Abstract

INTRODUCTION

For neoplasms that arise in the third and fourth parts of the duodenum (D3, D4), a duodenectomy that preserves the pancreas can provide adequate tumour clearance while avoiding the additional dissection and risk of the common alternative, pancreatoduodenectomy.

PATIENTS AND METHODS

Pancreas-sparing distal duodenectomy (PSDD) was performed in 14 patients with infrapapillary duodenal neoplasms between 1991–2002, and the clinical outcome is reviewed. The operation entails careful separation of the lower pancreatic head from D3, complete mobilisation of the ligament of Treitz and end-to-end duodenojejunal anastomosis 1–3 cm below the major duodenal papilla.

RESULTS

There were 9 men and 5 women of median age 56 years, who presented with iron-deficiency anaemia (n = 8), gastric outlet obstruction (n = 4), anaemia and gastric outlet obstruction (n = 1), epigastric pain or mass (1 each). There were 11 malignant neoplasms (adenocarcinoma 5, stromal tumour 4, recurrent seminoma 1, plasmacytoma 1), 2 benign neoplasms (villous adenoma, lipoma) and 1 patient with steroid-induced ulceration. In addition to D3 and D4, resection included the distal part of D2 in 5 patients, while 4 required concomitant partial colectomy. Median operation time was 240 min and median blood loss 1197 ml, being greater for malignant than benign lesions (1500 ml versus 700 ml). There was one death from gangrenous cholecystitis, one early re-operation for anastomotic bleeding and one late re-operation for delayed gastric emptying secondary to anastomotic stricture, but no pancreatic complications. At a median follow-up of 47 months, three patients had died of recurrent disease while the other 10 were alive and well with no upper gastrointestinal symptoms.

CONCLUSIONS

Provided there is a minimum 1-cm clearance at the papilla, PSDD is a useful alternative to formal pancreatoduodenectomy in patients with unusual neoplasms arising from the third and fourth parts of the duodenum. Although a major undertaking in its own right, it avoids the extra time of a pancreatic resection and the extra risk of a pancreatic anastomosis.
Although it comprises 75% of the total length of the gastrointestinal tract, the small bowel gives rise to merely 2–6% of all primary gastrointestinal malignancies.1,2 The duodenum constitutes only the first 25 cm of the small bowel, yet duodenal neoplasia accounts for 35% of all benign and 17% of all malignant small bowel tumours.3,4 The surgical management of duodenal pathology is challenging because of its retroperitoneal position and shared blood supply with the pancreas. For supraampullary and peri-ampullary neoplasms, the customary surgical option is pancreatoduodenectomy (PD), even if the pancreas is not involved and even in premalignant disease. A less radical procedure is local resection of the papilla (ampullectomy) with the adjacent pancreatic tissue containing the terminal bile and pancreatic ducts.5 More recently, pancreas-sparing total duodenectomy (PSTD) has been described, generally referring to total resection of the duodenum including the papilla but not the adjacent pancreatic tissue or the terminal biliary and pancreatic ducts.616 Its suggested advantages over local resection are that the dissection is carried out in a defined tissue plane – a long-term solution for diffuse duodenal disease (e.g. in familial adenomatous polyposis) – and simpler ductal anastomoses.
One report describes a pancreas-sparing suprapapillary duodenectomy for an exophytic hepatocellular carcinoma (HCC) directly invading the duodenum.17 Reports of the surgical management of infrapapillary duodenal pathology are largely limited to case reports and small series.1824 For neoplasms that arise in the third and fourth parts of the duodenum (D3, D4), a conservative duodenectomy that preserves the pancreas and papilla can provide adequate tumour clearance while avoiding the additional dissection and risk associated with the biliary and pancreatic anastomoses implicit in the common alternative PD (or PSTD). Other advantages of this procedure include a shorter operative time and the preservation of more normal anatomy and function allowing postoperative endoscopic surveillance. We describe our experience with pancreas-sparing distal duodenectomy (PSDD) for infrapapillary neoplasms.

Patients and Methods

PSDD was performed in 14 patients with infrapapillary duodenal neoplasms between 1991–2002; at least one of the authors was involved in every operation. Their clinical and histopathological features have been reviewed retrospectively. Data were collected from the hospital records and included details on the presentation, surgical resection (length of the operative procedure, estimated blood loss, type and position of anastomosis), adjuvant therapy and pathological features. Complications and clinical outcome were also reviewed.
The operation entails extensive mobilisation of the duodenum by Kocher's manoeuvre including the ligament of Treitz, with ligation and division of the mesentery of the duodenojejunal flexure and transection of the upper jejunum. The duodenojejunal specimen is then passed beneath the superior mesenteric vessels into the supracolic compartment, and D3 is carefully separated from the lower pancreatic head taking care not to injure the pancreas. At the proximal extent of the resection, the duodenum is divided 1–3 cm below the major duodenal papilla, and an end-to-end duodenojejunal anastomosis is performed in two layers either anterior or posterior to the superior mesenteric vessels (Fig. 1). When the proximal transection line lies close to the papilla, the papilla is identified by palpation and, if necessary, opening the duodenum anteriorly before completing the cut at a safe level. If this were not possible, one would have to perform a PD.
Figure 1 (A) The duodenum is divided 1–3 cm below the ampulla. (B) Completed end-to-end duodenojejunal anastomosis posterior to the superior mesenteric vessels. (C) Completed end-to-end duodenojejunal anastomosis anterior to the superior mesenteric vessels.

Results

There were 9 men and 5 women of median age 56 years (range, 27–73 years). The principal presentation was irondeficiency anaemia in 9 patients, one of whom had overt melaena and haematemesis and another gastric outlet obstruction. Three patients had gastric outlet obstruction alone, and one each had epigastric pain or mass. All but one patient with steroid-induced ulceration had duodenal neoplasia. There were 11 malignant neoplasms, of which 5 were primary duodenal adenocarcinomas, 4 were stromal tumours, one had a recurrent seminoma and one a plasmacytoma. There were 2 benign neoplasms, one villous adenoma and one ulcerated submucosal lipoma simulating cancer of D3 (Table 1).
Table 1 Clinical details of patients
No.SexAge (Years)PresentationDiagnosisCo-morbidityResectionAdjuvant treatment
1M53Gastric outlet obstructionAdenocarcinoma (stage II)Treated seminomaDistal D2/D3/D4
2M68AnaemiaAdenocarcinoma (stage III)Coeliac diseaseD3/D3Chemo#
3F47AnaemiaAdenocarcinoma (stage II)D3/D4
4M54Anaemia, gastric outlet obstructionAdenocarcinoma (stage III)D3/D4*
5M70AnaemiaAdenocarcinoma (stage I)Distal D2/D3/D4
6F43AnaemiaGISTD3 + right colon
7M52AnaemiaGISTD3/D4 + right colon*DXT
8M27AnaemiaGISTD4 + transverse colon*DXT
9M50Epigastric massGISTD3/D4
10M43Gastric outlet obstructionRecurrent seminomaTreated seminomaD3/D4 + left colon
11F73AnaemiaSmall bowel plasmacytomaHereditary haemorrhagic telangiectasiaDistal D2/D3/D4
12M71Melaena-anaemiaSteroid-induced ulcerationWegener's granulomatosisDistal D2/D3/D4
13F60Epigastric painVillous adenomaDistal D2/D3/D4
14F71Gastric outlet obstructionSubmucosal lipomaD3/D4
GIST, gastrointestinal stromal tumour; DXT, radiotherapy; D2/D3/D4, second, third and fourth parts of the duodenum.
*
Positive margins on definitive histopathology.
#
Patient received 2 cycles of postoperative chemotherapy (5-fluorouracil and folinic acid).
In addition to D3 and D4, resection included the distal part of D2 in 5 patients, while 4 required concomitant partial colectomy because of involvement of adjacent ascending (2), transverse (1) and splenic (1) mesocolon. All anastomoses were end-to-end, four being performed anterior to the superior mesenteric vessels. One juxtapapillary anastomosis was protected by temporary pancreatic diversion (as previously described25). Median operation time was 240 min (range, 180–330 min) and median blood loss 1197 ml (range, 200–4500 ml), being greater for malignant than benign lesions (1500 ml [range, 200–4500 ml] versus 700 ml [range, 300–1295 ml]). Median time to resumption of oral food was 10 days (range, 6–21 days) and median hospital stay was 11 days (range, 7–30 days).
Three patients had resection margins that were positive for cancer on definitive histopathology (Table 1); in two of these, the resection was definitely thought to be palliative at the time. Patient no. 4 had an advanced adenocarcinoma of D3 and D4 with infiltration into the adjacent mesentery and nodes that were obviously involved. A previous gastroenterostomy at another hospital had failed to relieve his vomiting (despite a patent stoma), and he was both emaciated and anaemic. Palliative duodenectomy corrected these problems, although the resolving gastric atony, the need for nutritional support and social circumstances kept him in hospital for 7 weeks afterwards. Patient no. 7 had a massive GIST of dumb-bell shape, the deeper moiety being closely adherent to the inferior vena cava (which was partly occluded). Resection was probably incomplete to the naked eye, and pathological examination confirmed tumour at the caval margin; the lesion was a high-grade sarcoma. Patient no. 8 also had a massive GIST (18-cm diameter) at, and just proximal to, the duodenojejunal flexure with wide invasion into the transverse mesocolon. Although the resection was macroscopically complete, tumour was reported at the mesocolic margin on histology so the patient received adjuvant radiotherapy; he is alive and well 10 years later. Each of these GISTs required concomitant colectomy, and all three patients had had pre-operative gastrointestinal haemorrhage, whether overt or occult.
One patient died postoperatively on day 16 from gangrenous cholecystitis after re-exploration on day 14. There was one early re-operation for anastomotic bleeding and one late re-operation for delayed gastric emptying secondary to an anastomotic stricture (Fig. 2). One other patient had transient gastric atony that settled with conservative treatment. There were no pancreatic complications. Two patients with incomplete resection of stromal tumours received adjuvant radiotherapy. At a median follow-up of 47 months (range, 3–179 months), three patients had died of recurrent disease while the other 10 were alive and well with no upper gastrointestinal symptoms.
Figure 2 Barium meal demonstrating postoperative anastomotic stricture.

Discussion

PD has become accepted as a safe and appropriate procedure for selected patients with benign, premalignant and malignant diseases of the duodenum. With increased experience in specialised units, operative mortality after PD is reported to be 2–4%, yet the incidence of postoperative morbidity can still approach 50%.2629 Similarly, a review of the literature of reported cases of PSTD reveals operative mortality to be low at 2% (1 of 43 patients9), but the morbidity remains high at 60% (26 of 43 reported cases), most of the complications being secondary to anastomotic leaks (11 of 43 patients6,8,1113,15). Thus PSDD, which eliminates the risk associated with biliary and pancreatic anastomoses of PD and PSTD, is an attractive alternative for isolated neoplasms of the infrapapillary duodenum without pancreatic involvement. This fact is reflected in a review of the literature of reported cases of PSDD (Table 2): there was one death secondary to an anastomotic leak (3%), and the morbidity rate was 41% (13 of 31 patients). Only 2 cases of pancreatic fistula were observed. Our series compares favourably with the reported literature with a postoperative mortality rate of 7% and a morbidity rate of 21% (Table 2).
Table 2 Documented cases of PSDD
ReferenceYearNo. of casesHistopathologyPostoperative complicationsOutcome
Kawano et al.1819951GISTNone?
*Maher et al.1919962411 adenocarcinoma1 death (anastomotic leak)Median survival 18.5 months
   4 other tumours2 pancreatic fistulaOthers, alive and well at 2 yrs
   5 trauma2 delayed gastric emptying 
   2 Crohn's disease2 anastomotic bleed 
   2 other#2 wound infection 
*Sohn et al.20199822 adenocarcinoma2 cholangitis 
Suzuki & Yasui21199911 GIST1 delayed gastric emptyingAlive and well at 2 years
Orda et al.22200011 GISTNoneAlive and well at 13 years
Ammori23200211 benign duodenal stricture (laparoscopic)  
    Laparoscopic Roux-en-Y?
    gastrojejunostomy, 
    Laparoscopic revision 
    gastrojejunostomy 
Eisenberger et al.24200411 GISTNoneAlive and well at 1 year
Present series2005145 adenocarcinoma1 re-operation for anastomotic stricture1 death 3 months post-operatively, median survival
    1 delayed gastric emptying56 months
   4 GISTNone1 death 3 months post-operatively, median survival
     120 months
   1 recurrent seminomaGangrenous cholecystitisDied at 16 days
   1 plasmacytomaEarly re-operation for anastomotic bleedingDied at 47 months
   1 steroid-induced ulcerationAlive and well at 63 months 
    None 
   1 villous adenomaNoneAlive and well at 41 months
   1 lipomaNoneAlive and well at 165 months
GIST, gastrointestinal stromal tumour.
*
Both studies from the same institution; Sohn et al.20 includes an additional 2 cases of adenocarcinoma to the previously described 11 cases.
#
1 complicated peptic ulcer disease, 1 high small bowel obstruction.
The median operative time for PSDD in this series was 240 min (range, 180–330 min), considerably shorter than the mean operative time of approximately 420 min reported for PD.27,30 Although reported figures are limited, times given for PSTD range between 217–360 min,8,12,16 whilst those for PSDD range between 300–330 min.19,21,23 Median blood loss of 1197 ml in this series was similar to that previously reported for PD (970 ml27), PSTD (690 ml16) and PSDD (1347 ml19). Blood loss was noted to be greater among the malignant cases (1500 ml) than the benign cases (700 ml), especially when concomitant partial colectomy was needed (2350 ml).
The indications for PSDD range from the obvious to the controversial. The operation can be considered for any benign neoplasm or ulceration of the distal duodenum, including Crohn's disease if medical treatment fails.19 PSDD has also been described for patients with severe injuries of the distal duodenum.19 Although villous adenomas at this site may be benign, larger neoplasms often contain foci of malignancy that can be missed on pre-operative biopsy.31,32 Up to 40% of these lesions are carcinoma in situ31;32 and thus potentially curable without a radical procedure. One patient in our series was free of recurrence 41 months after PSDD for a villous adenoma, and there is a reported case of similar success at 24 months.19 In patients with multiple villous adenomas, particularly in FAP, distal duodenectomy is insufficient as the entire duodenal mucosa is at risk.
Adenocarcinoma of the duodenum is the least common type of periampullary tumour, but the prognosis is generally better than for carcinoma of the pancreas or distal bile duct.33,34 PD is clearly indicated for duodenal adenocarcinomas that lie close to the papilla, but not necessarily so beyond that point. In the largest series of PSDDs for duodenal carcinoma (n = 13),20 survival rates were poorer than for PD (n = 35) at one year (76% versus 91%), two years (63% versus 73%) and 5 years (0% versus 69%). The likely explanation is that the peripapillary tumours presented earlier with obstructive jaundice. Our series includes 5 patients with adenocarcinoma of the infrapapillary duodenum treated by PSDD. Two of the five had advanced disease (stage III); in one of these, the resection was palliative with positive margins (patient no. 4). This patient died 3 months' postoperatively, whilst the others remain disease-free at median 56 months (range, 46–64 months). Although it is one conceivable option for palliation, luminal stenting remains difficult in the distal duodenum and does nothing to address persistent bleeding from the malignant ulcer. At present, one cannot say that PD is a better oncological operation than PSDD because comparative data do not exist. However, regional lymph node clearance is technically feasible in both procedures.
Duodenal GIST is a rare lesion accounting for 10–33% of all malignant duodenal tumours.35 It is generally agreed that the treatment of choice is surgical removal of the mass.1,3638 Local resection is appropriate when feasible, but wide resection can be justified as invasion of adjacent organs does not preclude a cure. Duodenal GISTs have a mean survival of 50 months35 and a 5-year survival of almost 50%.39 The 10-year survival is also 50% with resection but only 10% without resection.40 The reports of duodenal GISTs that have been resected completely with PSDD have shown freedom of recurrence at 12–156 months.18,21,22,24 Two of our 4 patients with stromal tumours had incomplete resections, and each of them was submitted to radical radiotherapy thereafter. Three of the 4 are alive and well with no evidence of recurrence at 36, 120 and 179 months, while one died during radiotherapy secondary to dehiscence of an ileocolic anastomosis that had previously healed.

Conclusions

PSDD appears to be a safe and useful alternative to PSTD and formal PD in patients with adenomas, stromal tumours and unusual neoplasms arising from the third and fourth parts of the duodenum, provided there is a minimum 1-cm clearance at the papilla. Although a major undertaking in its own right, it avoids the extra time of a pancreatic resection and the extra risk of a pancreatic anastomosis.

References

1.
Williamson RC, Welch CE, Malt RA. Adenocarcinoma and lymphoma of the small intestine. Distribution and etiologic associations. Ann Surg 1983; 197: 172–8.
2.
Ciccarelli O, Welch JP, Kent GG. Primary malignant tumors of the small bowel. The Hartford Hospital experience, 1969–1983. Am J Surg 1987; 153: 350–4.
3.
Cooper MJ, Williamson RC. Enteric adenoma and adenocarcinoma. World J Surg 1985; 9: 914–20.
4.
Manier MM, Bockus HLR. Duodenal neoplasms. Gastroenterology 1985; Philadelphia, PA: Saunders 1428–38.
5.
Chappuis CW, Divincenti FC, Cohn IJ. Villous tumors of the duodenum. Ann Surg 1989; 209: 593–8.
6.
Chung RS, Church JM, van Stolk R. Pancreas-sparing duodenectomy: indications, surgical technique, and results. Surgery 1995; 117: 254–9.
7.
Ryu M, Kinoshita T, Konishi M, Kawano N, Arai YTanizaki H, et al. Segmental resection of the duodenum including the papilla of Vater for focal cancer in adenoma. Hepatogastroenterology 1996; 43: 835–8.
8.
Tsiotos GG, Sarr MG. Pancreas-preserving total duodenectomy. Dig Surg 1998; 15: 398–403.
9.
Nagai H, Hyodo M, Kurihara K, Ohki J, Yasuda TKasahara K, et al. Pancreas-sparing duodenectomy: classification, indication and procedures. Hepatogastroenterology 1999; 46: 1953–8.
10.
Alarcon FJ, Burke CA, Church JM, van Stolk RU. Familial adenomatous polyposis: efficacy of endoscopic and surgical treatment for advanced duodenal adenomas. Dis Colon Rectum 1999; 42: 1533–6.
11.
Farnell MB, Sakorafas GH, Sarr MG, Rowland CM, Tsiotos GGFarley DR, et al. Villous tumors of the duodenum: reappraisal of local vs. extended resection. J Gastrointest Surg 2000; 4: 13–21.
12.
Kalady MF, Clary BM, Tyler DS, Pappas TN. Pancreas-preserving duodenectomy in the management of duodenal familial adenomatous polyposis. J Gastrointest 2002; 6: 82–7.
13.
Konsten JL, Kazemier G, Dees J, van Eijck CH. [Pancreas-preserving total duodenectomy due to familial adenomatous polyposis in 4 patients]. Ned Tijdschr Geneeskd 2002; 146: 621–4.
14.
Lundell L, Hyltander A, Liedman B. Pancreas-sparing duodenectomy: technique and indications. Eur J Surg 2002; 168: 74–7.
15.
Sarmiento JM, Thompson GB, Nagorney DM, Donohue JH, Farnell MB. Pancreas-sparing duodenectomy for duodenal polyposis. Arch Surg 2002; 137: 557–62.
16.
Takagi H, Miyairi J, Hata M, Tuboi J, Kamijou TNakajima K, et al. Multiple somatostatin- and gastrin-containing carcinoids of the duodenum: report of a case treated by pancreas-sparing duodenectomy. Hepatogastroenterology 2003; 50: 711–3.
17.
Cho A, Ryu M, Ochiai T. Successful resection, using pancreas-sparing duodenectomy, of extrahepatically growing hepatocellular carcinoma associated with direct duodenal invasion. J Hepatobiliary Pancreat Surg 2004; 9: 393–6.
18.
Kawano N, Ryu M, Kinoshita T, Konishi M, Iwasaki MFuruse J, et al. Segmental resection of the duodenum for treating leiomyosarcoma associated with von Recklinghausen's disease: a case report. Jpn J Clin Oncol 1995; 25: 109–12.
19.
Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL. Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg 1996; 171: 62–7.
20.
Sohn TA, Lillemoe KD, Cameron JL, Pitt HA, Kaufman HSHruban RH, et al. Adenocarcinoma of the duodenum: factors influencing long-term survival. J Gastrointest Surg 1998; 2: 79–87.
21.
Suzuki H, Yasui A. Pancreas-sparing duodenectomy for a huge leiomyosarcoma in the third portion of the duodenum. J Hepatobiliary Pancreat Surg 1999; 6: 414–7.
22.
Orda R, Sayfan J, Wasserman I. Surgical treatment of leiomyosarcoma of the distal duodenum. Dig Surg 2000; 17: 410–2.
23.
Ammori BJ. Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs). Surg Endosc 2002; 16: 1362–3.
24.
Eisenberger CF, Knoefel WT, Peiper M, Yekebas EF, Hosch SBBusch C, et al. Pancreas-sparing duodenectomy in duodenal pathology: indications and results. Hepatogastroenterology 2004; 51: 727–31.
25.
Williamson RC. A technique for pancreatic diversion to protect a healing duodenal anastomosis. Ann R Coll Surg Engl 1994; 76: 403–4.
26.
Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Ilstrup D. Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992; 127: 945–9.
27.
Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993; 217: 30–5.
28.
Strasberg SM, Drebin JA, Soper NJ. Evolution and current status of the Whipple procedure: an update for gastroenterologists. Gastroenterology 1997; 113: 983–94.
29.
Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HATalamini MA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226: 248–57.
30.
Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak MLTalamini MA, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995; 222: 580–8.
31.
Ryan DP, Schapiro RH, Warshaw AL. Villous tumors of the duodenum. Ann Surg 1986; 203: 301–6.
32.
Bjork KJ, Davis CJ, Nagorney DM, Mucha PJ. Duodenal villous tumors. Arch Surg 1990; 125: 961–5.
33.
Michelassi F, Erroi F, Dawson PJ, Pietrabissa A, Noda SHandcock M, et al. Experience with 647 consecutive tumors of the duodenum, ampulla, head of the pancreas, and distal common bile duct. Ann Surg 1989; 210: 544–54.
34.
Scott-Coombes DM, Williamson RC. Surgical treatment of primary duodenal carcinoma: a personal series. Br J Surg 1994; 81: 1472–4.
35.
Shukla SK, Elias EG. Primary neoplasms of the duodenum. Surg Gynecol Obstet 1976; 142: 858–60.
36.
Fishbein T, Carroll M, Beazley RM. Duodenal leiomyosarcoma. J Surg Oncol 1995; 58: 70–3.
37.
Barkan A, Wolloch Y, Dintsman M, Yeshurun D. Leiomyosarcoma of the duodenum. Two case reports and a literature review. Am J Proctol Gastroenterol Colon Rectal Surg 1981; 32: 18–2128.
38.
Petralia GA, Hansen PD, Bowyer RC, Williamson RC. Duodenal leiomyosarcoma. Dig Surg 1999; 16: 22–5.
39.
He LJ, Wang BS, Chen CC. Smooth muscle tumours of the digestive tract: report of 160 cases. Br J Surg 1988; 75: 184–6.
40.
Evans HL. Smooth muscle tumors of the gastrointestinal tract. A study of 56 cases followed for a minimum of 10 years. Cancer 1985; 56: 2242–50.

Information & Authors

Information

Published In

cover image The Annals of The Royal College of Surgeons of England
The Annals of The Royal College of Surgeons of England
Volume 89Number 2March 2007
Pages: 130 - 135
PubMed: 17346405

History

Published in print: March 2007
Published online: 11 March 2015

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Keywords

  1. Pancreas-sparing distal duodenectomy
  2. Duodenal pathology
  3. Surgery

Authors

Affiliations

DRC Spalding
Department of Surgery, Hammersmith Hospital London, UK
AM Isla
Department of Surgery, Hammersmith Hospital London, UK
JN Thompson
Department of Surgery, Royal Marsden Hospital London, UK
RCN Williamson
Department of Surgery, Hammersmith Hospital London, UK

Notes

Correspondence to RCN Williamson, Professor of Surgery, Hepatopancreatobiliary Unit, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK T: +44 (0)20 8383 3941; F: +44 (0)20 8383 3174; E: [email protected]

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