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

AIM To investigate the range of pathologies treated by pancreas preserving distal duodenectomy(PPDD) and present the outcome of follow-up.METHODS Neoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenumwas transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodenojejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed. RESULTS Twenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy(PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma(n = 6), adenomas(n = 5), gastrointestinal stromal tumours(n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression(n = 1 each). Median postoperative length of stay(LOS) was 8 d and morbidity was low [pain and nausea/vomiting(n = 2), anastomotic stricture(n = 1), pneumonia(n = 1), and overwhelming postsplenectomy sepsis(n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8(6-14) d vs PD 11(10-16) d, median(IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease(at 2 mo and at 8 years respectively).CONCLUSION PPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Successful treatment of a pancreatic schwannoma by spleen-preserving distal pancreatectomy

Schwannomas are neurogenic tumors that arise from the neural sheaths of peripheral nerves.These tumors can be located in any area of the human body;the most common locations are the head,neck,trunk and extremities.Pancreatic schwannomas are very rare.Over the past 40 years,only 67 cases of pancreatic schwannomas have been reported in the English literature.Here we present a case of pancreatic schwannoma in a 62-year-old male.The tumor was revealed by ultrasound and computed tomography in the neck and body of the pancreas.An accurate diagnosis was difficult to obtain preoperatively.The patient consented to the performance of a laparotomy,and the mass was found in the neck and body of the pancreas and successfully treated using a spleenpreserving distal pancreatectomy with splenic artery and vein preservation.The procedure has only been reported in one other case of pancreatic schwannoma;here we present the second reported case.Macroscopically,the tumor was well circumscribed,gray-white in color and3.3 cm×2.8 cm in size.Microscopically,the tumor cells were spindle-shaped and had a palisading arrangement with no atypia,which are results compatible with a benign tumor.Both hypercellular and hypocellular areas were visible.Immunohistochemically,the tumor cells were strongly positive for S-100 protein.The tumor was definitively diagnosed as a schwannoma of the pancreatic neck and body.The patient was followed for 72 mo and has been doing well without any complications.