JournalofVisceralSurgery(2019)156,77—78
Availableonlineat
ScienceDirect
www.sciencedirect.comCORRESPONDENCE
Sub-total
duodenectomy
for
secondary
duodenum
neoplastic
invasion
DearEditor,
The interesting paper by Baboudjian et al. focuses on
theduodenum(D)parietalresection[1].Inoncology,when
larger excisions are required, alternative procedures of pancreas-sparingsub-totalduodenectomycanbeconsidered basedonthefollowingsurgicalsteps[2,3].
After a Kocher manoeuvre,D3 is transacted beforeits undercrossingthe superior mesenteric vessels. It is retro-grade dissected up to the region of the Vater papilla in a plane just outside the D muscular layer, dividing the shortbranches ofthe pancreatico-duodenal vessels. After sectioningtheDbulb1.5—2cmfromthepyloricring, dissec-tionrestartsanterogradeuntiltheVaterpapilla,whichcan beexciseddividing theWirsungductandthe choledochus just outside the D wall (Fig.1A). These ducts will be re-implantatedinaRoux-en-Yjejunalloop,downstreamofthe anastomosis withthe D1 ‘‘cuff’’,usually on the guide of 2stents,workingalsoasexternaltemporarypostoperative drains[2—4].
Figure1. A.CompleteexcisionofD2andpartlyofD3.B.An‘‘island’’ofD2medialwallisdissected,encompassingthemajorandminor papilla,thatwillbeimplantedintheRoux-en-Yjejunalloop.
Differently,weproposetodissectanelliptical‘‘island’’
fromthemedial D2 wall,extending 3cm abovethe Vater
papilla, to include also the minor papilla (Fig. 1B). The
‘‘island’’vascularization isassuredbythebranchesofthe superior pancreatico-duodenal vessels. The digestive con-tinuityis restoredwithaRoux-en-Y jejunalloop, brought upin the supra-mesocolic space,withits anti-mesenteric sidefacingtheD2‘‘island’’.Anend-to-endjejunal anasto-mosisis performedwiththe D1‘‘cuff’’;moredistallythe D2‘‘island’’isre-implantedontheanti-mesentericsideof thejejunalloop.Afeedingjejunostomyis usefullyadded. Preoperatively, a MR cholangio-pancreatography helps to excludeanomaliesofthebiliarytreeandofthepancreatic ductsandtoverifythepresenceofsafeoncologicalmargins. Boththeseproceduresarelessinvasivethana pancreato-duodenectomy,andensurealargerexcision withprobable oncologicallysafermargins.Theirmainindicationsare rep-resented by neoplastic involvement of D2 lateral wall, usuallyfromtumorsoftherightkidneyoroftherightcolonic flexure.Theirconversion toa totalduodenectomyresults easy after a Cattell-Braasch manoeuvre: in this case the digestivetractisdirectlyreconstructedwiththe1stjejunal loop[2].
Inchoosingbetweenthese2techniques,itshouldbe con-sideredthatre-implantationofan‘‘island’’oftheD2wall
78 Correspondence
iseasierandsaferthanadoubleanastomosisofthe
chole-dochusandoftheWirsungduct.Weunderlinethatagood
functioningofaRoux-en-Yjejunalloopdemandsacareful
dissection of its vascular arcades and its cautious
mobi-lization,avoiding any inappropriate mesenteric torsionor
stretching,thatdamagesalsothevegetativenervousfibers.
Noticeable,adirectpancreato-jejunalanastomosisis
hin-deredbythediscrepancybetweenthesizeofthepancreatic
headandthejejunalloopcaliber.
A preserved pylorus preventsdumping syndrome;
how-ever the other functional disadvantages, secondary to
missed D endocrine-digestive functions, persist, although
less relevant.The onsetof a ‘‘duodenal blind loop’’
syn-dromeisunlikely,consideringtheshortlengthoftheD3-D4
remnantanditsintrinsicmotility[5].
Disclosureofinterest
Theauthorsdeclarethattheyhavenocompetinginterest.
References
[1]BaboudjianJM,LeTreutYP,GregoireE.Renalcellcancer duode-nalinvasion:towardstandardcare.JViscSurg2018;155:433—4.
[2]DelperoJR,TurriniO,EwaldJ.Totalduodenectomywithout pan-createctomyforfamilialadenomatouspoliposis(withvideo).J ViscSurg2014;151:473—4.
[3]ChungRS,ChurchJM,vanStolkR.Pancreas-sparing duodenec-tomy: indications, surgical technique, and results. Surgery 1995;117:254—9.
[4]TsiotosG,SarrMG.Pancreas-preservngtotalduodenectomy.Dig Surg1988;14:398—403.
A.Manentia,∗,G.Melegarib,M.Zizzoa,
A.Farinettia
aDepartmentofSurgery,UniversityofModena, Polyclinichospital,41124Modena,Italy bDepartmentofAnesthesiology,Universityof Modena,Polyclinichospital,41124Modena,Italy ∗Correspondingauthor. E-mailaddress:antonio.manenti@unimore.it (A.Manenti) Availableonline22November2018
https://doi.org/10.1016/j.jviscsurg.2018.11.001
