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Kato T, Ono Y, Oba A, Sato T, Ito H, Inoue Y, Saiura A, Takahashi Y. Treatment Strategy of Pancreas-Sparing Distal Duodenectomy for Distal Duodenal Malignancies with Adjustable Dissection Levels According to Disease Progression (with Video). World J Surg 2023; 47:1752-1761. [PMID: 36941481 DOI: 10.1007/s00268-023-06981-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Pancreas-sparing distal duodenectomy (PSDD) is a favorable option for distal duodenal neoplasms, and its procedure, including the extent of lymphadenectomy, should be modified according to the malignancy of the tumor. However, there are no coherent reports on the details of this procedure or long-term outcomes after each resection. METHODS This study included 24 patients who underwent PSDD at our institution between January 2009 and October 2020. Patients were divided into two groups according to the tumor progression: nine with (Lv-II) and fifteen without (Lv-I) mesopancreas dissection. Postoperative outcomes were compared between the two groups. RESULTS Two groups had similar operation times, blood loss, hospital stay, and the rate of delayed gastric emptying (DGE): 40% versus 44%. There were no Clavien-Dindo classification ≥ III complications in the Lv-II group. The Lv-II group had a larger number of examined lymph nodes (median: 29), and three (33%) patients had lymph node metastasis. No local recurrence was observed, although two patients in the Lv-II group had liver metastasis. The 5-year overall survival rates of the Lv-I and Lv-II groups were 100% and 78%, respectively. None of the patients had an impaired nutrition status after one year of surgery, and no rehospitalization was observed in either group. CONCLUSION Although PSDD with or without mesopancreas dissection entailed a high risk of DGE, this procedure showed favorable long-term outcomes and may be an alternative to pancreatoduodenectomy in patients with distal duodenal neoplasms.
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Affiliation(s)
- Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
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Sharma A, Nagar A, Varshney P, Tomar M, Sarin S, Choubey RP, Kapoor VK. Pancreas-preserving limited duodenal resection: Minimizing morbidity without compromising oncological adequacy. Ann Hepatobiliary Pancreat Surg 2022; 26:149-158. [PMID: 35168204 PMCID: PMC9136427 DOI: 10.14701/ahbps.21-124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Ajay Sharma
- Department of Surgical Gastroenterology, Mahatma Gandhi University of Medical Science and Technology, Jaipur, India
| | - Anand Nagar
- Department of Surgical Gastroenterology, Mahatma Gandhi University of Medical Science and Technology, Jaipur, India
| | - Peeyush Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Maunil Tomar
- Department of Surgical Gastroenterology, Mahatma Gandhi University of Medical Science and Technology, Jaipur, India
| | - Shashwat Sarin
- Department of Surgical Gastroenterology, Mahatma Gandhi University of Medical Science and Technology, Jaipur, India
| | - Rajendra Prasad Choubey
- Department of Surgical Gastroenterology, Mahatma Gandhi University of Medical Science and Technology, Jaipur, India
| | - V. K. Kapoor
- Department of Surgical Gastroenterology, Mahatma Gandhi University of Medical Science and Technology, Jaipur, India
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Busquets J, Lopez-Dominguez J, Gonzalez-Castillo A, Vila M, Pelaez N, Secanella L, Ramos E, Fabregat J. Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement. Hepatobiliary Pancreat Dis Int 2021; 20:485-492. [PMID: 33753002 DOI: 10.1016/j.hbpd.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 02/26/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy. METHODS Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy. RESULTS We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35). CONCLUSIONS Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.
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Affiliation(s)
- Juli Busquets
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Barcelona University, L'Hospitalet de Llobregat, Barcelona 08907, Spain.
| | - Josefina Lopez-Dominguez
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Barcelona University, L'Hospitalet de Llobregat, Barcelona 08907, Spain
| | | | - Marina Vila
- Department of General Surgery, Hospital de Mataró, Barcelona 08907, Spain
| | - Nuria Pelaez
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Barcelona University, L'Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Lluis Secanella
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Barcelona University, L'Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Emilio Ramos
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Barcelona University, L'Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Juan Fabregat
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitari de Bellvitge, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Barcelona University, L'Hospitalet de Llobregat, Barcelona 08907, Spain
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Lu C, Jin W, Mou Y, Shao H, Wu X, Li S, Xu B, Wang Y, Zhu Q, Xia T, Zhou Y. Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy? Cancer Manag Res 2020; 12:4725-4734. [PMID: 32606963 PMCID: PMC7310982 DOI: 10.2147/cmar.s254972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/29/2020] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Chao Lu
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China.,School of Medicine, Soochow University, Suzhou, Jiangsu Province, People's Republic of China
| | - Weiwei Jin
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yiping Mou
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China
| | - Hongliang Shao
- School of Medicine, Bengbu Medical College, Bengbu, Anhui Province, People's Republic of China
| | - Xiaosan Wu
- School of Medicine, Bengbu Medical College, Bengbu, Anhui Province, People's Republic of China
| | - Shaodong Li
- School of Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Biwu Xu
- School of Medicine, Bengbu Medical College, Bengbu, Anhui Province, People's Republic of China
| | - Yuanyu Wang
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China
| | - Qicong Zhu
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China
| | - Tao Xia
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yucheng Zhou
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, People's Republic of China.,Key Laboratory of Gastroenterology of Zhejiang Province, Hangzhou, Zhejiang Province, People's Republic of China.,School of Medicine, Soochow University, Suzhou, Jiangsu Province, People's Republic of China
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Side-to-side duodenojejunostomy after resection of third and fourth duodenal portions with pancreatic preservation. Updates Surg 2020; 72:1105-1113. [PMID: 32504267 DOI: 10.1007/s13304-020-00823-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 05/28/2020] [Indexed: 12/14/2022]
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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Choi SH, Park J, Kang CM, Lee WJ. Laparoscopic Partial Sleeve Duodenectomy for the Infra-Ampullary Gastrointestinal Stromal Tumors of the Duodenum. World J Surg 2019; 42:4005-4013. [PMID: 29947989 DOI: 10.1007/s00268-018-4707-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although organ-preserving operations are regarded as effective strategies for duodenal gastrointestinal stromal tumors (GISTs), laparoscopic partial sleeve duodenectomy (lap PSD) has not been fully evaluated. The aims of this study were to evaluate the effectiveness and technical feasibility of lap PSD. STUDY DESIGN Between January 2011 and March 2016, we reviewed 13 patients who underwent laparoscopic approach among 22 patients who underwent PSD. PSD for the infra-ampullary lesions was defined as infra-ampullary duodenal resection including the first portion of the jejunum. After resection, all patients underwent reconstruction via side-to-side duodenojejunostomy. RESULTS The total mean operation time was 273 min (range 160-346 min), and estimated mean blood loss was 80 ml (range scanty-200 ml). One patient was converted to open laparotomy because of mesocolonic tumor involvement. The median postoperative hospital stay was 10.5 days (range 4-36 days). There were no postoperative mortalities. Postoperative complications included 2 instances of delayed gastric emptying (DGE), 1 duodenojejunostomy stricture, and 2 intestinal obstructions. No patient was treated with adjuvant therapy. One patient experienced hepatic metastasis 28 months after surgery during a mean follow-up period of 48.6 months. CONCLUSION Lap PSD might be an oncologically effective strategy for duodenal GIST, and the laparoscopic approach is a technically feasible and appealing surgical modality in terms of safety and perioperative results. However, DGE and anastomosis strictures are concerns for postoperative complications, which need to be further investigated.
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Affiliation(s)
- Sung Hoon Choi
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jiae Park
- Department of Surgery, National Police Hospital, Seoul, Korea
| | - Chang Moo Kang
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.
| | - Woo Jung Lee
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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Di Saverio S, Segalini E, Birindelli A, Todero S, Podda M, Rizzuto A, Tugnoli G, Biondi A. Pancreas-sparing, ampulla-preserving duodenectomy for major duodenal (D1-D2) perforations. Br J Surg 2018; 105:1487-1492. [PMID: 30024637 DOI: 10.1002/bjs.10910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/20/2018] [Accepted: 05/14/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ideal surgical treatment for acute duodenal injuries should offer a definitive treatment, with low morbidity and mortality. It should be simple and easily reproducible by acute care surgeons in an emergency. Duodenal injury, due to major perforated or bleeding peptic ulcers or iatrogenic/traumatic perforation, represents a surgical challenge, with high morbidity and mortality. The aim was to review definitive surgery with pancreas-sparing, ampulla-preserving duodenectomy for these patients. METHODS Pancreas-sparing, ampulla-preserving D1-D2 duodenectomy was used for patients presenting with major duodenal injuries over a 5-year interval. The ampulla was identified and preserved using a transcystic/transpapillary tube. The outcomes were recorded. RESULTS Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65-84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170-377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1-11) days), and the overall mean hospital stay was 17·8 (range 10-32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications. CONCLUSION Pancreas-sparing, ampulla-preserving D1-D2 duodenectomy for emergency treatment of major duodenal perforations is feasible and associated with satisfactory outcomes.
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Affiliation(s)
- S Di Saverio
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Segalini
- Maggiore Hospital Regional Emergency Surgery and Trauma Centre, Bologna Local Health District, Bologna, Italy
| | - A Birindelli
- Maggiore Hospital Regional Emergency Surgery and Trauma Centre, Bologna Local Health District, Bologna, Italy
| | - S Todero
- Maggiore Hospital Regional Emergency Surgery and Trauma Centre, Bologna Local Health District, Bologna, Italy
| | - M Podda
- General, Emergency and Robotic Surgery Unit, San Francesco Hospital, Nuoro, Italy
| | - A Rizzuto
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - G Tugnoli
- Maggiore Hospital Regional Emergency Surgery and Trauma Centre, Bologna Local Health District, Bologna, Italy
| | - A Biondi
- Department of Surgery, University of Catania, Catania, Italy
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Pieroni E, Napoli N, Lombardo C, Marchetti P, Occhipinti M, Cappelli C, Caramella D, Consani G, Amorese G, De Maria M, Vistoli F, Boggi U. Duodenal graft complications requiring duodenectomy after pancreas and pancreas-kidney transplantation. Am J Transplant 2018; 18:1388-1396. [PMID: 29205793 DOI: 10.1111/ajt.14613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/02/2017] [Accepted: 11/21/2017] [Indexed: 01/25/2023]
Abstract
Duodenal graft complications are poorly reported complications of pancreas transplantation that can result in graft loss. Excluding patients with early graft failure, after a median follow-up period of 126 months (range 23-198) duodenectomy was required in 14 of 312 pancreas transplants (4.5%). All patients were insulin-independent at the time of diagnosis. Reasons for duodenectomy included delayed duodenal graft perforation (n = 10, 71.5%) and refractory duodenal graft bleeding (n = 4, 28.5%). In patients with duodenal graft bleeding, a total duodenectomy was performed. In patients with duodenal graft perforation, preservation of a duodenal segment was possible in five patients but completion duodenectomy was necessary in one patient. After total duodenectomy, immediate enteric duct drainage was feasible in seven patients. In two patients, a pancreaticocutaneous fistula was created that was subsequently converted to enteric drainage in one patient. In the other patient, enteric fistulization occurred as a consequence of silent pressure perforation of the draining catheter on the ascending colon. After a mean follow-up period of 52 months (21-125), all patients were alive, well, and insulin-independent. An aggressive and timely surgical approach may permit graft rescue in patients with severe duodenal graft complications occurring after pancreas transplantation. Generalization of these results remains to be established.
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Affiliation(s)
- Erica Pieroni
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Carlo Lombardo
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Piero Marchetti
- Division of Metabolism and Cell Transplantation, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Margherita Occhipinti
- Division of Metabolism and Cell Transplantation, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Carla Cappelli
- Division of Radiology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Davide Caramella
- Division of Radiology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Giovanni Consani
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Maurizio De Maria
- Division of Urology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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9
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Mitchell WK, Thomas PF, Zaitoun AM, Brooks AJ, Lobo DN. Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies. World J Gastroenterol 2017; 23:4252-4261. [PMID: 28694665 PMCID: PMC5483499 DOI: 10.3748/wjg.v23.i23.4252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/01/2017] [Accepted: 05/19/2017] [Indexed: 02/07/2023] Open
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.
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Abe N, Hashimoto Y, Kawaguchi S, Shimoyama H, Kojima Y, Yoshimoto E, Kondo E, Ohki A, Takeuchi H, Nagao G, Suzuki Y, Masaki T, Mori T, Sugiyama M. Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy. Asian J Endosc Surg 2016; 9:52-6. [PMID: 26781527 DOI: 10.1111/ases.12246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/20/2015] [Accepted: 09/03/2015] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Shouhei Kawaguchi
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hayato Shimoyama
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Youhei Kojima
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Eri Yoshimoto
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Eri Kondo
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Atsuko Ohki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hirohisa Takeuchi
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Gen Nagao
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Tadahiko Masaki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Toshiyuki Mori
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Masanori Sugiyama
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
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Surgical approach for tumours of the third and fourth part of the duodenum. Distal pancreas-sparing duodenectomy. Int J Surg 2015; 18:143-8. [DOI: 10.1016/j.ijsu.2015.04.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/24/2015] [Accepted: 04/18/2015] [Indexed: 01/10/2023]
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Rangelova E, Blomberg J, Ansorge C, Lundell L, Segersvärd R, Del Chiaro M. Pancreas-preserving duodenectomy is a safe alternative to high-risk pancreatoduodenectomy for premalignant duodenal lesions. J Gastrointest Surg 2015; 19:492-7. [PMID: 25564323 DOI: 10.1007/s11605-014-2738-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/17/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreas-preserving duodenectomy (PPD) can be considered a technical alternative to pancreaticoduodenectomy for the treatment of premalignant/low-grade malignant lesions of the duodenum. However, no many data are available comparing surgical results and costs of these two procedures. METHODS Prospectively collected data from the Karolinska University Hospital's electronic database was analyzed retrospectively for patients who underwent PD and PPD between January 2006 and December 2011. The demographics, length of stay (LOS), postoperative morbidity and mortality, and hospital costs were analyzed. RESULTS Twenty patients operated with PPD and 369 with PD were identified. Of the PDs, 81 were classified as HR-PDs, based on the intraoperative assessment of the gland. PPD patients were younger than those with HR-PD (50 vs 62 years; p = 0.0003), and with slight prevalence of overweight, BMI ≥25 (60 vs 45.7 %; p = 0.2). No differences were found in overall morbidity (55 vs 68 %; p = 0.3), in severe postoperative complications-Dindo-Clavien grade ≥3b (20 vs 30 %; p = 0.3), in delayed gastric emptying (10 vs 12 %, ns), and postpancreatectomy hemorrhage (10 vs 7.4 %, ns) between PPD and HR-PDs. However, the incidence of POPF was marginally lower in the PPD group (15 vs 37 %; p = 0.06) and was treated conservatively, while ten patients in the HR-PD group were reoperated and with POPF-associated mortality of 40 %. Also, shorter ICU stay (5 vs 12.%, ns), lower reoperation rate (10 vs 21 %, ns), lower mortality (0 vs 6.2 %), and shorter LOS (16.9 vs 24.6 days) were observed with PPD compared to HR-PD, but the numbers did not reach statistical significance. PPD was performed with shorter operative time (319 vs 418 min; p < 0.0001) and less intra-operative blood loss than HR-PD (521 vs 1027 ml; p = 0.003). The hospital costs for PPD were significantly lower than for HR-PD (29,170 vs 53,080 Euro, p = 0.03) CONCLUSIONS: PPD for resection of premalignant and low-grade malignant duodenal lesions in this small series shows to be an equivalent alternative to HR-PD, as it can be performed with shorter operative time, less intraoperative blood loss, and comparable, even slightly better, postoperative outcome and with lower costs.
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Affiliation(s)
- Elena Rangelova
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Pancreas-preserving partial duodenectomy of the distal region for large duodenal adenoma: report of a case. Surg Today 2014; 45:390-3. [DOI: 10.1007/s00595-014-0868-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/20/2013] [Indexed: 12/13/2022]
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Sali PA, Shah R, Jagannath P. Experience with the technique of pancreas-sparing distal duodenectomy. Indian J Gastroenterol 2014; 33:63-6. [PMID: 24243079 DOI: 10.1007/s12664-013-0429-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 10/15/2013] [Indexed: 02/04/2023]
Abstract
Pancreas-sparing distal duodenectomy (PSDD) is a novel surgical technique for tumors of distal duodenum below the ampulla to achieve oncologically free margins and avoid multiple anastomoses. We report PSDD performed in five cases, three duodenal adenocarcinoma, and two neuroendocrine tumors (NETs). Three patients had adenocarcinoma of D3 and D4 with free ampulla. PSDD was performed with total excision of regional nodes. In the two patients with NETs, one had a mass lesion close to the pancreatic head. The mass was excised followed by PSDD. There were four small primary NETs in the duodenum, and the mass was metastatic lymph node. The second patient had primary duodenal NET with liver metastases. After transarterial chemoembolization, PSDD with liver metastatectomy was performed. Specimens in all five cases showed clear margins. The patients had a smooth recovery and were well at a median follow up of 10 months.
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Affiliation(s)
- Priyanka A Sali
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, Bandra Reclamation, Mumbai, 400 050, India
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15
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Pancreas-sparing duodenectomy for gastrointestinal stromal tumor. Am J Surg 2013; 207:578-83. [PMID: 24119884 DOI: 10.1016/j.amjsurg.2013.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 04/23/2013] [Accepted: 05/16/2013] [Indexed: 12/18/2022]
Abstract
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.
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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. [PMID: 23462322 DOI: 10.1097/mpa.0b013e3182649956] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To learn the clinical outcome of patients undergoing laparoscopic partial sleeve duodenectomy (PSD) for lesions, which require sleeve resection of the duodenum. Traditionally, these lesions require en bloc excision of the head of the pancreas performed in an open fashion. METHODS A retrospective review of medical records of patients with nonampullary large or circumferential duodenal lesions, which were not amenable to endoscopic or local resection for complete removal, was performed. Characteristics, complications, and technical details were analyzed. RESULTS Ten patients (5 men and 5 women; mean age, 70 years) with duodenal lesions including adenoma (n = 5), adenocarcinoma (n = 2), lymphangiolipoma (n = 1), leiomyoma (n = 1), and neuroendocrine tumor (n = 1) were included. All patients underwent a laparoscopic approach with either a proximal PSD (n = 3) or distal PSD (n = 7) after separation of the duodenum from the pancreatic head. Reconstruction was carried out by a side-to-side duodenojejunostomy (n = 7), end-to-side duodenojejunostomy (n = 2), or gastrojejunostomy (n = 1). Mean length of stay was 5.6 days, and complications were 20%. CONCLUSIONS Laparoscopic PSD seems to be a safe and easily applicable technique for treatment of duodenal lesions not involving the ampulla, which requires separation of the duodenum from the pancreas head with sleeve resection of the duodenum and subsequent reconstruction.
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Yamashita S, Sakamoto Y, Kaneko J, Tamura S, Aoki T, Sugawara Y, Hasegawa K, Kokudo N. Resection of the second portion of the duodenum sacrificing the minor papilla but preserving the pancreas for a recurrent duodenal adenocarcinoma: report of a case. Biosci Trends 2012; 6:44-7. [PMID: 22426103 DOI: 10.5582/bst.2012.v6.1.44] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Duodenal adenocarcinoma is a relatively rare malignancy and pancreaticoduodenectomy would be a standard procedure to achieve curative resection. We report a case of resection of the 2nd portion of the duodenum with nodal dissection preserving the pancreas. The patient was a 75-year-old man with right-sided paresis suffering from early cancer in the 2nd portion of the duodenum. Despite 3 times of endoscopic mucosal resections, mucosal local recurrence was found. The depth of the tumour involvement continued to be limited within the mucosal layer. We performed segmental duodenal resection with nodal dissection sacrificing the minor papilla, while preserving the pancreas and the major papilla. The pathological diagnosis was primary intramucosal adenocarcinoma; the surgical margin was negative for cancer and there was no nodal metastasis. This procedure can be an alternative to pancreaticoduodenectomy in patients with earlystage adenocarcinoma in the 2nd portion of the duodenum when the major papilla can be spared, especially in high-risk patients.
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Affiliation(s)
- S Yamashita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Cho A, Yamamoto H, Kainuma O, Ota T, Park S, Yanagibashi H, Arimitsu H, Ikeda A, Souda H, Nabeya Y, Takiguchi N, Nagata M. RETRACTED ARTICLE: Totally laparoscopic pancreas-sparing duodenectomy. Surg Today 2012; 42:1032-5. [DOI: 10.1007/s00595-012-0285-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 08/28/2011] [Indexed: 10/28/2022]
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Pancreas-sparing duodenectomy in a patient with acute corrosive injury. Updates Surg 2012; 65:309-11. [PMID: 22623118 DOI: 10.1007/s13304-012-0159-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 05/09/2012] [Indexed: 01/07/2023]
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20
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Chen G, Wang H, Fan Y, Zhang L, Ding J, Cai L, Xu T, Lin H, Bie P. Pancreas-sparing duodenectomy with regional lymphadenectomy for pTis and pT1 ampullary carcinoma. Surgery 2011; 151:510-7. [PMID: 22033169 DOI: 10.1016/j.surg.2011.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 08/04/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND The role of pancreas-sparing duodenectomy (PSD) in the treatment of ampullary carcinoma (Amp Ca) with local lymph node metastasis remains controversial. The aim of this study was to investigate the feasibility, safety, and long-term prognosis of PSD with regional lymphadenectomy in the treatment of early-stage (pTis/pT1) Amp Ca with or without regional lymph node metastasis. METHODS Between May 2005 and November 2009, 31 consecutive patients with Amp Ca were enrolled in this study; 25 underwent PSD. A retrospective control group of 28 patients who underwent pancreatoduodenectomy (PD) for Amp Ca during the same period was established. These 2 groups were matched in terms of demographic data, tumor size, and TNM classification. RESULTS In the PSD group, 9 patients (36%) had regional lymph node metastasis, and 23 patients (92%) had R0 resection. Patients who underwent PSD achieved favorable results in intraoperative blood loss, duration of hospital stay, and morbidity rate. The 3-year overall and disease-free survival in PSD group were 72% and 61%, respectively. There were no differences in hospital mortality and long-term survival between the 2 groups, even for patients with lymph node metastasis (N1). CONCLUSION PSD with regional lymphadenectomy is feasible and safe in the treatment of pTis/pT1 Amp Ca with or without regional lymph node metastasis. Long-term survival and morbidity rates are also favorable. PSD can be performed as an alternative of PD in selected patients with Amp Ca.
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Affiliation(s)
- Geng Chen
- Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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21
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Boggi U, Vistoli F, Del Chiaro M, Moretto C, Croce C, Signori S, D'Imporzano S, Amorese G, Campani D, Calabrese F, Capocasale E, Marchetti P. Total duodenectomy with enteric duct drainage: a rescue operation for duodenal complications occurring after pancreas transplantation. Am J Transplant 2010; 10:692-7. [PMID: 20121744 DOI: 10.1111/j.1600-6143.2009.02981.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Duodenal graft complications (DGC) occur frequently after pancreas transplantation but rarely cause graft loss. Graft pancreatectomy, however, may be required when DGC compromise recipient's safety. We herein report on two patients with otherwise untreatable DGC in whom the entire pancreas was salvaged by means of total duodenectomy with enteric drainage of both pancreatic ducts. The first patient developed recurrent episodes of enteric bleeding, requiring hospitalization and blood transfusions, starting 21 months after transplantation. The disease causing hemorrhage could not be defined, despite extensive investigations, but the donor duodenum was eventually identified as the site of bleeding. The second patient was referred to us with a duodenal stump leak, 5 months after transplantation. Two previous surgeries had failed to seal the leak, despite opening a diverting stoma above the duodenal graft. Thirty-nine and 16 months after total duodenectomy with dual duct drainage, respectively, both patients are insulin-independent and free from abdominal complaints. Magnetic resonance pancreatography shows normal ducts both basal and after intravenous injection of secretin. The two cases presented herein show that when DGC jeopardize pancreas function or recipient safety, total duodenectomy with enteric duct drainage may become an option.
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Affiliation(s)
- U Boggi
- Divisione di Chirurgia Generale e Trapianti nell'Uremico e nel Diabetico, Ospedaliera-Universitaria Pisana, Pisa, Italy.
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Paluszkiewicz P, Dudek W, Lowery K, Hart CA. Pancreas sparing duodenectomy as an emergency procedure. World J Emerg Surg 2009; 4:19. [PMID: 19445694 PMCID: PMC2694147 DOI: 10.1186/1749-7922-4-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Accepted: 05/16/2009] [Indexed: 12/28/2022] Open
Abstract
Background The operative techniques to close extensive wounds to the duodenum are well described. However, postoperative morbidity is common and includes suture line leak and the formation of fistulae. The aim of this case series is to present pancreas sparing duodenectomy as a safe and viable alternative procedure in the emergency milieu. Methods Five patients underwent emergency pancreas sparing duodenal excisions. Re-implantation of the papilla of Vater or the papilla with a surrounding mucosal patch was performed in two patients. In one, the procedure was further supplemented with a duodenocholangiostomy, stapled pyloric exclusion and enterogastrostomy to defunction the pylorus. In another three patients, distal duodenal excisions were done. Results In four patients, an uneventful recovery was made. One patient died following a myocardial infarction. The surgery lasted meanly 160 minutes with average blood loss of approximately 500 milliliters. The mean hospital stay was 12 days. Enteral nutrition was introduced within the 20 hours after the surgery. Long term follow-up of all surviving patients confirmed a good outcome and normal nutritional status. Conclusion Based on the presented series of patients, we suggest that pancreas-sparing duodenectomy can be considered in selected patients with laceration of the duodenum deemed unsuitable for surgical reconstruction.
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Affiliation(s)
- Piotr Paluszkiewicz
- Department of Surgery and Surgical Nursing, Medical University of Lublin, Lublin, Poland
| | - Wojciech Dudek
- Department of Surgery, Pilgrim Hospital, Boston, Lincolnshire, UK
| | - Kathryn Lowery
- Department of Surgery, Pilgrim Hospital, Boston, Lincolnshire, UK
| | - Colin A Hart
- Department of Surgery, Pilgrim Hospital, Boston, Lincolnshire, UK
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Al-Sarireh B, Ghaneh P, Gardner-Thorpe J, Raraty M, Hartley M, Sutton R, Neoptolemos JP. Complications and follow-up after pancreas-preserving total duodenectomy for duodenal polyps. Br J Surg 2008; 95:1506-11. [DOI: 10.1002/bjs.6412] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Patients with duodenal polyps are at risk of duodenal cancer. Pancreas-preserving total duodenectomy (PPTD) is an alternative to partial pancreatoduodenectomy.
Methods
Twelve patients (seven men and five women) with a median age of 59 (interquartile range (i.q.r.) 50–67) years underwent PPTD for large (over 20 mm) solitary polyps or multiple (more than three) duodenal polyps confined to the muscularis propria on endoscopic ultrasonography.
Results
Median hospital stay was 21 (i.q.r. 10–36) days with no deaths and no blood transfusion. Six patients developed postoperative complications, one requiring reoperation. Histology demonstrated gastrointestinal stromal tumour in three patients, low-grade dysplasia in one, moderate-grade dysplasia in eight and duodenal intramucosal adenocarcinoma in one. During a median follow-up of 20 (i.q.r. 8–41) months one patient experienced recurrent acute pancreatitis (due to hypertriglyceridaemia) and one developed a jejunal adenocarcinoma in the neoduodenum.
Conclusion
The morbidity of PPTD is similar to that of partial pancreatoduodenectomy, but PPTD preserves the whole pancreas and reduces the number of anastomoses.
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Affiliation(s)
- B Al-Sarireh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - P Ghaneh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - J Gardner-Thorpe
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - M Raraty
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - M Hartley
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - R Sutton
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - J P Neoptolemos
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
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Müller MW, Dahmen R, Köninger J, Michalski CW, Hinz U, Hartel M, Kadmon M, Kleeff J, Büchler MW, Friess H. Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis? Am J Surg 2008; 195:741-8. [PMID: 18436175 DOI: 10.1016/j.amjsurg.2007.08.061] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 07/31/2007] [Accepted: 08/08/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND Duodenal adenomatosis is a premalignant condition often not treatable by local resection or endoscopy. An option for treatment is a pylorus-preserving (pp)-Whipple resection. Since the introduction of pancreas-preserving total duodenectomy (PPTD), the question has arisen whether a pp-Whipple resection is still needed to treat duodenal adenomatosis. PATIENTS AND METHODS In a 5-year period 23 PPTDs were performed for duodenal adenomatosis. In a matched-pairs analysis the outcome following PPTD (16 patients with a follow-up longer than 12 months) was compared with pp-Whipple. RESULTS Hospital mortality in all 23 patients was 4.3% and total morbidity 30% after PPTD. Operation time, intensive care and hospital stay, morbidity, and mortality were comparable between the matched paired groups (16 patients). Patients with PPTD had significantly lower intraoperative blood loss. No PPTD patient required pancreatic enzyme substitution, compared with 12 patients after pp-Whipple. Quality-of-life analysis in PPTD patients revealed no difference compared to a normal control population and the pp-Whipple group. CONCLUSIONS PPTD is a safe surgical procedure for duodenal adenomatosis that avoids pancreatic head resection, provides high quality of life, and shows advantages over the pp-Whipple procedure.
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Affiliation(s)
- Michael W Müller
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, D-81675 Munich, Germany
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Spalding DRC, Isla AM, Thompson JN, Williamson RCN. Pancreas-sparing distal duodenectomy for infrapapillary neoplasms. Ann R Coll Surg Engl 2007; 89:130-5. [PMID: 17346405 PMCID: PMC1964558 DOI: 10.1308/003588407x155815] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION For neoplasms that arise in the third and fourth parts of the duodenum (D(3), D(4)), a duodenectomy that preserves the pancreas can provide adequate tumour clearance while avoiding the additional dissection and risk of the common alternative, pancreatoduodenectomy. PATIENTS AND METHODS Pancreas-sparing distal duodenectomy (PSDD) was performed in 14 patients with infrapapillary duodenal neoplasms between 1991-2002, and the clinical outcome is reviewed. The operation entails careful separation of the lower pancreatic head from D(3), complete mobilisation of the ligament of Treitz and end-to-end duodenojejunal anastomosis 1-3 cm below the major duodenal papilla. RESULTS There were 9 men and 5 women of median age 56 years, who presented with iron-deficiency anaemia (n = 8), gastric outlet obstruction (n = 4), anaemia and gastric outlet obstruction (n = 1), epigastric pain or mass (1 each). There were 11 malignant neoplasms (adenocarcinoma 5, stromal tumour 4, recurrent seminoma 1, plasmacytoma 1), 2 benign neoplasms (villous adenoma, lipoma) and 1 patient with steroid-induced ulceration. In addition to D(3) and D(4), resection included the distal part of D(2) in 5 patients, while 4 required concomitant partial colectomy. Median operation time was 240 min and median blood loss 1197 ml, being greater for malignant than benign lesions (1500 ml versus 700 ml). There was one death from gangrenous cholecystitis, one early re-operation for anastomotic bleeding and one late re-operation for delayed gastric emptying secondary to anastomotic stricture, but no pancreatic complications. At a median follow-up of 47 months, three patients had died of recurrent disease while the other 10 were alive and well with no upper gastrointestinal symptoms. CONCLUSIONS Provided there is a minimum 1-cm clearance at the papilla, PSDD is a useful alternative to formal pancreatoduodenectomy in patients with unusual neoplasms arising from the third and fourth parts of the duodenum. Although a major undertaking in its own right, it avoids the extra time of a pancreatic resection and the extra risk of a pancreatic anastomosis.
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Affiliation(s)
- DRC Spalding
- Department of Surgery, Hammersmith HospitalLondon, UK
| | - AM Isla
- Department of Surgery, Hammersmith HospitalLondon, UK
| | - JN Thompson
- Department of Surgery, Royal Marsden HospitalLondon, UK
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Hurtuk MG, Devata S, Brown KM, Oshima K, Aranha GV, Pickleman J, Shoup M. Should all patients with duodenal adenocarcinoma be considered for aggressive surgical resection? Am J Surg 2007; 193:319-24; discussion 324-5. [PMID: 17320527 DOI: 10.1016/j.amjsurg.2006.09.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 09/20/2006] [Accepted: 09/20/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Long-term survival for duodenal adenocarcinoma is inconsistent in the literature, and the biology of duodenal adenocarcinoma is poorly understood. METHODS One institution's experience with duodenal adenocarcinoma from 1984 to 2005 is reviewed. Clinicopathologic data were analyzed, and overall survival was estimated using Kaplan-Meier curves with log-rank test. RESULTS Of the 52 patients, 35 (67%) underwent potentially curative surgery; 31 survived the postoperative period and were included in the analysis. Of these, the median survival was 34 months (range 6 to 186 months) compared with 13 months (range 1 to 24 months) for those not undergoing curative surgery (P < or = .001). Clinicopathologic factors favoring long-term survival were tumor size >3.5 cm (P < or = .001) and T-stage < or =4 (P = .014). CONCLUSIONS Clinicopathologic factors important to survival in duodenal cancer are T4 tumor status and tumor size. Interestingly, larger tumors were less likely to be invasive, and patients with these tumors had improved survival. The biology of this cancer is poorly understood; therefore, aggressive resection for all duodenal adenocarcinomas is recommended for all patients medically fit to undergo resection.
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Affiliation(s)
- M G Hurtuk
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153, USA
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Orsenigo E, Di Palo S, Vignali A, Staudacher C. Laparoscopic excision of duodenal schwannoma. Surg Endosc 2006; 21:1454-6. [PMID: 17177083 DOI: 10.1007/s00464-006-9073-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Revised: 07/10/2006] [Accepted: 08/10/2006] [Indexed: 12/29/2022]
Abstract
BACKGROUND Benign duodenal tumours are rare and less common than malignant tumours. They comprise a wide variety of pathologies. Schwannoma is an ectodermal neoplasm arising from the nerve sheath that envelops axons. A duodenal location is extremely rare. Therapy consists in the radical excision of the tumour. Our aim was to describe a minimally invasive technique used for the excision of duodenal schwannoma, so that a laparotomy has been avoided. METHODS A laparoscopic operation under general anaesthesia was undertaken with the patient in supine position with the legs abducted. No macroscopic peritoneal seedling was found. Therefore, a laparoscopic Kocher maneuver was performed. The retroperitoneum was entered using the harmonic scalpel and the dissection extended beyond the vena cava and the duodenum. The location and the size of the lesion have been confirmed using an intraoperative endoscopic ultrasound examination. The excision of the lesion was performed by use the harmonic scalpel. Then, the duodenal wall was sutured by use endoscopic stitches. The resected lesion was then placed in a retrieval bag and extracted through the port incision. Operating time was 300 min and blood loss 200 ml. RESULTS The postoperative course was uneventful. Histological findings showed a benign schwannoma. CONCLUSIONS The minimally invasive technique may be a valid alternative to open surgery in the treatment of benign duodenal tumors.
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Affiliation(s)
- E Orsenigo
- Department of Surgery, University Vita-Salute, San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
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Cueto J, Benotto JA, Catalina R, Vazquez-Frias JA. Large duodenal villous adenoma requiring head of the pancreas and pylorus-preserving total duodenectomy. Surg Laparosc Endosc Percutan Tech 2005; 15:230-2; discussion 232-3. [PMID: 16082312 DOI: 10.1097/01.sle.0000174552.79424.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Villous adenomas of the duodenum (VAD) are infrequent lesions of the gastrointestinal tract but have a high risk of recurrence and malignancy. For these reasons and its specific topographic location, the surgical treatment of VAD is still controversial. Herein we present a case of large VAD located in the second duodenal portion that was successfully treated with a head of the pancreas, pylorus-preserving total duodenectomy (PPTD). PPTD should be an excellent option in patients with large adenomas because it allows preservation of the pancreas, gastrointestinal function is maintained, the possibility of a recurrence and of an invasive carcinoma of the ampulla is eliminated, and finally because it permits an adequate endoscopic follow-up. PPTD should not be used in the presence of malignancy and/or high-grade dysplasia.
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Affiliation(s)
- Jorge Cueto
- Department of Surgery, Angeles de las Lomas Hospital, Mexico City, Mexico.
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Köninger J, Friess H, Wagner M, Kadmon M, Büchler MW. Die Technik der pankreaserhaltenden Duodenektomie. Chirurg 2005; 76:273-81. [PMID: 15668807 DOI: 10.1007/s00104-004-0992-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Even in pancreatic surgery, as in other organs, there is a tendency towards subtle organ-preserving techniques. Benign duodenal tumors which cannot be resected transduodenally or multiple dysplastic duodenal adenomas in patients with familial adenomatous polyposis (FAP) usually require partial pancreaticoduodenectomy. However, pancreas-preserving duodenectomy may represent a viable alternative. This technique allows for the resection of the entire duodenum without resection of the pancreatic head. Large duodenal adenomas, multiple adenomas with dysplasia in patients with FAP, and based on the literature extended duodenal injury after trauma may represent indications for this surgical technique. Compared with duodenopancreatectomy, this intervention can be performed with a comparably low morbidity and leads to good functional results. Beside the preservation of pancreatic parenchyma and the reduction of the number of anastomoses, this technique offers the advantage of uncomplicated endoscopic follow-up. In this article we describe the surgical technique of pancreas-preserving duodenectomy and our experience with this intervention.
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Affiliation(s)
- J Köninger
- Abteilung für Allgemein-, Viszeral- und Unfallchirurgie, Universität Heidelberg
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Abstract
Cancer of the small bowel is a rare entity but its incidence is rising. Historically, outcome is poor despite apparent curative resection. At present surgery remains the only treatment modality of proven benefit in the management of this disease. Recent data would suggest 5-year survival rates in the order of 40-50% at all sites of small bowel cancer. To improve upon this, earlier diagnosis with a high index of suspicion and multicentre adjuvant therapy trials are required.
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Bravo Neto GP, Araújo PCDM, Fernandes RA. Adenoma viloso com transformação carcinomatosa da ampola de Vater. Rev Col Bras Cir 2001. [DOI: 10.1590/s0100-69912001000100012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Eisenberger CF, Izbicki JR, Broering DC, Bloechle C, Steffen M, Hosch SB, Broelsch CE. Strictureplasty with a pedunculated jejunal patch in Crohn's disease of the duodenum. Am J Gastroenterol 1998; 93:267-9. [PMID: 9468257 DOI: 10.1111/j.1572-0241.1998.00267.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgical treatment for duodenal stenosis caused by Crohn's disease is only indicated in symptomatic duodenal obstruction when conservative treatment has failed. Previously described operative procedures include strictureplasty for short stenoses and bypass or resectional procedures, if duodenal stenosis is extensive. In this case of an extensive duodenal Crohn's stenosis, we performed a strictureplasty of the duodenum with a pedunculated jejunal patch. Thus, duodenal passage could be well preserved, and the patient has remained asyptomatic during a follow-up of more than 9 months.
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Affiliation(s)
- C F Eisenberger
- Department of Surgery, University Hospital-Eppendorf, Hamburg, Germany
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