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Side-to-side duodenojejunostomy after resection of third and fourth duodenal portions with pancreatic preservation

Abstract

Infra-ampullary duodenal lesions are rare and surgical management is controversial. Reconstruction after resection is usually performed by end-to-end or end-to-side duodenojejunostomy. The goal was to analyze our experience, perioperative management, and results after side-to-side duodenojejunostomy. Therefore, we retrospectively evaluated short- and long-term results of surgical resections of third and fourth duodenal portions for several kinds of lesions and reconstruction through duodenojejunostomy performed in our facilities between January 2012 and December 2018. In total, 12 patients were selected for our study, six were male. The median age was 66.3 (IQR: 77.3–59.4). Lesion classification was as follows: 6 cases (50%) of duodenal adenocarcinoma, 4 cases (33.3%) of gastrointestinal stromal tumors (GISTs), and 2 cases (16.7%) of benign pathology. The most frequent clinical presentation was obstruction with vomiting. The surgical technique of choice was resection of third and fourth duodenal portions with a segment of proximal jejunum. Digestive continuity was restored through side-to-side duodenojejunostomy in 11 cases (91.6%). The median operation time was 182.5 min (IQR 237.5–136.3 min). Nine of the 12 patients (75%) did not receive intra- or postoperative blood transfusions. Six patients (50%) experienced complications during post-op. Four of them (33%) experienced major complications (Clavien–Dindo > IIIa) and three required re-op. The median follow-up was 58.3 (95% CI 15–101.5) months. Of the 11 patients with long-term follow-up, 10 have remained asymptomatic during follow-up. The average disease-free survival (DFS) was 43.1 months for adenocarcinoma, and 93 months for GIST. Based on the results of our series, although small, pancreas-sparing duodenectomy could be considered a feasible and safe technique with adequate oncological results. Side-to-side duodenojejunostomy appears to be a safe technique, is easy to perform, and has good functional outcomes. More studies with a larger number of patients are necessary to confirm these findings.

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References

  1. Zhou Y, Wang X, Si X et al (2019) Surgery for duodenal gastrointestinal stromal tumor: a systematic review and meta-analysis of pancreaticoduodenectomy versus local resection. Asian J Surg. https://doi.org/10.1016/j.asjsur.2019.02.006

    Article  PubMed  Google Scholar 

  2. Spalding DRC, Isla AM, Thompson JN, Williamson RCN (2007) Pancreas-sparing distal duodenectomy for infrapapillary neoplasms. Ann R Coll Surg Engl 89:130–135. https://doi.org/10.1308/003588407X155815

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. Garcia-Molina FJ, Mateo-Vallejo F, de Franco-Osorio JD et al (2015) Surgical approach for tumours of the third and fourth part of the duodenum. Distal pancreas-sparing duodenectomy. Int J Surg 18:143–148. https://doi.org/10.1016/j.ijsu.2015.04.051

    Article  PubMed  Google Scholar 

  4. Tocchi A, Mazzoni G, Puma F et al (2003) Adenocarcinoma of the third and fourth portions of the duodenum: results of surgical treatment. Arch Surg 138:80–85. https://doi.org/10.1001/archsurg.138.1.80

    Article  PubMed  Google Scholar 

  5. Maher MM, Yeo CJ, Lillemoe KD et al (1996) Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg 171:62–67

    CAS  Article  Google Scholar 

  6. Cavaniglia D, Petrucciani N, Lorenzon L et al (2012) Partial duodenectomy with end-to-end anastomosis for duodenal gastrointestinal stromal tumor. Am Surg 78:E273–E275

    Article  Google Scholar 

  7. Agha RA, Borrelli MR, Farwana R et al (2018) The process 2018 statement: updating consensus preferred reporting of case series in surgery (PROCESS) guidelines. Int J Surg 60:279–282. https://doi.org/10.1016/j.ijsu.2018.10.031

    Article  PubMed  Google Scholar 

  8. Campbell F, Cairns A, Duthie F, Feakins R (2017) Dataset for the histopathological reporting of carcinomas of the pancreas, ampulla of Vater and common bile duct. London. Available at: https://www.rcpath.org/uploads/assets/34910231-c106-4629-a2de9e9ae6f87ac1/G091-Dataset-for-histopathological-reporting-of-carcinomas-of-the-pancreas-ampulla-of-Vater-and-common-bile-duct.pdf

  9. Cattell RB, Braasch JW (1960) A technique for the exposure of the third and fourth portions of the duodenum. Surg Gynecol Obstet 111:378–379

    CAS  PubMed  Google Scholar 

  10. Shen Z, Chen P, Du N et al (2019) Pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors: a systematic review and meta-analysis. BMC Surg 19:121. https://doi.org/10.1186/s12893-019-0587-4

    Article  PubMed  PubMed Central  Google Scholar 

  11. El-Gendi A, El-Gendi S, El-Gendi M (2012) Feasibility and oncological outcomes of limited duodenal resection in patients with primary nonmetastatic duodenal GIST. J Gastrointest Surg 16:2197–2202. https://doi.org/10.1007/s11605-012-2034-z

    Article  PubMed  Google Scholar 

  12. Hoeppner J, Kulemann B, Marjanovic G et al (2013) Limited resection for duodenal gastrointestinal stromal tumors: surgical management and clinical outcome. World J Gastrointest Surg 5:16. https://doi.org/10.4240/wjgs.v5.i2.16

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dorcaratto D, Heneghan HM, Fiore B et al (2015) Segmental duodenal resection: indications, surgical techniques and postoperative outcomes. J Gastrointest Surg 19:736–742. https://doi.org/10.1007/s11605-015-2744-0

    CAS  Article  PubMed  Google Scholar 

  14. Cavallaro G, Polistena A, D’Ermo G et al (2012) Duodenal gastrointestinal stromal tumors: review on clinical and surgical aspects. Int J Surg 10:463–465. https://doi.org/10.1016/j.ijsu.2012.08.015

    CAS  Article  PubMed  Google Scholar 

  15. Cloyd JM, Norton JA, Visser BC, Poultsides GA (2015) Does the extent of resection impact survival for duodenal adenocarcinoma? Analysis of 1611 cases. Ann Surg Oncol 22:573–580. https://doi.org/10.1245/s10434-014-4020-z

    Article  PubMed  Google Scholar 

  16. Bae J-M, Park J-W, Yang H-K, Kim J-P (1998) Nutritional status of gastric cancer patients after total gastrectomy. World J Surg 22:254–261. https://doi.org/10.1007/s002689900379

    CAS  Article  PubMed  Google Scholar 

  17. Sauniere JF, Sarles H (1988) Exocrine pancreatic function and protein-calorie malnutrition in Dakar and Abidjan (West Africa): silent pancreatic insufficiency. Am J Clin Nutr 48:1233–1238. https://doi.org/10.1093/ajcn/48.5.1233

    CAS  Article  PubMed  Google Scholar 

  18. Wu L, Nahm CB, Jamieson NB et al (2020) Risk factors for development of diabetes mellitus (Type 3c) after partial pancreatectomy: a systematic review. Clin. Endocrinol 92:396–406

    Article  Google Scholar 

  19. Cananzi FCM, Ruspi L, Samà L et al (2019) Short-term outcomes after duodenal surgery for mesenchymal tumors: a retrospective analysis from a single tertiary referral center. Updates Surg 71:451–456. https://doi.org/10.1007/s13304-019-00667-8

    Article  PubMed  Google Scholar 

  20. Buchs NC, Bucher P, Gervaz P et al (2010) Segmental duodenectomy for gastrointestinal stromal tumor of the duodenum. World J Gastroenterol 16:2788–2792. https://doi.org/10.3748/wjg.v16.i22.2788

    Article  PubMed  PubMed Central  Google Scholar 

  21. Fujiwara H, Yamasaki M, Nakamura S et al (2002) Reconstruction of a large duodenal defect created by resection of a duodenal tubulovillous adenoma using a double-tract anastomosis to a retrocolic roux-en-y loop: report of a case. Surg Today 32:824–827. https://doi.org/10.1007/s005950200159

    Article  PubMed  Google Scholar 

  22. Duffy MJ, Lamerz R, Haglund C et al (2014) Tumor markers in colorectal cancer, gastric cancer and gastrointestinal stromal cancers: European group on tumor markers 2014 guidelines update. Int J Cancer 134:2513–2522. https://doi.org/10.1002/ijc.28384

    CAS  Article  PubMed  Google Scholar 

  23. Cusack JC, Overman MJ, Kunitake H (2019) Treatment of small bowel neoplasms. In: Post TW, Walthan MA (Eds) Uptodate Inc. https://www.uptodate.com. Accessed Apr 6 2020.

  24. El Nakeeb A, El Sorogy M, Ezzat H et al (2018) Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: a retrospective study of 5-year survivors. Hepatobiliary Pancreat Dis Int 17:443–449. https://doi.org/10.1016/j.hbpd.2018.08.004

    Article  PubMed  Google Scholar 

  25. Chok A-Y, Koh Y-X, Ow MYL et al (2014) A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors. Ann Surg Oncol 21:3429–3438. https://doi.org/10.1245/s10434-014-3788-1

    Article  PubMed  Google Scholar 

  26. Sohn TA, Lillemoe KD, Cameron JL et al (1998) Adenocarcinoma of the duodenum: factors influencing long-term survival. J Gastrointest Surg 2:79–87

    CAS  Article  Google Scholar 

  27. Solej M, D’Amico S, Brondino G et al (2008) Primary duodenal adenocarcinoma. Tumori 94:779–786

    Article  Google Scholar 

  28. Onkendi EO, Boostrom SY, Sarr MG et al (2012) 15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas. J Gastrointest Surg 16:682–691. https://doi.org/10.1007/s11605-011-1808-z

    Article  PubMed  Google Scholar 

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GB-F, IG-S, DL-G, and IJ-T are involved study conception and design. GB-F, AR-H, IG-S, DL-G, and IJ-T are involved in acquisition of data. GB-F, NDAC, DL-G, and IJ-T analyzed and interpreted the data.GB-F, AR-H, NDAC, DL-G, and IJ-T are involved in drafting of manuscript. GB-F, AR-H, NDAC, IG-S, DL-G, and IJ-T are involved in critical revision of manuscript.

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Correspondence to Diego López-Guerra.

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Blanco-Fernández, G., Rojas-Holguín, A., De-Armas-Conde, N. et al. Side-to-side duodenojejunostomy after resection of third and fourth duodenal portions with pancreatic preservation. Updates Surg 72, 1105–1113 (2020). https://doi.org/10.1007/s13304-020-00823-5

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  • DOI: https://doi.org/10.1007/s13304-020-00823-5

Keywords

  • Duodenal neoplasm
  • Duodenal resection
  • Duodenojejunostomy
  • Postoperative morbidity