More with Less: Pancreas-Preserving Total Duodenectomy

Abstract

A 49-year-old man was initially referred to the hepatobiliary and pancreatic surgery team following an incidental discovery of a duodenal ampullary polyp during esophagogastroduodenoscopy (EGD), which was carried out for worsening gastroesophageal reflux disease (GERD) symptoms.His past medical history included GERD, colon polyps on screening colonoscopy, and anxiety disorder. His surgical history included only tonsillectomy and no prior abdominal operations. His father had a history of colorectal cancer and his mother colon polyps. The patient did not smoke and drank two glasses of wine per day.Physical examination revealed an alert and oriented patient in no distress. His weight was stable at 80 kg. His abdominal examination revealed a soft and non-tender abdomen with no palpable masses. Laboratory findings were unremarkable. A computed axial tomography (CT) scan revealed an expansile filling defect in the second portion of duodenum without any evidence of duodenal adenopathy, peri-duodenal fat invasion, or distant disease ( Fig. 1). Re-endoscopy revealed a very large polypoid mass protruding from the ampulla of Vater in the second portion of the duodenum. Since the mass was nearly occlusive, it was not amenable to endoscopic resection.Biopsy samples confirmed fragments of adenomatous polyp. A small intestinal radiologic contrast study confirmed the presence of a large polypoid mass with a filling defect spanning over 6 cm.The patient was referred to the hepatobiliary and pancreatic surgery team for consideration for surgical resection. Given the size of the lesion and the presumption of benignity (based on biopsy and CT findings), the patient was taken to the operating room for what was planned to most likely be a pancreas-preserving total duodenectomy (PPTD). The case commenced with a cholecystectomy and opening of the cystic duct, which was cannulated with a guidewire to facilitate identification of the ampulla within the polyp. Visualization of the mass via a duodenotomy created at the level of the ampulla of Vater revealed it to be 10 cm with circumferential extension, confirming its near occlusive size within the second portion of the duodenum (Fig. 2). Thus, it was clearly not feasible to pursue a local resection as an ampullectomy. The duodenum was then meticulously freed proximally and distally, except at the ampulla, where the bile duct and pancreatic duct were transected sharply where they entered the duodenal wall. Next, the two ducts were slightly spatulated and sutured together to provide a common channel for a single anastomosis (Fig. 3). A two-layer anastomosis was created between the common ductal channel and the jejunal limb, and a Roux-en-Y reconstruction was fashioned to reestablish gastrointestinal continuity (Fig. 4). A JacksonPratt (JP) drain was placed in the surgical field beneath the biliary and pancreatic anastomosis.Formal pathologic analysis of the resected specimen revealed an adenomatous polyp with focal high-grade dysplasia (Fig. 5). Postoperatively, the patient made a full recov...

Pancreas‐preserving duodenectomy after living donor liver transplantation for invasive cytomegalovirus disease

“…In a young patient, the future occurrence of endocrine or exocrine dysfunctions resulting from partial pancreatectomy is unpredictable, and therefore, we believe that this technique was appropriate for this patient. Another disadvantage associated with performing pancreatic resection of a healthy pancreas is the risk of anastomotic complications: Pancreaticojejunostomy in a soft pancreas has been associated with higher rates of anastomotic fistulas . However, whether pancreas‐preserving duodenectomy is superior to the classic Whipple procedure in terms of pancreatic leakage remains to be elucidated in randomized controlled trials.…”