Pancreas-sparing duodenectomy with preservation of peripapillary part of duodenal wall: a new option of surgical treatment for duodenal tumor lesions

Currently, with duodenal tumor lesion (duodenum), the possibility of performing economical operations that significantly improve the immediate results and quality of life of patients is increasingly being considered as an alternative to gastropancreatoduodenal resection.
using the example of clinical observation, the article presents a new type of economical surgical intervention – duodenectomy with preservation of the peripapillary flap. The operation was performed in a patient with cancer of the resected stomach with a low spread of the tumor along the wall of the duodenum. At the control examination 9 months after the operation, the patient’s condition is satisfactory, without signs of impaired biliodynamics and passage of food through the intestinal tube. The proposed method differs from the existing prototype (papilloservative duodenectomy) by preserving the peripapillary flap of the duodenal wall.

The insertion into the jejunum of not the fater papilla, but the surrounding wall of the duodenum eliminates its deformation and violation of patency and provides greater reliability of the formed suture, and the preservation of the small duodenal papilla with an additional pancreatic duct of Santorini can help reduce the frequency of postoperative pancreatitis and pancreonecrosis. In addition to cases of low lesions of the duodenum in gastric cancer, the method can be used in patients with non-epithelial and neuroendocrine tumors, as well as in secondary tumor invasion of the duodenum from the outside. The criterion limiting the performance of this type of operation is the distance from the edge of the tumor to the fater papilla less than 2.0–2.5 cm.

Duodenectomy with preservation of the peripapillary flap can be considered as a way to improve the safety and quality of life in the surgical treatment of patients with a tumor lesion of the duodenum.

1. Kubyshkin V.A., Vishnevsky V.A. Cancer of the pancreas. Moscow: Medpraktika-M, 2003. 386 p. (In Russ.)

2. De Oliveira M.L., Winter J.M., Schafer M. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244(6):931–9. DOI: 10.1097/01.sla.0000246856.03918.9a

3. Solaini L., Jamieson N.B., Metcalfe M. et al. Outcome after surgical resection for duodenal adenocarcinoma in the UK. Br J Surg 2015;102(6):676–81. DOI: 10.1002/bjs.9791

4. Poultsides G.A., Huang L.C., Cameron J.L. et al. Duodenal adenocarcinoma: clinicopathologic analysis and implications for treatment. Ann Surg Oncol 2012;19(6):1928–35. DOI: 10.1245/s10434-011-2168-3

5. Patyutko Yu. I., Kudashkin N.E., Kotelnikov A.G. Various types of pancreatodigestive anastomosis in pancreatoduodenectomy. Annaly khirurgicheskoy gepatologii = Annals of Surgical Hepatology 2013;18(3):9–14. (In Russ.)

6. Chung J.C., Kim H.C., Hur S.M. Limited resections for duodenal gastrointestinal stromal tumours and their oncologic outcomes. Surg Today 2016;46(1):110–6. DOI: 10.1007/s00595-015-1163-x

7. Zhou B., Zhang M., Wu J. Pancreaticoduodenectomy versus local resection in the treatment of gastrointestinal stromal tumours of the duodenum. World J Surg Oncol 2013;11(1):196. DOI: 10.1186/1477-7819-11-196

8. Stilidi I.S., Arkhiri P.P., Nikulin M.P. Surgical treatment of patients with primary localized and locally advanced gastrointestinal stromal tumors. Vestnik RONC im. N.N. Blokhina RAMN = Journal of N.N. Blokhin Russian Cancer Research Center RAMS 2010;21(1):77–82. (In Russ.)

9. Nikulin M.P., Nered S.N., Yugay V.V. et al. Gastrointestinal stromal tumors of the duodenum: diagnostic errors and modern approaches to treatment. Khirurgiya. Zhurnal im. N.I. Pirogova = Surgery. Journal named after N.I. Pirogov 2021;(8):125–30. DOI: 10.17116/hirurgia2021081125

10. Arkhiri P.P., Stilidi I.S., Nered S.N. et al. Peculiarities of surgical and combined treatment of patients with duodenal stromal tumor. Khirurgiya. Zhurnal im. N.I. Pirogova = Surgery. Journal named after N.I. Pirogov 2021;(8):11–9. DOI: 10.17116/hirurgia202108111

11. Stilidi I.S., Nered S.N., Nikulin M.P. et al. Distal duodenal resection: a new method of surgical treatment for tumor lesions of the duodenum. Khirurgiya. Zhurnal im. N.I. Pirogova = Surgery. Journal named after N.I. Pirogov 2019;(9):5–12. DOI: 10.17116/hirurgia20190915

12. Sohn T.A., Lillemoe K.D., Cameron J.L. et al. Adenocarcinoma of the duodenum: factors influencing long-term survival. J Gastrointest Surg 1998:2(1):79–87. DOI: 10.1016/s1091-255x(98)80107-8

13. Poultsides G.A., Huang L.C., Cameron J.L. et al. Duodenal adenocarcinoma: clinicopathologic analysis and implications for treatment. Ann Surg Oncol 2012;19(6):1928–35. DOI: 10.1245/s10434-011-2168-3

14. Tran T.B., Qadan M., Dua M.M. et al. Prognostic relevance of lymph node ratio and total lymph node count for small bowel adenocarcinoma. Surgery 2015;158(2):486–93. DOI: 10.1016/j.surg.2015.03.048

15. Cloyd J.M., Norton J.A., Visser B.C., Poultsides G.A. Does the extent of resection impact survival for duodenal adenocarcinoma? Analysis of 1.611 cases. Ann Surg Oncol 2015;22(2):573–80. DOI: 10.1245/s10434-014-4020-z

16. Tocchi A., Mazzoni G., Puma F. et al. Adenocarcinoma of the third and fourth portions of the duodenum: results of surgical treatment. Arch Surg 2003;138(1):80. DOI: 10.1001/archsurg.138.1.80

17. Hu J.X., Miao X.Y., Zhong D.W. et al. Surgical treatment of primary duodenal adenocarcinoma. Hepatogastroenterology 2006;53:858–62.

18. Oshima N., Tokunaga M., Tanizawa Y. et al. Prognostic value of duodenal invasion length in patients with gastric cancer. J Clinl Oncol 2011;29(4 Suppl).

19. Rie M., Tomoyuki I., Yutaka T. et al. Pancreaticoduodenectomy for gastric cancer. J Cancer Metastasis Treat 2018;4:26. DOI: 10.20517/2394-4722.2018.15

20. Jae-Seok M., Sung-Ho J., Sunhoo P. et al. Prognosis of curatively resected pt4b gastric cancer with respect to invaded organ type. Ann Surg Oncol 2012;19:494–501. DOI: 10.1245/s10434-011-1987-6

21. Shih-Chun Ch., Chi-Ming T., Puo-Hsien L. et al. Impact of pancreatic resection on survival in locally advanced resectable gastric cancer. Cancers (Basel) 2021;13(6):1289. DOI: 10.3390/cancers13061289

22. Sarmiento J., Thompson G., Nagorney D. et al. Pancreas-sparing duodenectomy for duodenal polyposis. Arch Surg 2002;137(5):557–63. DOI: 10.1001/archsurg.137.5.557

23. Müller M.W., Dahmen R., Köninger J. et al. Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis? Am J Surg 2008;195:741–8. DOI: 10.1016/j.amjsurg.2007.08.061

24. Yusuke N., Masaru K., Naoto G. et al. Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy. Surg Today 2017;47(6):705–11. DOI: 10.1007/s00595-016-1418-1