicts of interest to declare in association with this study.
References 1. Azih LC, Broussard BL, Phadnis MA, Heslin MJ, Eloubeidi MA, Varadarajulu S, et al. Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas. World J Gastroenterol. 2013;19:511–5. 2. Spalding DR, Isla AM, Thompson JN, Williamson RC. Pancreassparing distal duodenectomy for infrapapillary neoplasms. Ann R Coll Surg Engl. 2007;89:130–5. 3. Sarmiento JM, Thompson GB, Nagorney DM, Donohue JH, Farnell MB. Pancreas-sparing duodenectomy for duodenal polyposis. Arch Surg. 2002;137:557–62 (discussion 562–3). 4. Chung RS, Church JM, vanStolk R. Pancreas-sparing duodenectomy: indications, surgical technique, and results. Surgery. 1995;117:254–9.
123
5. Eisenberger CF, Knoefel WT, Peiper M, Yekebas EF, Hosch SB, Busch C, et al. Pancreas-sparing duodenectomy in duodenal pathology: indications and results. Hepatogastroenterology. 2004;51:727–31. 6. Keidar S, Pappo I, Shperber Y, Orda R. Cecal diverticulitis: a diagnostic challenge. Dig Surg. 2000;17:508–12. 7. Orda R, Sayfan J, Wasserman I. Surgical treatment of leiomyosarcoma of the distal duodenum. Dig Surg. 2000;17:410–2. 8. Yamada S, Shimada M, Utsunomiya T, Morine Y, Imura S, Ikemoto T, et al. Surgical results of pancreatoduodenectomy in elderly patients. Surg Today. 2012;42:857–62. 9. Stauffer JA, Raimondo M, Woodward TA, Goldberg RF, Bowers SP, Asbun HJ. Laparoscopic partial sleeve duodenectomy (PSD) for nonampullary duodenal neoplasms: avoiding a Whipple by separating the duodenum from the pancreatic head. Pancreas. 2013;42:461–6. 10. Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL. Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg. 1996;171:62–7. 11. Kawano N, Ryu M, Kinoshita T, Konishi M, Iwasaki M, Furuse J, et al. Segmental resection of the duodenum for treating leiomyosarcoma associated with von Recklinghausen’s disease: a case report. Jpn J Clin Oncol. 1995;25:109–12. 12. Sohn TA, Lillemoe KD, Cameron JL, Pitt HA, Kaufman HS, Hruban RH, et al. Adenocarcinoma of the duodenum: factors influencing long-term survival. J Gastrointest Surg. 1998; 2:79–87. 13. Suzuki H, Yasui A. Pancreas-sparing duodenectomy for a huge leiomyosarcoma in the third portion of the duodenum. J Hepatobiliary Pancreat Surg. 1999;6:414–7. 14. Ammori BJ. Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs). Surg Endosc. 2002;16:1362–3. 15. Waisberg J, Joppert-Netto G, Vasconcellos C, Sartini GH, de Miranda LS, Franco MI. Carcinoid tumor of the duodenum: a rare tumor at an unusual site. Case series from a single institution. Arq Gastroenterol. 2013;50:3–9. 16. Cavaniglia D, Petrucciani N, Lorenzon L, Caterino S, Cavallini M. Partial duodenectomy with end-to-end anastomosis for duodenal gastrointestinal stromal tumor. Am Surg. 2012;78:E273–5.
CASE REPORT
Pancreas-preserving partial duodenectomy of the distal region for large duodenal adenoma: report of a case Kenji Shimizu • Daisuke Hashimoto • Shinya Abe • Akira Chikamoto • Hideo Baba
Received: 20 August 2013 / Accepted: 20 November 2013 Ó Springer Japan 2014
Abstract For neoplasms in the third and fourth parts of the duodenum, a duodenectomy that preserves the pancreas may provide feasible tumor clearance while avoiding the additional dissection and pancreaticoduodenectomy. We herein describe the case of a 40-year-old male patient with an adenoma in the third part of the duodenum. The patient underwent a partial duodenectomy of the distal region, preserving the pancreas and Vater’s papilla. The residual duodenum and jejunum were successfully reconstructed by an end-to-side anastomosis. We also present a review of the English literature regarding pancreas-preserving partial duodenectomy of the distal region.
points and pitfalls of this operation have not been sufficiently discussed. We herein describe the case of a patient with an adenoma in the third part of the duodenum, in whom partial duodenectomy was performed. The technique used for the partial duodenectomy of the distal region, preserving the pancreas and Vater’s papilla, is described in detail below. Additionally, we herein present a review of the English literature regarding partial duodenectomy of the distal region, describing the indications, reconstruction and postoperative complications associated with this procedure.
Keywords Duodenal adenoma Operation Duodenectomy
Case report
Introduction Tumors that arise in the duodenum are relatively rare (only 1 % of gastrointestinal tumors) [1]. The surgical management of duodenal pathology is challenging because of its retroperitoneal position and shared blood supply with the pancreas [2]. Most pancreas-preserving duodenectomy procedures, although technically demanding, eliminate the need for pancreatic resection [3–8]. However, there have been few reports in which a partial duodenectomy of the distal region was described specifically, and the technical
K. Shimizu D. Hashimoto S. Abe A. Chikamoto H. Baba (&) Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan e-mail: [email protected]
A large polypoid lesion with a diameter of 4.0 cm was accidentally discovered in the duodenum of a 40-year-old male by esophago-gastro-duodenoscopy (Fig. 1a). The patient had no symptoms. Hypotonic duodenography confirmed that the tumor existed in the third part of the duodenum (Fig. 1b). An endoscopic biopsy revealed tubular adenoma, but it was considered that endoscopic mucosal resection would be difficult due to the location of the tumor. Therefore, the patient underwent a planned partial resection of the duodenum after providing written informed consent. Before the operation, a clip was left by endoscopy near the Vater’s papilla as a palpable guide (Fig. 1b). After Kocher’s mobilization, the duodenum was cut using a PROXIMATEÒ Linear Cutter (Ethicon Endo-Surgery, Johnson & Johnson, Inc.) 5.0 cm distal from the Treitz ligament (Fig. 2a). The third part of the duodenum was divided from the Treitz ligament, and then from the uncinate process of the pancreas. The duodenum was then cut 2.0 cm below Vater’s papilla, and it was confirmed that the clip was left in the proximal residual duodenum
123
Surg Today Fig. 1 The preoperative findings. Upper gastrointestinal endoscopy (a) and hypotonic duodenography (b) indicated the presence of a 3-cm polypoid lesion (arrowheads) in the third part of the duodenum. A clip (b, circle) was left using the endoscope near Vater’s papilla
Fig. 2 Resection of the distal duodenum. The duodenum was cut 5.0 cm distal from the Treitz ligament (a, solid arrow). The third part of the duodenum (b, arrowheads) was divided from the pancreas 2 cm below Vater’s papilla (a and b, dotted arrow), and was resected
Fig. 3 The reconstruction by an end-to-side anastomosis. The residual duodenum and jejunum were reconstructed (a and b, solid arrow) by an end-to-side anastomosis
(Fig. 2a, b). Thus, pancreas-preserving partial duodenectomy of the distal region was archived, and the residual duodenum and jejunum were reconstructed by a retrocolic end-to-side anastomosis (Fig. 3a, b). An abdominal drain
123
was placed behind the anastomosis, and was later removed without any postoperative complications. Macroscopically, the tumor was 4.0 9 2.5 cm, and the oral margin was 2.5 cm (Fig. 4). A postoperative
Surg Today
Fig. 4 The postoperative findings. Macroscopically, the tumor was 4.0 9 2.5 cm, and the oral margin was 2.5 cm
histological examination confirmed that it was a duodenal adenoma.
Discussion Larger duodenal lesions involve a significant portion of the circumference, and those in an unfavorable location, like the presented case, are usually not amenable to endoscopic mucosal resection or wedge resection [9]. For such lesions, the most commonly practiced approach has been to perform a pancreaticoduodenectomy (PD) [9]. However, PD
may be too aggressive for benign lesions that would not require PD for oncological reasons. Pancreas-sparing duodenectomy is an attractive option for selected cases with isolated duodenal pathology [10], as it shortens the length of the operation, avoids resection of the distal bile duct and pancreas and obviates the need for the biliary– enteric and pancreatic–enteric anastomoses required for a pancreaticoduodenectomy [3, 9]. We reviewed the English literature, in which 55 cases were reported that have undergone pancreas-preserving partial duodenectomy of the distal region, including the present case [2, 5, 7, 9–16] (Table 1). The procedure was performed for 18 patients with duodenal adenocarcinoma [2, 9, 10, 12], four with adenoma (including the present case) [9], nine with gastrointestinal stromal tumors [5, 7, 11, 13, 16], and for other tumors in the other cases. In spite of the benefits of the procedure, two patients died due to gangrenous cholecystitis and anastomotic leakage [2, 10]. Additionally, postoperative complications, such as a pancreatic fistula, anastomotic stenosis and delayed gastric emptying, were reported for 13 other cases [2, 9, 10, 12– 14]. These high mortality and morbidity rates have not been emphasized in the previous literature, although some cases were performed as laparoscopic surgery [9]. Therefore, in terms of safety, the best technique for this operation has not been discussed, and there is currently no established method that provides an optimal outcome.
Table 1 A summary of the cases treated by pancreas-preserving partial duodenectomy of the distal region Author Stauffer [9]
No. of cases 7
Histopathology
Anastomosis
Complication(s)
3 adenoma
7 side-to-side
1 DGE and pancreatic fistula
2 adenocarcinoma 2 others Waisberg [15]
1
Carcinoid
NA
NA
Cavaniglia [16]
1
GIST
End-to-end
NA
5 adenocarcinoma
14 end-to-end
1 death (cholecystitis)
Spalding [2]
14
4 GIST 5 others
1 anastomotic stenosis 1 DGE 1 anastomotic hemorrhage
Eisenberger [5]
1
GIST
NA
none
Ammori [14]
1
Benign stricture
NA
Abdominal hemorrhage
Orda [7]
1
GIST
NA
None
Suzuki [13]
1
GIST
End-to-side
DGE
Sohn [12]
2
2 adenocarcinoma
NA
2 cholangitis
Maher [10]
24
11 adenocarcinoma
10 end-to-end
1 death (anastomotic leak)
4 other tumors
8 end-to-side
2 pancreatic fistula
2 Crohn’s disease
3 side-to-end
2 DGE
7 others
3 side-to-side
2 anastomotic hemorrhage
Kawano [11]
1
GIST
End-to-side
None
Present case
1
Adenoma
End-to-side
None
DGE delayed gastric emptying, GIST gastrointestinal stromal tumor
123
Surg Today
End-to-end duodenojejunostomy was often performed [2, 10, 16], followed by end-to-side anastomosis [10, 11, 13]. Although Spalding et al. [2] reported one late reoperation for delayed gastric emptying secondary to anastomotic stenosis after end-to-end duodenojejunostomy; end-to-end anastomosis can better replicate the physiological continuity. End-to-side anastomosis, keeping the regional blood supply, especially at the anal side of the anastomosis, was adopted for the present case, and was performed successfully. Further studies should thus be planned that include more patients to compare the safety of these different reconstructions. In conclusion, a careful surgical technique and perioperative management are necessary for pancreas-preserving partial duodenectomy of the distal region because of the high morbidity rate. However, it appears to represent an effective treatment for patients with distal duodenal neoplasms. Conflict of interest Kenji Shimizu and co-authors have no conflicts of interest to declare in association with this study.
References 1. Azih LC, Broussard BL, Phadnis MA, Heslin MJ, Eloubeidi MA, Varadarajulu S, et al. Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas. World J Gastroenterol. 2013;19:511–5. 2. Spalding DR, Isla AM, Thompson JN, Williamson RC. Pancreassparing distal duodenectomy for infrapapillary neoplasms. Ann R Coll Surg Engl. 2007;89:130–5. 3. Sarmiento JM, Thompson GB, Nagorney DM, Donohue JH, Farnell MB. Pancreas-sparing duodenectomy for duodenal polyposis. Arch Surg. 2002;137:557–62 (discussion 562–3). 4. Chung RS, Church JM, vanStolk R. Pancreas-sparing duodenectomy: indications, surgical technique, and results. Surgery. 1995;117:254–9.
123
5. Eisenberger CF, Knoefel WT, Peiper M, Yekebas EF, Hosch SB, Busch C, et al. Pancreas-sparing duodenectomy in duodenal pathology: indications and results. Hepatogastroenterology. 2004;51:727–31. 6. Keidar S, Pappo I, Shperber Y, Orda R. Cecal diverticulitis: a diagnostic challenge. Dig Surg. 2000;17:508–12. 7. Orda R, Sayfan J, Wasserman I. Surgical treatment of leiomyosarcoma of the distal duodenum. Dig Surg. 2000;17:410–2. 8. Yamada S, Shimada M, Utsunomiya T, Morine Y, Imura S, Ikemoto T, et al. Surgical results of pancreatoduodenectomy in elderly patients. Surg Today. 2012;42:857–62. 9. Stauffer JA, Raimondo M, Woodward TA, Goldberg RF, Bowers SP, Asbun HJ. Laparoscopic partial sleeve duodenectomy (PSD) for nonampullary duodenal neoplasms: avoiding a Whipple by separating the duodenum from the pancreatic head. Pancreas. 2013;42:461–6. 10. Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL. Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg. 1996;171:62–7. 11. Kawano N, Ryu M, Kinoshita T, Konishi M, Iwasaki M, Furuse J, et al. Segmental resection of the duodenum for treating leiomyosarcoma associated with von Recklinghausen’s disease: a case report. Jpn J Clin Oncol. 1995;25:109–12. 12. Sohn TA, Lillemoe KD, Cameron JL, Pitt HA, Kaufman HS, Hruban RH, et al. Adenocarcinoma of the duodenum: factors influencing long-term survival. J Gastrointest Surg. 1998; 2:79–87. 13. Suzuki H, Yasui A. Pancreas-sparing duodenectomy for a huge leiomyosarcoma in the third portion of the duodenum. J Hepatobiliary Pancreat Surg. 1999;6:414–7. 14. Ammori BJ. Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs). Surg Endosc. 2002;16:1362–3. 15. Waisberg J, Joppert-Netto G, Vasconcellos C, Sartini GH, de Miranda LS, Franco MI. Carcinoid tumor of the duodenum: a rare tumor at an unusual site. Case series from a single institution. Arq Gastroenterol. 2013;50:3–9. 16. Cavaniglia D, Petrucciani N, Lorenzon L, Caterino S, Cavallini M. Partial duodenectomy with end-to-end anastomosis for duodenal gastrointestinal stromal tumor. Am Surg. 2012;78:E273–5.
