IISOLATED DUODENAL RESECTIONS: TOWARD DEFINING INDICATIONS, COMPLEXITY, AND CODING
Devanshi D. Patel*1, Stephen W. Behrman2
1Surgery, The University of Tennessee Health Science Center, The University of Tennessee Health Science Center, Memphis, TN, US, academic/health, Memphis, TN; 2Baptist Memorial Hospital-Memphis, Memphis, TN
Introduction:
Segmental resections of the duodenum are uncommonly performed and are technically challenging due to intimate relationships with the biliary tree, pancreas, and the super mesenteric vessels. Operations can involve proximal resections involving the first (D1) and proximal second portion of the duodenum (D2) or resections distal to the ampulla of Vater including D2, the 3rd and/or 4th portion (D3/D4). The objective of this study was to assess indications, operative strategy, pathology, and outcomes of duodenal resections (DR). Due to the complexity involved, we suggest this form of resection deserves its own unique Current Procedural Terminology (CPT) and Relative Value Unit (RVU) structure.
Methods:
Patients undergoing duodenal resection from 2008-2021 at University of Tennessee Health Science Center (UTHSC) affiliated hospitals were retrospectively reviewed. Factors examined included clinical presentation and diagnostic evaluation, operative time and technique, pathologic outcomes, and 90-day morbidity and mortality.
Results:
Of the 30 patients identified the majority involved distal D2, D3, and/or D4 (n =22). 17 were female and common presenting symptoms included abdominal pain, nausea, and hematochezia. Diagnostic studies utilized included computed tomography and upper endoscopy with 9 requiring push enteroscopy. Reconstruction following resection most often involved a side-to-side duodenojejunostomy to the C-loop of the duodenum opposite the ampulla. Intraoperative evaluation (IOE) and instrumentation of the biliary tree was utilized to assess and protect the biliary tree and/or ampulla of Vater in relation to the area of resection in eleven patients. Median operative time was 209 minutes increasing to 237 minutes when IOE was necessary. Procedure related morbidity was 20%, including 1 Grade B pancreatic fistula, 1 duodenal fistula, and 4 intra-abdominal abscesses with 1 mortality. Median postoperative length of stay was 9.5 days. Pathology included benign adenoma (n=4), adenocarcinoma (n = 14), GIST (n = 5), neuroendocrine neoplasms (n = 6), and an erosive metastatic deposit (n=1). An R0 resection was obtained in all but 1 with malignancy. Median number of lymph nodes retrieved in adenocarcinoma was 7.2.
Conclusions:
Duodenal resections can be utilized to safely address varying pathologies but are uniquely more complex, associated with longer operative times, extended hospital stay, and greater postoperative morbidity compared with more distal small bowel resections. We suggest modification to current CPT coding to accurately identify these distinct procedures for future research endeavors. This would allow development of a RVU valuation that more accurately captures a meaningful value for the work effort involved.
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