Pancreas-Preserving Total Duodenectomy: A Systematic Review

Abstract

<b><i>Background:</i></b> The management of the pancreas in patients with duodenal trauma or duodenal tumors remains a controversial issue. Pancreas-preserving total duodenectomy (PPTD) requires a meticulous surgical technique. The most common indication is familial duodenal adenomatous polyposis (FAP). The aims of this study are to carry out a systematic review of the literature on the indications for PPTD and to highlight the risks and benefits compared with other more aggressive procedures. <b><i>Summary:</i></b> A systematic literature review was performed following PRISMA recommendations of studies published in PubMed, Embase, and Cochrane library until May 2019. Thirty articles describing 211 patients were chosen. The mean age was 48 years. The surgical indication in 75% of patients was FAP. The mean operating time was 329 min and mean intraoperative bleeding 412 mL. Postoperative morbidity rate was 49.7% (76% Clavien-Dindo <IIIa), and mortality rate was 1.4%. The mean hospital stay was 22 days. Overall survival at 1–3–5 years was >97.8%. <b><i>Key Messages:</i></b> PPTD is indicated for patients with benign and premalignant duodenal lesions without involvement of the pancreatic head. It is a feasible procedure offering an alternative to other more aggressive procedures in selected patients. Mortality is below 1.5%.

How to treat gastrinomas in patients with multiple endocrine neoplasia type1: surgery or long-term proton pump inhibitors?

“…Some surgeons may think that PPTD is a difficult procedure, but it has been accepted internationally as less invasive for duodenal tumors because it does not include resection of the pancreatic parenchyma [42][43][44]. According to Cantalejo-Diaz M et al who systematically reviewed reports of 211 patients who underwent PPTD for various diseases, including familial adenomatous polyposis and neuroendocrine tumors, the mortality rate was less than 1.4% [45]. In our series of PPTD for 10 patients with MEN1 and gastrinomas, the mortality rate was 0% and the morbidity rate was less than 10%.…”

Indocyanine green‐fluorescent imaging for a detection of accessory pancreatic duct in pancreas‐preserving duodenectomy

“…While the standard treatment for duodenal carcinoma of the second portion is PD, the POPF rate is high (28.9%–38%) and POPF grade C can result in a long hospital stay or mortality. 4 , 7 , 8 This is because patients with duodenal carcinoma are at a high risk of pancreatic fistula as proposed by Callery et al, that is, soft pancreatic gland, small pancreatic duct, high‐risk pathologies such as ampullary and duodenal tumors, and excessive intraoperative blood loss. 9 PPD was reported as an alternative option by Chung in 1995, 10 after which, many case reports and several retrospective studies were published and more than 200 PPDs were reported.…”

“… 4 PPD was considered advantageous for preserving pancreatic endocrine and exocrine function, and avoiding hepaticojejunostomy. 4 …”

“… 1 In cases with widespread or ampullary invasion, pancreas‐preserving duodenectomy (PPD) can be an option. 4 In this procedure, detection of the minor ampullary and accessory pancreatic duct is critically important to prevent postoperative pancreatic fistula. 4 , 5 Here we describe a case of second portion duodenal carcinoma where PPD was performed.…”

“… 4 In this procedure, detection of the minor ampullary and accessory pancreatic duct is critically important to prevent postoperative pancreatic fistula. 4 , 5 Here we describe a case of second portion duodenal carcinoma where PPD was performed. The accessory pancreatic duct was confidently detected and closed using intraoperative indocyanine green‐fluorescent (ICG) imaging.…”