Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies

Table 1 Patient characteristics

No.	Age	Sex	Presentation	Comorbidities	CCI	Radiological assessment	Endoscopic assessment	Nutritional support	Year
1	67	M	Asymptomatic (incidental on OGD)	Coeliac disease	4	CT	OGD, EUS		2011
2	56	F	Weight loss, anaemia, vomiting	Malnutrition	3	CT, Ba study	OGD	NJ	2004
3	66	F	Vomiting	Asthma, depression	4	CT	-		2015
4	51	M	Epigastric pain, weight loss, vomiting	Nil	3	CT	OGD		2016
5	68	M	Epigastric pain, vomiting	Hiatus hernia	4	CT	-		2015
6	77	M	Epigastric pain, weight loss, vomiting, anaemia	Bronchiectasis, GORD	6	CT	OGD, enteroscopy		2016
7	73	F	Anaemia	Metachronous colonic cancer	10	CT	-		2016
8	61	M	Asymptomatic (incidental on ultrasound)	GORD	4	CT	OGD, EUS		2013
9	48	F	Epigastric pain, weight loss, vomiting	Nil	2	CT	OGD, EUS		2014
10	65	M	Asymptomatic (incidental on aneurysm screening)	Nil	4	CT	OGD, EUS		2016
11	83	F	Epigastric pain, weight loss, vomiting	Glaucoma, hypothyroidism	6	CT	-		2016
12	76	F	Dyspepsia/reflux	NASH, cirrhosis, colectomy for cancer	4	CT	OGD		2008
13	76	M	Epigastric pain, back pain	Functional asplenia	3	CT	OGD, EUS		2006
14	76	M		HTN, Stroke, MI	5	-	OGD		2007
15	64	F	Dyspepsia/reflux	Hiatus hernia	2	CT	OGD, EUS		2004
16	68	F	Epigastric pain, vomiting, early satiety	Stricture post EMR	1	CT, Wat Sol St	OGD, EUS	NJ	2016
17	36	M	Recurrent pancreatitis	Nil	0	CT	OGD		2003
18	80	F	Melaena	Glaucoma	4	CT	OGD		2004
19	39	F	Epigastric pain, weight loss, vomiting	Nil	0	CT, Wat Sol St	OGD		2016

Ba: Barium; CCI: Charlson comorbidity index; CT: Computed tomography; EMR: Endoscopic submucosal resection; EUS: Endoscopic ultrasound; GORD: Gastroesophageal reflux disease; HTN: Hypertension; MI: Myocardial infarction; NASH: Non-alcoholic steatohepatosis; NJ: Nasojejunal; OGD: Oesophagogastroduodenoscopy; Wat Sol St: Water soluble contrast study.

Table 2 Pathology and outcome

No.	Diagnosis	Total lymph nodes	Nodes +ve	Proximal margin (mm)	Blood transfusion (units)	Length of stay (d)	FU (mo)	Complications	Outcome
1	Adenocarcinoma Mod diff pT4 Nx Mx G2 V0 R0	0	-	15	0	4	72	-	Alive, disease free2
2	Adenocarcinoma Mod diff pT3 N0 Mx G2 V1 R0	4	0	55	NR	14	155	-	Alive, disease free
3	Adenocarcinoma Mod diff T4 N1 Mx V0 G2 R0	11	1	30	0	13	181	Recurrence	Died (distant metastases)2
4	Adenocarcinoma Poorly diff T4 N2 Mx V1 G3 R0	29	16	62	0	5	13	-	Alive, disease free2
5	Adenocarcinoma Mod diff pT3 N0 M0 V1 G2 R0	7	0	30	0	14	15	Incisional hernia at 1 yr	Alive, disease free
6	Adenocarcinoma Mod diff pT3 N0 Mx V1 G2 R0	19	0	25	0	6	7	-	Alive, disease free
7	Adenocarcinoma of colon	10	1		2	7	100	-	Alive, disease free2
8	GIST (low grade malignant potential)	0	0		0	4	48	-	Alive, disease free
9	GIST (low grade malignant potential)	0	0		0	10	36	Anast. stricture; GJ at 2 yr	Alive, disease free
10	GIST (low grade malignant potential)	1	0		0	8	10	-	Alive, disease free
11	GIST (low grade malignant potential)	6	0		0	6	5	-	Alive, disease free
12	Villous adenoma (high grade dysplasia)	NR	-		8	19	21	Ascitic leak (cirrhotic)	Died of unrelated causes
13	Tubulovillous adenoma (high grade dysplasia)	NR	-		NR	21	126	OPSI	Alive, disease free
14	Tubular adenoma (high grade dysplasia)	NR	-		0	8	1021	-	Died of unrelated causes
15	Tubular adenoma (low grade dysplasia)	NR	-		0	18	146	Postoperative pneumonia	Alive, disease free
16	Multiple tubular adenomas (low grade dysplasia)	1	0		0	7	8	-	Alive, disease free
17	Lipoma	NR	-		NR	10	168	-	Alive, disease free
18	Bleeding duodenal diverticulum	NR	-		NR	13	144	-	Alive, disease free
19	Superior mesenteric artery syndrome	NR	-		0	5	12	Poor pain control, N&V	Alive, disease free

¹Postoperative death;

²Received adjuvant chemotherapy. Mod diff: Moderately differentiated; NR: Not relevant; GIST: Gastrointestinal stromal tumour; GJ: Gastrojejunostomy; OPSI: Overwhelming postsplenectomy infection; N&V: Nausea and vomiting.

Table 3 Published reports of distal duodenectomy

First Author	Year	No. of cases	Histology	Anastomosis	Complications	Outcome
Kerremans et al[8]	1979	1	1 adenocarcinoma	-	Jejunocutaneous fistula	Death at 20 mo
Kawano et al[9]	1995	1	1 GIST	1 end-to-side	-	NR
Maher et al[12]	1996	24	11 adenocarcinomas	10 end-to-end	1 death (anastomotic leak)	Adenocarcinoma;
			1 GIST	8 end-to-side	2 pancreatic fistulae	Median survival 18.5 mo
			2 adenomas	3 side-to-end	2 DGE	GIST; NR
			1 lymphoma	3 side-to-side	2 anastomotic bleeds
			1 liposarcoma
			2 Crohn’s disease
			5 trauma
			1 peptic ulceration
Sohn et al[13]	1998	2	2 adenocarcinomas	NR	2 cholangitis	NR
Suzuki et al[14]	1999	1	1 GIST	1 end-to-side	DGE	Alive/ well 2 yr postop
Orda et al[15]	2000	1	1 GIST	end-to-end	-	Alive/ well 13 yr postop
Ammori[16]	2002	1	1 benign stricture	side-to-side	Intra-abdominal bleeding	NR
Eisenberger et al[17]	2004	1	1 GIST	NR	-	Alive/ well 1 yr postop
Spalding et al[18]	2007	14	5 adenocarcinomas	14 end-to-end	1 death (cholecystitis)	Adenocarcinoma; 1 death at 3 mo,
			4 GIST		1 anastomotic stricture (reoperated)	Median survival 56 mo.
			1 adenoma		1 DGE
			1 lipoma		1 anastomotic bleed (reoperated)	GIST; 1 death at 3 mo,
			1 metastatic seminoma			Median survival 120 mo
			1 ulcer
			1 plasmacytoma
Cavaniglia et al[19]	2012	1	1 GIST	1 end-to-end	-	NR
Stauffer et al[3]	2013	1	5 adenomas	7 side-to-side	1 DGE	NR
			2 adenocarcinomas	2 end-to-side	1 pancreatic fistula
			1 lymphangiolipoma	gastrojejunostomy
			1 GIST
			1 NET
Waisberg et al[20]	2013	1	1 carcinoid	NR	NR	Death at 6 mo
Shimizu et al[21]	2015	1	1 adenoma	1 end-to-side	NR	NR
García-Molina et al[22]	2015	8	1 adenocarcinoma		1 death	Adenocarcinoma; 1 death at 12 mo
			5 GIST
			1 metastasis from lung			GIST; 5 Alive/ well at 4-6 yr
			1 colon cancer
Current series	2017	19	6 adenocarcinomas	19 side-to-side	1 recurrent adenocarcinoma	Adenocarcinoma: 1 death at 18 mo
			5 adenomas		1 anastomotic Stricture	Alive/well 1 < 1 yr, 2 > 1 yr, 1 > 6 yr, 1 > 12 yr
			4 GIST		1 incisional hernia	GIST: Alive/ well 2 < 1 yr, 2 > 3 yr
			1 lipoma
			1 colon cancer
			1 bleeding diverticulum
			1 extrinsic compression

DGE: Delayed gastric emptying; GIST: Gastrointestinal stromal tumour; NET: Neuroendocrine tumor; NR: Not recorded.