Case Control Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 21, 2017; 23(23): 4252-4261
Published online Jun 21, 2017. doi: 10.3748/wjg.v23.i23.4252
Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies
W Kyle Mitchell, Pradeep F Thomas, Abed M Zaitoun, Adam J Brooks, Dileep N Lobo
W Kyle Mitchell, Pradeep F Thomas, Adam J Brooks, Dileep N Lobo, Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
Abed M Zaitoun, Cellular Pathology, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
Author contributions: Mitchell WK designed this work, collected data, drafting of manuscript, final approval, accountability for the manuscript; Thomas PF designed of the work, collected data, drafting of manuscript, art work, final approval, and accountability for the manuscript; Zaitoun AM designed this work, collected and interpreted data, critical revision of manuscript, final approval, accountability for the manuscript; Brooks AJ designed this work, collected data and interpretation, critical revision of manuscript, final approval, accountability for the manuscript; Lobo DN conceived and designed this work, collected and interpreted data, critical revision of manuscript, final approval, accountability for the manuscript, overall supervision.
Institutional review board statement: The prospective maintenance of a database of operative procedures is considered part of routine clinical governance. This database has been used in line with local information governance policy.
Conflict-of-interest statement: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Dileep N Lobo, Professor, Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Derby Rd, Nottingham NG7 2UH, United Kingdom. dileep.lobo@nottingham.ac.uk
Telephone: +44-115-8231149 Fax: +44-115-8231160
Received: January 26, 2017
Peer-review started: February 3, 2017
First decision: February 23, 2017
Revised: April 1, 2017
Accepted: May 19, 2017
Article in press: May 19, 2017
Published online: June 21, 2017
Abstract
AIM

To investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up.

METHODS

Neoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed.

RESULTS

Twenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively).

CONCLUSION

PPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Keywords: Pancreas preserving distal duodenectomy, Duodenojejunostomy, Duodenal disease, Surgical technique, Adults, Indications, Treatment, Outcome

Core tip: Pancreas preserving distal duodenectomy is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma. It avoids the morbidity and mortality of a pancreaticoenteric anastomosis and can be undertaken safely with shorter postoperative length of stay than pancreaticoduodenectomy.