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Society for Surgery of the Alimentary Tract

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Ji Yoon Yoon*1, Neal Mehta2, Carol A. Burke2, Toms Augustin3, Margaret O'Malley2, Lisa A. LaGuardia2, Michael W. Cruise4, Gautam N. Mankaney2, James M. Church5, Matthew Kalady5, R Matthew Walsh3, Amit Bhatt2
1Internal Medicine, Cleveland Clinic, Cleveland, OH; 2Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; 3General Surgery, Cleveland Clinic, Cleveland, OH; 4Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH; 5Colorectal Surgery, Cleveland Clinic, Cleveland, OH

Consideration of prophylactic duodenal surgery is recommended in patients with Familial Adenomatous Polyposis (FAP) and Spigelman stage IV duodenal polyposis to prevent cancer. Pylorus-sparing approaches of pancreatoduodenectomy (PD) and pancreas-sparing duodenectomy (PSD) are often performed over a complete Whipple procedure. Pylorus-sparing techniques, with the benefit of reduced rates of gastric dumping syndrome, create a duodeno-jejunal anastomosis at the apex of the duodenal bulb, which remains at risk of recurrent adenoma. Our study aims to evaluate the prevalence and severity of polyposis of the duodenal bulb after pylorus-sparing duodenectomy.

We identified consecutive FAP patients following duodenal resection (PD, PSD, or segmental duodenectomy) at Cleveland Clinic, between 05/1992 and 01/2018 from the David G. Jagelman Inherited Colon Cancer Registries. Those who had a pylorus-sparing procedure with a remnant duodenal bulb on post-operative anatomy were included in the study. Those without endoscopic follow up data after surgery were excluded. Medical records data was used to determine time to occurrence, maximal size, histology, and dysplasia of duodenal bulb polyps in patients after duodenal resection.

Results A total of 64 FAP patients with duodenal resection were identified. Of these, 56 (88%) had a pylorus-sparing procedure and were included in the study. Patient characteristics are outlined in Table 1. 7/56 (12.5%) patients with duodenal bulb polyposis were identified (Table 2). 6 of 7 patients were post-PSD. 1 patient had undergone proximal segmental duodenectomy. Median time to polyp occurrence in the duodenal bulb was 43 months [IQR 19-62]. All 7 patients developed large polyps ≥ 20 mm. 2 of 7 had tubulovillous adenoma, the remainder tubular adenoma on biopsy. Endoscopic resection with submucosal injection was attempted on 5 of 7 cases, and complete resection was achieved in one case. The remaining 4 lesions demonstrated no lift on submucosal injection. In one case, initial endoscopic resection was successful, but recurrent adenoma at the site of resection after 12 months was not amenable to resection due to fibrosis (patient 5, Table 2). There were no cases of carcinoma or surgical resection for duodenal bulb polyps

Discussion A minority of patients develop polyps in the duodenal bulb after pylorus-sparing duodenectomy. They are difficult to manage endoscopically due to failure of endoscopic resection with frequent non-lifting with submucosal injection. This could be secondary to the proximity to the surgical anastomosis, prevalence of Brunner's glands in the proximal duodenum, and previous attempted removal. Optimal approaches to prevent duodenal bulb polyps after pylorus-sparing duodenectomy are needed.

Table 1. Patient characteristics (N=56)
CharacteristicNormal duodenal bulbDuodenal bulb polyps
Age, years, mean sd61.9 12.6 54.9 13.8
GenderMale26 (53.1)6 (85.7)
40 (81.6)
6 (12.2)
3 (6.1)
6 (85.7)
1 (14.3)
SurgeryWhipple procedure
Pancreas-sparing duodenectomy
Segmental duodenectomy
12 (24.5)
31 (63.3)
6 (12.2)
6 (85.7)
1 (16.7)
Duration of follow up after surgery, median months [Q1, Q3]107 [53, 140]96 [56, 120]

sd standard deviation; Q1 first quartile; Q3 third quartile

Table 2. Duodenal bulb polyp development after duodenectomy (N=7)
PatientTime to polyp detection (months)No. of post-operative EGDsMaximal size
Maximal histologySuccess of endoscopic therapy?Comments
1191660TANoNo lift with injection. Failed cold snare and, underwater EMR
243420TAYesCold snare EMR
356240TANoNo lift with injection
4621250TANoNo lift with injection
514725TVANoInitial successful EMR. Recurrence with non-lifting portions
627240TVANot attempted 
7105935TANot attempted 

EGD esophagogastroduodenoscopy; TA tubular adenoma; TVA tubulovillous adenoma; EMR endoscopic mucosal resection

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