Pancreas-Sparing Surgery for Benign Duodenal Lesions: Four Surgical Techniques (With Video)
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ORIGINAL ARTICLE – PANCREATIC TUMORS
Pancreas-Sparing Surgery for Benign Duodenal Lesions: Four Surgical Techniques (With Video) Tatiana Codjia, MD1, Edouard Roussel, MD1, Matthieu Monge, MD1, Guillaume Gagnat, MD1, Jean Jacques Tuech, MD, PhD1,2, and Lilian Schwarz, MD, PhD1,2 1
Department of Digestive Surgery, Rouen University Hospital, Rouen Cedex, France; 2Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, Normandie Univ, UNIROUEN, UMR 1245 INSERM, Rouen, France
Indications for pancreas-sparing duodenectomy (PSD) are rather rare, and PSD is performed primarily for nonmalignant duodenal lesions (sporadic adenoma or adenoma in the spectrum of familial adenomatous polyposis) or duodenal tumors that rarely spread to the lymph node (gastrointestinal stromal tumors).1–4 The use of PSD also is restricted to lesions not amenable to endoscopic or transduodenal excision. The choice of the surgical procedure is guided by the size of the tumor, its location on the duodenal wall, and its distance from the major papilla. The PSD procedure was developed to reduce postoperative morbidity and the long-term sequelae of pancreaticoduodenectomy (PD).1,5 These organ-preserving procedures, although technically demanding, carry a lower risk of major morbidity than PD but expose patients to the risk of duodenal anastomosis leakage and pancreatic fistula.4,6 This report describes the four main surgical PSD procedures: ampulla-preserving segmental duodenectomy (proximal and distal duodenectomy), duodenectomy with ampulla reimplantation, surgical ampullectomy, and
Electronic supplementary material The online version of this article (https://doi.org/10.1245/s10434-020-09238-3) contains supplementary material, which is available to authorized users. Society of Surgical Oncology 2020 First Received: 29 May 2020 Accepted: 26 September 2020 L. Schwarz, MD, PhD e-mail: [email protected]
duodenectomy with bile and pancreatic duct reimplantation. The procedures are described in the text and in dedicated didactic videos. PREOPERATIVE ASSESSMENT A standardized preoperative workup helps surgeons tailor the procedure. This workup includes upper gastrointestinal (GI) endoscopy, endosonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Upper GI endoscopy should be performed with both axial and lateral view endoscopes for clear analysis of the ampulla region. This exam should provide a precise cartography of the lesion and rule out endoscopic resectability. Endosonography evaluates the depth of invasion into the duodenal wall for duodenal lesions and the intraductal invasion of ampullary lesions. Submucosal or intraductal invasion leads to extension of the resection to the pancreas. Biopsies for histopathologic analysis must be performed during these endoscopic examinations. Both CT scan and MRI provide extraluminal information, particularly when gentle distension of the duodenum is coupled with the intravenous administration of an iodinated contrast
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