Pancreas-sparing duodenectomy for a huge leiomyosarcoma in the third portion of the duodenum

A duodenal leiomyosarcoma which was resected by pancreas-sparing duodenectomy is reported. The tumor arose in the third portion of the duodenum and grew in an extraluminal direction. The tumor was huge (13 cm × 9 cm × 8 cm) but did not involve the pancreas, and there were no findings of periduodenal lymph node metastases. Because the possibility of metastasis to the lymph nodes around the root of the superior mesenteric artery (which are removed only in a pancreatoduodenectomy) was judged to be low, pancreas-sparing duodenectomy was performed, with dissection of the pancreaticoduodenal lymph nodes. The proximal duodenum was transected between the second and third portions of the duodenum, and the distal end was cut in the jejunum at the portion of the first jejunal artery. Reconstruction was performed by end-to-side anastomosis between the duodenum and jejunum, using an end-to-end anastomosis instrument. Since the incidence of lymph node metastasis of leiomyosarcoma is low, resection of the head of the pancreas for extensive lymph node dissection does not always seem necessary. Pancreas-sparing duodenectomy can be a good option for a leiomyosarcoma in the third and fourth portions of the duodenum which does not invade the pancreas and is not accompanied by any apparent periduodenal lymph node metastases. Received for publication on May 1, 1997; accepted on April 21, 1999     

Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs)

BACKGROUND: Chronic ingestion of nonsteroidal antiinflammatory drugs (NSAIDs) has rarely been associated with the development of intestinal diaphragm-like strictures. We have explored the role of laparoscopic surgery for the management of NSAID-related long distal duodenal strictures. METHOD: A 49-year-old woman had been on NSAID therapy (ibuprofen) for backache more than 2 years. She showed symptoms of gastric outlet obstruction and gastrointestinal blood loss, and investigations showed a long stricture in the third and fourth parts of the duodenum. She underwent a laparoscopic pancreas-preserving distal duodenectomy with duodenojejunal anastomosis. RESULT: Relaparoscopy on postoperative day 1 for bleeding showed no active source of bleeding. The patient's subsequent recovery was uneventful, and she was discharged on postoperative day 4. Further symptomatic strictures developed 2 months later at the previously ulcerated pylorus and distal duodenal bulb and were managed by a laparoscopic Roux-en-Y gastrojejunostomy. The patient was discharged on postoperative day 3, but represented 2 months later with symptomatic stenosis at the gastrojejunostomy which was managed by a laparoscopic revision gastrojejunostomy. Discharged on the postoperative day 2, she had regained weight and remained symptom free at follow-up assessment 3 months later. CONCLUSION: Laparoscopic pancreas-preserving distal duodenectomy for the management of benign duodenal strictures is feasible and safe. Moreover, we have demonstrated the beneficial role of relaparoscopy for the management of postoperative complications and for revision surgical procedures.     

Successful resection,using pancreas-sparing duodenectomy,of extrahepatically growing hepatocellular carcinoma associated with direct duodenal invasion

A 50-year-old man with extrahepatically growing hepatocellular carcinoma (HCC) associated with direct duodenal invasion underwent a right posterior segmentectomy associated with pancreas-sparing duodenectomy. Neither periduodenal lymph-node metastasis nor pancreatic invasion was detected, thus we separated the supra-ampullary duodenum from the pancreatic head and performed pancreas-sparing supra-ampullary duodenectomy. The resected specimen was observed to be a centrally necrotic tumor that had infiltrated the duodenal wall, resulting in exposure of the lumen. Pathology examination revealed that the tumor consisted of poorly differentiated HCC, which had extensively infiltrated the mucosa of the duodenum. Gastrointestinal tract involvement in patients with HCC is rare, and pancreas-sparing duodenectomy is a safe and effective treatment for patients with HCC associated with direct duodenal invasion. Received: December 31, 2001 / Accepted: April 14, 2002     

Primary adenocarcinoma of the fourth portion of the duodenum: “A case report and literature review”

INTRODUCTIONPrimary adenocarcinoma of the 4th portion of the duodenum is reported less frequently than those other portions of the duodenum. Therefore, few reports discuss the diagnosis and treatment of this malignancy.PRESENTATION OF CASEA 54-year-old woman was admitted to our hospital with a complaint of nausea and vomiting after a meal. Upper gastrointestinal examination and a duodenogram revealed a Type 2 tumor of the 4th portion of the duodenum, which was diagnosed as well-differentiated tubular adenocarcinoma by endoscopic biopsy. Partial resection of the duodenum and jejunum was performed on the basis of intraoperative evaluation of negative lymph node metastasis around the pancreas and proximal duodenum with no macroscopic invasion toward the pancreas and proximal duodenal margin. Her postoperative course was uneventful without any sign of recurrence 5 years later.DISCUSSIONPrimary adenocarcinoma in the 4th portion is relatively less common. It is not easy to diagnose this disease. Patients with primary duodenal adenocaricinoma, who are medically fit to undergo surgery, should be given the option of aggressive resection. Duodeno-cephalo-pancreatectomy remains the standard treatment for adenocarcinomas of the 1st and 2nd portion of the duodenum. Partial resection is the preferred surgical method for patients with adenocarcinoma of the 3rd and 4th portions of the duodenum.CONCLUSIONThis report describes a rare case of primary adenocarcinoma of the 4th portion of the duodenum, successfully treated by partial resection of the duodenum and jejunum. However, larger studies are required to clarify the indications for the preferred surgical method for this malignancy.     

保留胰腺的十二指肠切除术治疗十二指肠肿瘤4例报告

目的介绍保留胰腺的十二指肠切除术。方法对2例恶性肿瘤，2例良性肿瘤，行保留胰腺的十二指肠全切除术3例，乳头以下的十二指肠切除术1例。结果无手术死亡，1例出现胸腔积液，1例出现吻合口梗阻，无其他严重并发症，均痊愈出院。结论对十二指肠良性疾病或低度恶性肿瘤，保留胰腺的十二指肠切除术是适宜的选择。     

Totally laparoscopic pancreas-sparing duodenectomy

Pancreas-sparing duodenectomy (PSD) is a practical surgical procedure for patients with duodenal adenoma, which is difficult to resect endoscopically. We describe how we performed a totally laparoscopic PSD to resect a duodenal adenoma in a 64-year-old woman, who had been referred for treatment of a 50-mm villous polypoid mass in the second portion of the duodenum. We performed end-to-side anastomosis between the common duct of the bile and pancreatic ducts and the jejunal limb intracorporeally following the duodenal resection. A biliary leak developed, but resolved spontaneously and the patient was discharged on postoperative day (POD) 32. The surgical margin was free of neoplastic change. Although there is limited experience and appropriate indications must await future studies, this case demonstrates that laparoscopic PSD is feasible, safe, and effective for selected patients.     

Laparoscopic pancreas-preserving total duodenectomy for familial adenomatous polyposis

Patients with duodenal polyps associated with familial adenomatous polyposis (FAP) have a considerable risk of developing duodenal carcinoma. Prophylactic resection of the duodenum for Spigelman stage III disease is the treatment of choice to prevent progression to cancer. Pancreaticoduodenectomy and pancreas-preserving total duodenectomy (PPTD) are the techniques that have been described for the surgical treatment of duodenal polyposis. We report the first case of laparoscopic PPTD in a patient with previous total colectomy for FAP and Spigelman stage III duodenal polyposis. A laparoscopic total dissection of the duodenum was carried out and the restoration was achieved performing pancreatico-biliary-jejunostomy and gastrojejunostomy. The postoperative period was uneventful. Laparoscopic PPTD can be performed safely in selected cases for the management of FAP.     

Rare resected eight cases of duodenal adenocarcinomas

IntroductionDuodenal adenocarcinoma is a rare malignancy; recently, it has been found to be accompanied by operative indications.MethodsNine consecutive rare cases were diagnosed with duodenal carcinoma (DC), in which clinicopathological characteristics were retrospectively examined. Age was ranged over middle-aged males and females. No clinical onset with severe symptoms was observed, and the specific treatment for accompanied diseases or habits was not found.OutcomesOne case of two T1 stage DCs that underwent pancreas-sparing duodenectomy. Stage II DC was diagnosed in three cases, and stage III DC was diagnosed in four cases. Pancreaticoduodenectomy (PD) mainly occurred in seven patients, and duodenectomy was limited in two patients. All operations were safely performed, and the postoperative course showed no severe morbidity. Histological findings showed R0 resection in eight cases and R1 at the retroperitoneal dissecting part in one case. Five patients with advanced-stage DC underwent adjuvant chemotherapy; however, four patients showed tumor recurrence within 12 months. With additional strong chemotherapy, eight patients survived up to 84 months, and one died of liver metastasis at 43 months after surgery. Three representative cases of mucosal invasion with widespread pancreas-sparing duodenectomy and advanced-stage DC cases undergoing duodenectomy or PD are shown.ConclusionIn the field of upper digestive tract surgery, duodenal adenocarcinoma and various applications of surgery or adjuvant chemotherapy for long-term survival are important.     

Duodenal rupture due to giant inguinal hernia: A case report

IntroductionGiant inguinal hernia is unusual, and duodenal rupture accompanying it is particularly very rare and significantly hard to manage surgically.Presentation of caseAn 81-year-old man was admitted to our institution with upper abdominal pain. He had tenderness of the upper mid abdomen and a bilateral large inguinal hernia but he did not have pain in the inguinal–scrotal area. Computed tomography (CT) showed slight dilatation of the small bowel and stomach. There were no remarkable signs of incarceration of the inguinal hernia. Therefore, he was admitted to the internal ward. On the second day in hospital, he suddenly went into shock. CT revealed that there was free air and ascites in the inguinal hernia and therefore an emergency operation was performed.The tranverse colon, ascending colon, and ileum were incarcerated, and perfolation of the cecum was found. We also detected duodenal rupture at the inferior duodenal angle. We resected the terminal ileal (almost 90 cm) and ileocecal area, followed by side-to-side anastomosis of duodenum and jejunum. We only repaired the peritoneum at the internal hernia ring. After the operation, despite intensive-care therapy, this patient passed away on the 18th postoperative day.DiscussionThe mesocolon and third portion of the duodenum were strongly pulled down into giant inguinal hernia, probably causing the rupture of the inferior duodenal angle.ConclusionGiant inguinal hernia possibly provokes duodenal rupture and therefore should definitively be repaired if feasible.     

Pancreas-sparing duodenectomy: technique and indications.

OBJECTIVE: To assess the feasibility, safety, and short-term functional outcome of a pancreas-sparing duodenectomy. DESIGN: Prospective, uncontrolled study. SETTING: University hospital, Sweden. SUBJECTS: Four patients with extensive lesions in the duodenum (2 familial polyposis, 1 villous adenoma, and 1 giant multiple lipoma). RESULTS: All 4 patients had a duodenectomy with sparing of 1-1.5 cm of the duodenal bulb and reinplantation of the biliary and pancreatic ducts into the jejunum. Except for one early postoperative bile leak the operative and postoperative courses were uneventful. The functional results have been promising with unaltered alimentary function in the 3 patients who had no preoperative outlet obstruction and complete resolution of symptoms in the patient with duodenal lipomas who had chronic incomplete obstruction preoperatively. CONCLUSIONS: Although the indications for pancreas-preserving duodenectomy are limited, the procedure can be done safely with gastrointestinal function maintained.     

Simple segmental resection of the second portion of the duodenum for the treatment of gastrointestinal stromal tumors

Background Adequate surgical procedure for gastrointestinal stromal tumors (GISTs) arising in the second portion of the duodenum remains controversial. Materials and methods Segmental resection of the second portion of the duodenum and Roux-en-Y reconstruction was performed in two patients with duodenal GISTs. In case 1, a huge tumor arising from the second portion of the duodenum occupied the right upper quadrant of the abdomen. Preoperative treatment using imatinib mesylate decreased the tumor size from 22 to 8 cm. In case 2, the tumor was located in the second portion of the duodenum longitudinally. In both of the cases, the major papilla was preserved. Results The postoperative course was uneventful, and they were discharged on day 11. Surgical margins were negative. Conclusion The present simple segmental duodenectomy can be applied in the treatment of GISTs or other low-grade malignancies.     

A case of mesenteric cystic lymphangioma in an adult which caused duodenal stenosis after resection

INTRODUCTIONWe present a rare case of mesenteric lymphangioma in a middle-aged female.PRESENTATION OF CASEA 56-year-old female was admitted to the hospital with upper abdominal pain. Abdominal computed tomography revealed a multicystic mass surrounding the mesentery. We made the decision to resect the mass, suspecting that was a mesenteric lymphangioma based on additional imaging studies. The tumor adhered strongly to parts of the duodenum and the upper jejunum. In order to preserve the jejunum, we dissected its serosa away from the tumor. Approximately 1 week after surgery the patient experienced a constriction of the third portion of the duodenum. Her symptoms were improved with conservative therapy, and she was discharged from the hospital 62 days after surgery.DISCUSSIONLymphangioma originating from the mesentery may have cause adhesions due to exfoliated tumor cells; it is necessary to be concerned about postoperative obstruction.CONCLUSIONThe preoperative diagnosis of lymphangioma is based on various imaging modalities.     

Obstruction in the third portion of the duodenum due to a diospyrobezoar: a case report

Background

Duodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors. Obstruction due to bezoars is rare. We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy for early gastric cancer.

Case presentation

A 73-year-old man who underwent laparoscopic distal gastrectomy for early gastric cancer 15 months before admission experienced abdominal distension and occasional vomiting. The symptoms worsened and ingestion became difficult; therefore, he was admitted to our department. Computed tomography (CT) performed on admission revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach. Esophagogastroduodenoscopy (EGD) revealed a bezoar deep in the third portion of the duodenum. We could neither remove nor crush the bezoar. At midnight on the day of EGD, he experienced sudden abdominal pain. Repeat CT revealed that the bezoar had vanished from the duodenum and was observed in the ileum. Moreover, small bowel dilatation was observed on the oral side of the bezoar. Although CT showed neither free air nor ascites, laboratory data showed the increase of leukocyte (8400/μL) and C-reactive protein (18.1 mg/dL), and abdominal pain was severe. Emergency surgery was performed because conservative treatment was considered ineffective. We tried advancing the bezoar into the colon, but the ileum was too narrow; therefore, we incised the ileum and removed the bezoar. The bezoar was ocher, elastic, and hard, and its cross-section was uniform and orange. The postsurgical interview revealed that the patient loved eating Japanese persimmons (Diospyros kaki); therefore, he was diagnosed with a diospyrobezoar. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings.

Conclusions

We describe a rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer.

     

Reconstruction of a Large Duodenal Defect Created by Resection of a Duodenal Tubulovillous Adenoma Using a Double-Tract Anastomosis to a Retrocolic Roux-en-Y Loop: Report of a Case

Adenomas arising in the duodenum are uncommon. The surgical approach to adenoma of the duodenum remains controversial. We herein report the successful closure of a large defect after a partial duodenectomy for an adenoma. A 60-year-old man developed duodenal adenoma. An upper gastrointestinal roentgenographic series and endoscopy revealed a 2.5-cm tumor located adjacent to the duodenal papilla. The tumor was too large to be removed endoscopically, and therefore it was resected en bloc by a partial duodenectomy. Histology confirmed the diagnosis of benign tubulovillous adenoma. The large duodenal defect created by resection of the tumor was closed with double-tract anastomosis to a retrocolic Roux-en-Y loop. Large duodenal defects represent difficult surgical problems. Closure by direct anastomosis to a Roux-en-Y loop side-to-side is thus considered to be the procedure of choice. Received: August 29, 2001 / Accepted: March 5, 2002     

Laparoscopic treatment of duodenal carcinoid tumor

A 46-year-old man with epigastralgia and slight elevation of urinary 5-hydroxyindole acetic acid (5HIAA) was found to have a well-demarcated carcinoid tumor in the duodenal bulb. The tumor measured 8 mm in size, and showed submucosal involvement but no metastasis to the liver and regional lymph nodes. After laparoscopic exposure and lifting of the duodenal wall around the tumor, wedge resection of the duodenal bulb including the tumor was performed successfully with a laparoscopic endostapler under direct endoscopic control. The postoperative course of the patient was uneventful. Laparoscopic wedge resection of the duodenum would be an appropriate minimally invasive treatment for selected duodenal neoplasms with special preoperative assessments and intraoperative considerations. Received: 27 January 1997/Accepted: 4 December 1997     

Early laparoscopic repair for blunt duodenal perforation in an adolescent

Duodenal perforation secondary to blunt abdominal trauma in children is rare and usually associated with delays in diagnosis and surgical intervention. The authors encountered such a case in a 12-year-old boy owing to his falling over the handlebar of a bicycle. Imaging examination showed that there was a perforation over the fourth portion of the duodenum without concomitant injuries. Using a 5-port transperitoneal laparoscopic technique, primary closure of the perforation was successfully performed at 6 hours after the impact. Laparoscopic approach appears to be safe and feasible in hemodynamically stable children with solitary traumatic duodenal perforation if the operation can be performed early in the course of the incident.     

Laparoscopic distal pancreatectomy

Background: Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. Laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this study was to review our preliminary experience with laparoscopic distal pancreatectomy for benign and malignant pancreatic pathologies.Methods: A retrospective chart review of consecutive patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in a university-affiliated department of surgery between 1997 and 2003 was performed. Data relative to demographic and clinical characteristics, indications for surgery, surgical procedure, and postoperative course were recorded.Results: Laparoscopic distal pancreatectomy was attempted for 12 patients with benign (n = 8) and malignant (n = 4) pancreatic tumors and successfully completed laparoscopically in 75%, of these cases. Six early postoperative complications (two abscesses, two instances of diabetes mellitus, two pancreatic leaks) developed in three patients. The spleen was successfully preserved in 58% of the cases.Conclusions: This preliminary experience suggests that laparoscopic distal pancreatectomy is a feasible and safe procedure with a morbidity rate comparable with that for the conventional open procedure. However, laparoscopic surgery for malignant pancreatic tumors remains controversial. Larger series with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the treatment of pancreatic pathologies.Presented as a poster at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, 31 March 3–April, 2004     

Laparoscopic resection of a periampullary villous adenoma

Background: Adenomas of the duodenal papilla are rare lesions. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection, transduodenal local excision, and pancreaticoduodenectomy. This report details a case of periampullary villous adenoma diagnosed endoscopically and resected laparoscopically via a transduodenal approach. Case report: A healthy 75-year-old woman with heartburn underwent an upper endoscopy for vague right upper abdominal pain. A periampullary tumor was diagnosed. Endoscopic biopsy results were consistent with a villous adenoma, and endoscopic ultrasound showed distal bile duct involvement. The patient underwent laparoscopic transduodenal local excision of the tumor with biliary reconstruction. Conclusions: Laparoscopic transduodenal resection of periampullary lesions provides advantages similar to those of an endoscopic resection by removal of the tumor using minimally invasive techniques. In addition, laparoscopic surgery maintains the surgical tenents of open transduodenal resection with en bloc tumor resection including the adjacent duodenal wall and ductal structures as necessary. As noted in this case, laparoscopic techniques resect ampullary lesions involving the ductal structures as well. Laparoscopic transduodenal ampullectomy is a valuable treatment option for benign and selected premalignant ampullary lesions.     

Pancreas sparing duodenectomy for duodenal trauma

Background

Although blunt abdominal trauma is frequently encountered, isolated duodenal injury is relatively uncommon. The management of such patients is challenging and various surgical procedures are described for their management.

Methods

Two patients presented to our emergency department with isolated duodenal injuries (transection and devascularisation) secondary to blunt abdominal trauma.

Results

Both patients underwent exploratory laparotomy, revealing transection of the duodenum along with proximal devascularization and detachment of mesentery at duodeno-jejunal junction without any other intra-abdominal injury (especially pancreas, colon, vena cava) for which pancreas-sparing duodenectomy (infra-ampullary) was performed.

Conclusion

Pancreas-sparing duodenectomy is a valuable tool in the management of duodenal trauma, allowing the surgeon (and the patient) to avoid the complications of major surgical resections.

     

Chronic inguinal pain after laparoscopic intraperitoneal onlay mesh (IPOM) repair for inguinal hernia treated successfully with laparoscopic selective neurectomy: A case report

IntroductionLaparoscopic intraperitoneal onlay mesh (IPOM) repair is occasionally used for inguinal hernia repair. Here, we report a case of chronic neuropathic pain after laparoscopic IPOM repair for inguinal hernia, which was treated successfully with laparoscopic selective neurectomy.Presentation of caseA 59-year-old man with bilateral inguinal hernia underwent laparoscopic repair. Transabdominal preperitoneal repair was performed on the left side, whereas IPOM repair was performed on the right side due to a peritoneal defect. At postoperative month 1, he presented with severe pain and numbness distributed from the right inguinal region to the inner thigh region. The symptoms had persisted for 1 year despite medical treatment. We diagnosed that the symptoms might be due to the entrapment of nerves in the contracted mesh, and performed a second surgery via laparoscopic approach 13 months after the first surgery. On laparoscopic exploration, the lateral side of the mesh was contracted and involved nerve branches. We ligated and cut off these nerve branches. His symptoms resolved immediately after the surgery. At postoperative month 12, he has passed without any pain, numbness, and hernia recurrence.DiscussionLaparoscopic exploration would be useful to figure out chronic neuropathic pain after laparoscopic inguinal hernia repair.ConclusionLaparoscopic IPOM repair for inguinal hernia should be avoided as much as possible because it may cause chronic neuropathic pain. Laparoscopic selective neurectomy is an option for patients with chronic neuropathic pain after laparoscopic hernia repair.