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Ho et al. | Journal of Clinical and Translational Research 2023; 9(5): 327-331 329
distal duodenum) [6]. In our patient, pancreas-sparing distal
duodenectomy was performed with transection at the level of the
ampulla of Vater. With regards to the management of the ampulla of
Vater, three types of technical modifications are described [7,17].
Type I includes the preservation of the pancreas’s major and
minor papilla and the upper or lower portion of the duodenal
wall. Type II only preserves the major papilla anastomosed to the
jejunum. Type III is an excision of the intraduodenal segment of
the major papilla to expose the distal segments of the bile duct
and pancreatic ducts before anastomosing them to the jejunum.
In our patient, the Type I technique was sufficient for achieving
oncological clearance [7,17].
PSDR saves the need for pancreaticoduodenectomies with a
reduction in the risk of POPF. Preserving the pancreas allows
for shorter surgical time, less intraoperative bleeding, and the
Figure 2. Surveillance computerized tomography scan of abdomen and omission of a hepaticojejunostomy in an undilated bile duct [8].
pelvis showing the ileocolic anastomosis (white arrowhead) as well as a Pancreas-sparing procedures allow for the preservation of both
duodenal invasion (white arrows). endocrine and exocrine function of the pancreas with reduced risk
of malabsorption and diabetes mellitus [8]. To note, PSDR is not
Histology revealed a moderately differentiated adenocarcinoma, always technically feasible, and all patients should be counseled
suggestive of recurrence of the previously resected tumor, directly for pancreaticoduodenectomy as the final decision rests on
invading the duodenum. The proximal and distal margins of the intraoperative assessment. In our patient, the uncinate process of
ileocolic resection were uninvolved by the invasive carcinoma, the pancreas was in proximity but not directly involved, and thus,
and metastasis in five out of 12 regional lymph nodes was found. we managed to shave the tumor along with the pancreatic capsule,
The postoperative course was complicated by a Grade B POPF which contributed to a POPF. Cirocchi et al. have reported that
according to the International Study Group of Pancreatic Surgery multi-visceral resections, including synchronous duodenal
definition and this was managed with antibiotics and percutaneous resections, are safe and feasible in patients with locally advanced
image-guided drainage. The patient recovered well. However, a colon cancer and should be performed when R0 resection can
CT scan done at 3 months showed sub-centimetre hepatic lesions be achieved [10]. Although the perioperative morbidity was
suspicious of metastases (Figure 1). Considering patient preferences comparable for patients with pancreaticoduodenectomies (n = 39)
for omitting intravenous chemotherapy, palliative oral capecitabine and duodenal resections (n = 14), the survival of patients with
was commenced. She died of metastatic disease 28 months after the pancreaticoduodenectomies was superior when compared to local
index surgery (Figure 1). duodenal resection patients. Our patient had underwent duodenal
resection for metastatic local recurrence and we decided to
3. Discussion perform a PSDR rather than a pancreaticoduodenectomy as we
were able to achieve R0 resection.
PSDRs are uncommon procedures performed for benign, Although a pancreas-sparing procedure can achieve a lower
premalignant, or early-stage malignant duodenal lesions. For morbidity rate compared to a standard pancreaticoduodenectomy [8],
example, in patients with familial duodenal adenomatous post-operative morbidity is still significant [18]. A PSDR leads
polyposis, PSDR is done with prophylactic intent to reduce the to greater difficulty in reconstruction, with an increased risk of
risk of malignant transformation [11-16]. PSDR is anecdotally anastomotic leak and stenosis [19]. In a systematic review by
reported in malignant infiltration of the duodenum from other Cantalejo et al. involving 211 patients, 49.7% of patients who
organs [6,14,15], or local invasion from colon cancer [10], and underwent a pancreatic preserving duodenectomy had post-
this is one of the first reports of PSDR for metastatic right colonic operative complications [8]. The most common complications
adenocarcinoma infiltrating into the duodenum. reported were POPF (36.0%), delayed gastric emptying (15.7%),
PSDR is a technically challenging procedure, and it involves and wound infection (10.5%) [8]. Thus, even though the number of
two considerations: Total or partial duodenal resection and anastomoses is reduced in PSDR, the morbidity is comparable to a
management of the ampulla of Vater with its biliopancreatic standard pancreaticoduodenectomy. Hence, PSDR is not performed
digestive juices. With regards to the length of duodenal segment with the intent of reducing post-operative morbidity, but instead to
resection, Konishi et al. described four types of PSDR: (a) Pancreas- preserve pancreas function. If morbidity is reduced, it is a welcomed
sparing total duodenectomy (complete resection of the duodenum, by-product. It is also important to consider nodal clearance in
including pylorus), (b) pancreas-sparing subtotal duodenectomy surgical decision-making and not only R0 resection. Thus, even
(preserving the pylorus and duodenal bulb), (c) pancreas-sparing though R0 clearance was achieved in most patients, survival after
proximal duodenectomy (resection of the proximal duodenum), a pancreaticoduodenectomy was superior compared to duodenal
and (d) pancreas-sparing distal duodenectomy (resection of the resection in patients with locally advanced colon cancer [10].
DOI: http://dx.doi.org/10.18053/jctres.09.202305.22-00228