SSAT - Pancreas Sparing Partial Sleeve Duodenectomy (Psd) for Non-Ampullary Duodenal Neoplasia

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Pancreas Sparing Partial Sleeve Duodenectomy (Psd) for Non-Ampullary Duodenal Neoplasia
Ruchir Puri^*, John Stauffer, Mauricia Buchanan, Steven P. Bowers, Horacio J. Asbun
General Surgery, Mayo Clinic, Jacksonville, FL

Background
Duodenal neoplasia is being increasingly diagnosed due to prevalence of screening upper gastrointestinal endoscopy. As our expertise with endoscopy has grown we have moved away from performing radical duodeno-pancreatic resections for these lesions. Large and/or endoscopically unresectable lesions will require surgical intervention. PSD involves separating the duodenum from the head of the pancreas and thus allowing pancreas preservation. The objective of this study was to evaluate our outcomes with pancreas sparing partial sleeve duodenectomy (PSD) for non ampullary duodenal neoplasia which were too large for simple wedge duodenal resections.
Methods
A retrospective review of medical records of patients with non ampullary duodenal neoplasia which underwent partial sleeve duodenectomy from August 2008 to September 2013 was performed. Pathological characteristics of the lesions, surgical approach, technique depending on location, and outcomes were analyzed.
Results
Twenty patients with non ampullary duodenal neoplasia were identified (13 men, 7 women, mean age of 70 years). Surgical approach was laparoscopic (n=17), open (n=2) and hand assisted (n=1) with either a distal PSD (n=13) or proximal PSD (n=7). Reconstruction was performed via a side to side stapled duodenojejunostomy (n=13), end to side hand sewn duodenojejunostomy (n=4), end to end duodenojejunostomy (n=1), stapled gastrojejunostomy (n=1) and hand sewn gastrojejunostomy (n=1). Pathology of these duodenal lesions revealed tubulovillous adenoma (n=8), neuroendocrine tumors (n=4), adenocarcinoma (n=3), tubular adenoma (n=2), leiomyoma (n=1), lymphangiolipoma (n=1) and chronic duodenitis (n=1). Mean operative time was 259 minutes and mean length of stay was 6 days (range 3-15 days). Morbidity was 15% with no thirty day periprocedural mortality.
Conclusion
Pancreas sparing partial sleeve duodenal resection for neoplasia requires advanced laparoscopic skills but is technically feasible and has acceptable morbidity. Pancreas preservation obviates the need for a pancreatic duct - enteric anastomosis and its attendant complications.

Patient Demographics, Technique and Outcomes

Patient	Age	Sex	Approach	Resection	Reconstruction	Final Pathology	LOS	Complications
1	70	F	Lap	D1/D2/Pylorus	BII, Stapled GJ	5cm TA	3	None
2	77	F	Lap	D1/D2	Hand sewn end/side DJ	3.5cm TVA	8	Deconditioning
3	78	M	Lap	D1/D2	Hand sewn end/side DJ	2cm Carcinoid	6	None
4	19	F	Hand assist	D3/D4	Stapled side/side DJ	8.5cm Lymphangiolipoma	9	DGE, Pancreatic Fistula
5	90	M	Lap	D3/D4	Stapled side/side DJ	T1b Adenocarcinoma	5	None
6	77	M	Lap	D3/D4	Stapled side/side DJ	5cm TVA	8	None
7	75	M	Lap	D3/D4	Stapled side/side DJ	6.5cm TVA	4	None
8	79	F	Lap	D3/D4	Stapled side/side DJ	2.4cm leiomyoma	3	None
9	84	M	Lap	D3/D4	Stapled side/side DJ	T3 Adenocarcinoma	6	None
10	49	F	Lap	D3/D4	Stapled side/side DJ	5cm TVA	4	None
11	84	M	Lap	D1/D2	Hand sewn end/side DJ	Duodenitis	6	None
12	63	M	Lap	D3/D4	Stapled side/side DJ	4cm TVA with HGD	4	None
13	76	M	Lap	D3/D4	Stapled side/side DJ	T1b Adenocarcinoma	6	None
14	76	M	Lap	D1/D2	Hand Sewn GJ	0.9 and 0.5cm Carcinoid	15	DGE
15	66	F	Lap	D3/D4	Stapled side/side DJ	5cm TVA with HGD	5	None
16	55	M	Lap	D1/D2	Stapled side/side DJ	0.7cm Carcinoid	4	None
17	66	M	Lap	D1/D2	Hand sewn end/side DJ	0.7cm Carcinoid	4	None
18	79	M	Lap	D3/D4	Stapled side/side DJ	3.5cm TVA	4	None
19	64	M	Open	D3/D4	Stapled side/side DJ	No residual TA	7	None
20	82	F	Open	D3/D4	Hand sewn end/end DJ	2cm TVA	5	None

BII: Billroth II Gastrectomy GJ: Gastrojejunostomy DJ: Duodenojejunostomy TA: Tubular Adenoma TVA: Tubulovillous Adenoma HGD: High Grade Dysplasia DGE: Delayed Gastric Emptying

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