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Endoscopic and Surgical Management of Duodenal Polyps: Avoiding a Whipple
Ruchir Puri*2, 1, Michael J. Bartel3, Daniel Kim1, John Stauffer1, Mauricia Buchanan1, Steven P. Bowers1, Timothy a. Woodward3, Michael Wallace3, Massimo Raimondo3, Horacio J. Asbun1
1Surgery, Mayo Clinic, Jacksonville, FL; 2General Surgery, Mayo Clinic Health System, Waycross, GA; 3Gastroenterology, Mayo Clinic, Jacksonville, FL
Background
Duodenal polyps are uncommon tumors of the upper gastrointestinal tract. The mainstay of management is a therapeutic duodenal endoscopy. Few patients, not amenable to endoscopic resections will require operative intervention. The objective of this study is to evaluate the combined endoscopic and surgical experience related to these neoplasms at our tertiary care center.
Methods
A retrospective review of medical records of all patients with duodenal neoplasia which underwent a pancreas preserving duodenectomy (PPD) or a therapeutic endoscopy from August 2008 to February 2014 was performed. Pathological characteristics of the lesions, endoscopic/ surgical technique and outcomes were analyzed.
Results
One hundred twenty eight patients were identified. Ninety three patients in the endoscopy arm underwent one hundred ten EMRs (Endoscopic Mucosal Resection). The mean polyp size was 15.9 mm. The polyp was removed piecemeal in 53/110 (48%) and en bloc in 57/110(52%). APC (Argon beam coagulation) and hemoclips were used in 59/110 (54%) and 32/110(29%) respectively for hemostasis. Bleeding was noted in 8/110(8.6%) patients.
Thirty five patients underwent a pancreas preserving partial sleeve duodenectomy (PPPSD) (n=20) and a pancreas preserving total duodenectomy (PPTD) (n=15). Surgical approach was laparoscopic (n=25), open (n=7), conversion to open (n=2) and hand assisted (n=1). Reconstruction for infraampullary tumors was performed via a side to side stapled duodenojejunostomy (n=13); for supraampullary tumors an end to side hand sewn post pyloric duodenojejunostomy (n=4) and end to end post pyloric duodenojejunostomy (n=1). Two patients required an antrectomy and a stapled and a hand sewn gastrojejunostomy due to the proximity of the tumor to the pylorus. Mean operative time was 259 minutes and mean length of stay was 6 days (range 3-15 days). Morbidity was 15% with no mortality.
PPTD patients underwent a pancreaticojejunostomy (n=14) and pancreaticogastrostomy (n=1). Gastrointestinal continuity was obtained via an end to side duodenojejunostomy (n=12), end to side gastrojejunostomy (n=2) and gastrojejunostomy (n=1). The mean operative time was 430 minutes and mean length of stay of 13.2 days (range 5-40 days). The morbidity was 53% with no mortality.
Pathology of all surgically resected duodenal lesions revealed TVA (n=14), TA (n=7), adenocarcinoma (n=5), neuroendocrine tumors (n=4), VA (2), leiomyoma (n=1), lymphangiolipoma (n=1) and chronic duodenitis (n=1).
Conclusion
Management of duodenal neoplasia requires a multidisciplinary approach. EMR is the mainstay of therapy and PPD offers a good surgical option for benign lesions not amenable to endoscopic resection and allows pancreas preservation. As expected PPPSD has a lower morbidity compared to PPTD.
Patient Demographics, Technique and Outcomes following Partial Duodenectomy
| No. | Age | Sex | Approach | Resection | Reconstruction | Final Pathology | LOS (days) | Complications | | 1 | 70 | F | Lap | Pylorus/ D1/D2 | Billroth II, 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 | 5 | None | | 14 | 76 | M | Lap | Pylorus/D1/D2 | Billroth II, 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 Patient Demographics, Technique and Outcomes following Total Duodenectomy | No. | Age | Sex | Approach | Resection | Reconstruction | Final Pathology | LOS (days) | Complications | | 1 | 56 | M | Lap | D1 to D4 | End/Side GJ Billroth II | multiple adenomas up to 7mm | 30 | Intra abdominal abscess | | 2 | 64 | M | Lap | D1 to D4 | End/side DJ | 2cm TVA | 9 | None | | 3 | 67 | F | Lap | D1 to D4 | End/side DJ | 4cm TA | 6 | Intra abdominal Abscess | | 4 | 60 | F | Lap | D1 to D4 | End/side DJ | 5.5cm TVA, 0.4cm adenocarcinoma T1N0 | 7 | None | | 5 | 51 | F | Open | D1 to D4 | End/Side GJ | Multiple TAs and submucosal carcinoid | 7 | Readmission for gastroparesis, Intra abdominal abscesses | | 6 | 71 | F | Open | D1 to D4 | Handsewn End/Side DJ | 8.5cm villous adenoma with HGD | 8 | None | | 7 | 42 | M | Lap to Open | D1 to D4 | PG, Stapled GJ | 2.4cm TVA | 40 | Hemoperitoneum | | 8 | 59 | F | Open | D1 to D4 | Handsewn End/Side DJ | 6.5cm TVA with HGD | 26 | Gastroparesis | | 9 | 52 | F | Open | D1 to D4 | Handsewn End/side DJ | 3.0cm TVA | 5 | None | | 10 | 78 | M | Lap | D1 to D4 | End/side DJ | 3.5cm TVA | 20 | Intra abdominal abscess, aspiration pneumonia, enterocutaneous fistula | | 11 | 86 | M | Lap | D1 to D4 | End/side DJ | 1.5cm TVA with HGD | 13 | Biliopancreatic leak | | 12 | 66 | M | Lap to Open | D1 to D4 | Handsewn End/side DJ | 6.5cm TVA | 8 | None | | 13 | 77 | F | Open | D1 to D4 | Handsewn End/side DJ | 2.2cm ampullary adenoma | 5 | None | | 14 | 64 | F | Lap | D1 to D4 | End/side DJ | 4cm adenoma | 5 | None | | 15 | 77 | M | Lap | D1 to D4 | End/side DJ | 5.0cm polyp TisN0 adenocarcinoma | 9 | Urninary Retention |
BII: Billroth II Gastrectomy GJ: Gastrojejunostomy DJ: Duodenojejunostomy PG: Pancreatogastrostomy TA: Tubular Adenoma TVA: Tubulovillous Adenoma HGD: High Grade Dysplasia DGE: Delayed Gastric Emptying
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