Limited distal duodenal resection: Surgical approach and outcomes. A case series

Segmental Duodenal Resections: Toward Defining Indications, Complexity, and Coding

BACKGROUND

Segmental resections of the duodenum are uncommonly performed and are technically challenging due to intimate relationships with the biliary tree, pancreas, and superior mesenteric vessels. The objective of this study was to assess indications, operative strategy, and outcomes of duodenal resections and to advocate that this form of resection deserves its own unique Current Procedural Terminology (CPT) and Relative Value Unit (RVU) structure.

METHODS

Patients undergoing isolated and partial duodenal resection from 2008-2023 at University of Tennessee Health Science Center affiliated hospitals were retrospectively reviewed. Factors examined included clinical presentation, diagnostic evaluation, operative time, and technique, 90-day morbidity and mortality, and pathologic and survival outcomes.

RESULTS

Thirty-one patients were identified with majority female and a median age of 61. Diagnostic studies included computed tomography and upper (including push) endoscopy. Reconstruction most often involved side-to-side duodenojejunostomy following distal duodenal resection. Intraoperative evaluation (IOE) of the biliary tree was utilized to assess and protect pancreaticobiliary structures in eleven patients. Median operative time was 206 min, increasing to 236 min when IOE was necessary. Procedure-related morbidity was 23% with one 90-day mortality. Median postoperative length of stay was 9 days. Pathology included benign adenoma, adenocarcinoma, GIST, neuroendocrine neoplasms, and erosive metastatic deposit.

CONCLUSION

Duodenal resections can be effectively employed to safely address diverse pathologies. These procedures are characterized by long operative times, extended hospital stays, and an incidence of postoperative complications that mimics that of pancreatic resection. This work highlights the need for modification to the CPT system to accurately define these distinct procedures for future research endeavors and development of a more accurate valuation unit.

Pancreas-preserving limited duodenal resection: Minimizing morbidity without compromising oncological adequacy

Backgrounds/Aims

Pancreaticoduodenectomy is the most common procedure for the management of duodenal pathologies. However, it is associated with substantial morbidity and a low risk of mortality. Pancreas-preserving limited duodenal resection (PPLDR) can be performed under specific scenarios. We share our experience with PPLDR and its outcome.

Methods

We retrospectively analyzed a prospectively maintained database of patients undergoing limited duodenal resection in the form of wedge (sleeve) resection or segmental resection of one or more duodenal segments from March 2016 to March 2021 at a tertiary care center in North India.

Results

During the study period, 10 patients (including 9 males) underwent PPLDR. Five of these 10 patients showed primary duodenal or proximal jejunal pathology, while the remaining five had duodenal pathology involving an adjacent organ tumor. Four patients underwent wedge (sleeve) resection, while the remaining six underwent segmental duodenal resection of one or more duodenal segments. Mean hospital stay was 6 days (range, 3-11 days) without 30-day mortality. Morbidity occurred in 4 patients (Grade I-II, n = 3; Grade III, n = 1). All patients were alive and disease-free at the time of last follow-up. The mean follow-up duration was 23 months (range, 2-48 months).

Conclusions

PPLDR is a safe and effective alternative for pancreaticoduodenectomy when selected carefully for specific tumor types and location.

Simple Versus Radical Resection for Duodenal Adenocarcinoma: A Propensity Score Matched Analysis of National Cancer Database

BACKGROUND

Duodenal adenocarcinoma treatment consists of either simple or radical surgical resection. Existing evidence suggests similar survival outcomes between the two but is limited by small numbers and single-institution analysis. We aim to compare survival after partial versus radical resection for duodenal adenocarcinoma using the National Cancer Database (NCDB).

METHODS

Using NCDB results from 2004 to 2014, we compared patients with duodenal adenocarcinoma undergoing partial resection (n = 1247) and radical resection (n = 1240) by age, sex, facility type, facility location, cancer stage, cancer grade, lymph node sampling, node status, tumor size, margin status, neoadjuvant therapy, and adjuvant therapy using chi-square analysis. Survival was compared using propensity matching.

RESULTS

Patients undergoing partial resection had overall earlier cancer stage, more favorable tumor grade, and were less likely to undergo lymph node sampling and neoadjuvant therapy. When overall survival was compared between the 2 propensity-matched groups, the median survival was 46.7 months after partial resection and 43.2 months after radical resection (P = .329), and overall survival was similar between the 2 groups (P = .894). The use of adjuvant therapy demonstrated improved survival over either surgery alone (P < .0001, P = .0037).

CONCLUSION

Partial resection did not demonstrate worse survival outcomes than radical resection for duodenal adenocarcinoma. The use of adjuvant therapy in addition to surgery demonstrated improved survival regardless of surgery type and played a larger role in survival than the type of surgery. Our findings provide evidence to support the continued use of both partial and radical surgical resections to treat duodenal malignancy.

Distal duodenectomy: a new option of surgical treatment for duodenal tumors

OBJECTIVE

To assess severity, safety and functional advisability of distal pancreatectomy using original surgical technique developed in the Blokhin National Medical Research Centre of Oncology.

MATERIAL AND METHODS

There were 10 patients with duodenal malignancies who have undergone distal pancreatectomy in the Blokhin National Medical Research Centre of Oncology for the period 2006-2018. Distal pancreatectomy for primary duodenal tumors was performed in 8 patients, 2 patients underwent surgery for external invasion of the duodenum.

RESULTS

Postoperative complications Clavien-Dindo grade 1 and 2 occurred in 4 (40%) patients. Surgical complication grade 2 occurred in 1 (10%) patient (pancreatic fistula with effective conservative management). There were no cases of leakage of duodenal stump and duodenojejunostomy, impaired bile flow and stenosis of anastomosis with delayed stomach emptying.

CONCLUSION

Distal duodenectomyis associated with low postoperative morbidity, good functionality and quality of life. This procedure is preferred for non-epithelial and neuroendocrine tumors, as well as with secondary malignant duodenal invasion.