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Pancreas-Sparing Duodenectomy: Effective Management for Familial Adenomatous Polyposis
Richard Mackey, Richard M. Walsh, Raphael Chung, Andrew Smith, Nancy Brown, James Church, Carol Burke, Cleveland Clinic Foundation, Cleveland, OH

Background:
Duodenal adenocarcinoma remains a leading cause of death in Familial Adenomatous Polyposis (FAP) patients who have previously undergone colectomy. Upper gastrointestinal surveillance and Spigelman classification system is being used to guide which patients may benefit from a duodenal resection prior to the development of invasive cancer. A retrospective review was done to evaluate the effectiveness of pancreas-sparing duodenectomy (PSD) for the management of duodenal polyps in FAP.

Results:
There were 21 patients with FAP who underwent successful PSD between 1992-2004 at the Cleveland Clinic Foundation. There were 15 men and 6 women with a mean age of 55.3 +/- 10.6 years. All patients were in an endoscopic surveillance program (range 1-7 years). Nineteen patients were Spigelman IV, one III and one II at the time of operation. No patient had a preoperative biopsy of invasive cancer. The mean time from diagnosis of FAP to duodenectomy was 26.7 +/- 12.5 years. Operative times averaged 327 +/- 61 minutes with mean estimated blood loss (EBL) of 503 +/- 266 cc. There was no mortality and eight patients (38%) had 12 complications; 6 patients (29%) had delayed gastric emptying, 4 patients (19%) had biliary/pancreatic anastamotic leak, 1 patient had pancreatitis and 1 had a wound infection. There were two re-operations; a gastrojejunostomy was performed for persistent delayed gastric emptying and re-exploration was performed for an early biliary leak requiring t-tube placement. The mean length of stay (LOS) was 13.1 +/- 10.8 days. Only one patient (4%) was upstaged with their pathology, finding invasive cancer in both the duodenal specimen and one lymph node. The remaining 16 patients were cancer free. All patients have been followed with serial endoscopies for a mean of 79 months (range 3-152 months). Two patients developed recurrent polyps; one patient at the neo-duodenal ampulla and a 4 cm polyp in the advanced jejunum at 68 months and the second developed a 1 cm polyp in the duodenal cuff at 96 months, both have been endoscopically treated. Two patients had late complications of a stomal ulcer at 48 months and intestinal obstruction at 24 months.

Conclusions:
PSD represents a definitive treatment for duodenal involvement from FAP, and can obviate the need for pancreaticoduodenectomy.


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