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Upper Gastrointestinal (lips to ileocecal valve, including esophagus and stomach)

E459: Pancreas Preserving Distal Duodenectomy Compared to Pancreaticoduodenectomy for Primary Duodenal Adenocarcinoma: Experience at a Quaternary Referral Center.

Introduction: Small bowel malignancies account for 2% of gastrointestinal cancers in the United States. Adenocarcinomas of the small bowel are mostly found in the duodenum. Due to the duodenum’s anatomic associations, a pancreaticoduodenectomy (PD) procedure is often performed for duodenal malignancies, especially those in close association to the ampulla of Vater. Alternatively, a pancreatic preserving distal duodenectomy (PPDD) may be appropriate for lesions within the distal duodenum and has been shown to be a safe and effective alternative for gastrointestinal stromal tumors and adenomas but remains controversial for adenocarcinoma due to concerns of adequate margins and lymph node yield to provide an appropriate oncologic outcome. 

Methods: A retrospective experience at a single institution, quaternary referral center for patients who underwent surgical treatment of resectable primary duodenal adenocarcinoma from 2016 to 2023. Patients with the pathologic diagnosis of pancreatic adenocarcinomas, ampullary adenocarcinomas, and duodenal adenomas were excluded. Outcomes including number of lymph nodes, postoperative LOS, complications, disease free and overall survivals were evaluated. 

Results: From 2016 to 2023, 18 patients underwent surgical resection for duodenal adenocarcinoma; 10 PD and 8 PPDD. Groups were similar except for age (mean age PD=72 yrs vs PPDD=59 yrs). Lymph node resection rates were similar (PD =16, PPDD 14, p=0.44).  Mean proximal margin was greater in the PD group (9.5 + 4.3 cm vs 3.7 + 2.3 cm) and mean distal margin was greater in the PD group (15.6 + 8 cm vs 8 + 1.7cm). All margins in the PPDD and the PD groups were adequate per the NCCN guidelines. Mean hospital length of stay was shorter in the PPDD group (7 + 2 days vs 12 + 6 days). Postoperative complications were fewer in the PPDD group; 1 patient required abscess drainage vs 4 patients in the PD group. Two patients in the PD group died in the immediate postoperative period secondary to aspiration events. Kaplan-Meier estimate found the relapse-free survival rate at 30 months was 56.3% for both groups (p=0.77). To date, the mean follow-up time for the PPDD group is 33.4 + 22.9 months and all patients are still alive. In the PD group, overall survival rate at 33 months was 50%. 

Conclusions: Pancreas preserving distal duodenectomy is a safe oncologic alternative to pancreaticoduodenectomy for duodenal adenocarcinoma and should be considered when a negative resection margin can be obtained. Due to the short follow-up time and small sample size, further study in this area is required.  

Learning Objectives:

  • Upon completion, participant will be able to descirbe the difference between a distal duodenectomy and a WHIPPLE for duodenal adenocarcinomas in terms of oncologic outcomes.
  • Upon completion, a participant will be able to describe the difference between a distal duodenectomy and a WHIPPLE for duodenal adenocarcinomas in terms of morbidity and mortality.
  • Upon completion, a participant will be able to list the indications to perform a distal duodenectomy in the setting of duodenal adenocarcinomas instead of a WHIPPLE.