SlideShare a Scribd company logo
1 of 61
Download to read offline
Dr. Tim Wiyule Mutafya
COSECSA General surgery resident
Kamuzu Central Hospital, Malawi
Background
Duodenal Surgical anatomy
Epidemiology
Approach to neoplasms
Surgical management
Sympathetic
• Vagus nerve
• Greater splanchnic nerves T5-T9 along PD
arteries
Parasympathetic
• celiac and superior mesenteric plexus
Absorption
mucus production
mucus production
antimicrobial
HCO3 mucus
Benign vs Malignant
Clinical approach
Non modifiable Modifiable
Age > 60
M > F
Inherited conditions
• familial adenomatous polyposis
• Lynch syndrome
• Peutz-Jeghers syndrome
• cystic fibrosis
• Gardner’s Syndrome
Intestinal disease
• Chrons disease
• Celiac disease
• H-pylori- duodenal ulcer
• Smocking
• Alcohol
• Diet
• Hypegastrineamia
Duodenal tumors are rare, ranging from benign lesions that can be
managed by endoscopic resections to adenocarcinoma that will require
surgery. They are usually asymptomatic. 90% are benign
They are usually incidental finding during endoscopic examination.
Adenomatous polyps are the most common benign lesions
Primary malignant tumors of the duodenum represent 0.3% of all GIT tumors
but up to 50% of small bowel malignancies.
• Primary malignant tumors of the duodenum must be differentiated from
malignant tumors of the ampulla, pancreas and common bile duct.
• The most frequent tumor of the duodenum is adenocarcinoma
Benign Malignant
Epithelial
• Adenoma polyps (tubular, villous, tubulovillous)
• Brunner’s Gland Adenoma
Primary
• Adenocarcinoma
• Lymphomas
• Duodenal GIST
• Leiomyosarcomas
• Carcinoid Tumors
• Gastrinomas,
• Stromal Tumors.
Mesenchymal
• Leiomyoma
• Leiomyoblastoma
• Lipoma
• Fibroma
• Neurogenic
Secondary
• Ampulla
• Pancreas
• Biliary tree
Anatomical/clinicopathological groups
• Ampullary
• non- ampullary
They remain asymptomatic for long periods of time. The non-specific
symptoms depend on the tumor size, location and complications arising
from the tumor (eg: UGI bleeding and ulceration)
Malignant symptoms
• Abdominal pain (15 - 60% )
• Weight loss (30 - 59%)
• Nausea and vomiting (25 - 30%)
• Jaundice (20 - 30%)
• GI bleeding (10 - 38%).
• A palpable abdominal mass < 5%.
Fagniez PL Et al
Laboratory studies
• FBC
• Renal and liver function
• Tumor markers
• Fecal-occult blood
Imaging
• CXR & AXR
• Barium swallow (1st part)
• Abdominal USS
• Esophagogastroduodenoscopy (+push enteroscopy)
• Colonoscopy
• CT and MRI with contrast
• ERCP
• Magnifying Endoscopy; narrow bind imaging (ME-NBI)
Tumor
markers
Likely
CEA Gastric
CA 19-9 Pancreatic
Calcitonin NET
C-KIT(CD117) GIST
LDH NHL
MUC5AC and MUC6 Gastric type
CDX2 and MUC2 Intestinal type
24hr-Urine
serotonin
carcinoind
Clinical-Pathology
• Biopsy
• Cytology
• IHC for phenotypes
• Genetic typing
Papillary: < 2cm from major papilla of
duodenum
Non-papillary: > 2cm and any location in
duodenum
Tumors are classified in relations to their
anatomical relation to the papilla because:
• Clinical symptoms
• Origin of tumors
• Staging of tumors
• Treatment approach
According to several studies, site, size, color, macroscopic type, and biopsy results are important
assessment indicators for endoscopic diagnosis.
Ampullary Tumors Primary
Duodenal
1. Ampullary
adenoma
2. Inflammatory
myofibroblastic
tumor
3. Gastrointestinal
stromal tumor
4. Duodenal
lipoma.
5. adenocarcinoma
Difficult staging
Can cause bile and pancreatic duct dilation, which is seen as the “double-duct sign”
The tumors of this region are named periampullary adenocarcinomas, but the histologic type of
these malignancies are an independent prognostic factors.
Clinico-pathologic types
Intestinal
• Tall
• Pseudostratified
• oval nuclei
• presence of mucin
Pancreatic-biliary(poor prognosis)
• Surrounded by a desmoplastic stroma
• Cuboidal to low columnar epithelium
• No pseudo stratification
• The round nuclei.
CK7
CK17
MUC1
CK20
CDX2
MUC2
Node category is one of the most powerful
predictors of survival
Lymphovascular invasion is a significant prognostic
factor.
Distant metastases are identified at onset in > 50% of cases
at diagnosis.
Superficial Non-ampullary Duodenal
Epithelial Tumors(SNADETs)
The prevalence of non- ampullary primary duodenal tumors is 0.02%-0.5% of GI
malignancies but Benign tumors are generally predominant.
Both benign adenoma and cancer arise most frequently in the second portion
of the duodenum, especially the periampullary area
Most of the lesions are detected incidentally by endoscopic examinations but
large lesions can cause obstructive symptoms or complaints related to tumor
progression and metastasis.
60% of SNADETs occur in patients with familial adenomatous polyposis (FAP) +
other genetic syndromes
• when detected in a patient, an extra colonoscopy is strongly recommended
Vienna Classification of Gastrointestinal Epithelial Neoplasia
A simple endoscopic scoring system for SNADETs
Kakushima N et al Endosc Int Open. 2017;5:E763. et al
Used to differentiate between VCL 3 and VCL 4 or higher SNADETs
A score ≥ 3 points indicated the histology of VCL 4 or higher, with sensitivity and
specificity of 88% and 86%
CDX2 and MUC2 markers
MUC5AC and MUC6 marker
Chen ZM et al Am J Surg Pathol. 2009;33:186
Gastric-type SNADETs show more aggressive
biological behavior than intestinal-type
SNADETs
Duodenal adenomas are the most common type of polyp
arising from the duodenum. They can occur within and outside
of genetic syndromes.
• Usually at 2nd and 3rd parts reflecting the exposure of
duodenal mucosa to bile acids
Histology- tubular 80-86% villous 5% tubulovillous(8-16%)
• Villous adenomas
• 15-25% malignant risk ( 40% > 4 cm in diameter)
• 30-50% of ampullaly Villous adenomas are malignant
• 20-25% of duodenal villous adenomas are malignant
(A) (B) Stage II. (C) Stage III. (D) Stage IV.
2. Lipoma
• The duodenum is the third most frequent site for lipomas
in the gastrointestinal tract, after the colon and ileum.
• Rare, being most common in elderly men.
• They are often asymptomatic, but > 4 cm in diameter can
cause symptoms such as abdominal pain, obstruction, or
gastrointestinal bleeding due to pressure,
intussusception, or ulceration
• CT is reliable in its diagnosis, showing a lesion with
smooth margins and typical negative Hounsfield values.
• A rounded submucosal well-circumscribed mass with homogeneous enhancement in the absence of other lesions or
metastases
• Rarely occur in duodenum
• No malignancy risk
• Calcification and ulceration are more often seen with larger tumors.
• Radiologic findings of leiomyoma are similar to other submucosal mesenchymal tumors being virtually impossible
to differentiate a leiomyoma from GIST based on cross-sectional imaging alone, particularly if necrosis and
ulceration are present.
• Gastrointestinal bleeding is the main presenting symptom.
3. Leiomyomas
4. Brunner’s gland hamartoma
• BGH represent about 5–10% of benign duodenal tumours1 and have an estimated incidence
of <0.01%.
• > 70% occurring in the proximal duodenum and a decreasing frequency occurring
throughout the rest of the duodenum.4
• Brunner’s glands are located in the submucosa of the duodenum. They secrete an alkaline
fluid containing mucin, which protects the mucosa from the acidic stomach contents
entering the duodenum
• It is suggested that hyperacidity or Helicobacter pylori may provoke proliferation of these
protective glands
• Brunner’s glands secrete urogastrone, which inhibits gastric acid secretion, and may have a
protective role against peptic ulcer development
It may be an incidental finding during an investigation but can also present acutely with hemorrhage or
obstruction
1- 8% of GIT tumors, about 90% of duodenal NETs are located in the first and second parts.
• 65% are G-cell tumors , and one-third are functional gastrinomas15% D-cell somatostatinomas,
which occur exclusively in and around the papilla of Vater
• nonfunctional serotonin-containing tumors (20%)
• poorly differentiated neuroendocrine carcinomas (< 3%)
• gangliocytic paragangliomas (< 2%).
5. Duodenal Neuroendocrine tumors
(D-NETs)
• Duodenal carcinoids have morphologic and functional similarities to pancreatic islet-cell tumors.
carcinoid syndrome features
Duodenal carcinoids represent less than 3% of
all carcinoid tumors; most are sporadic,
although they can also be associated with
clinical syndromes such as multiple endocrine
neoplasia type 1 (MEN-1) and
neurofibromatosis type 1 (NF-1)
Most carcinoid tumors are nonfunctional, so
they present as bowel obstruction, abdominal
pain, upper gastrointestinal bleeding, or when
periampullary, as jaundice.
Duodenal NETs rarely manifest with classic
carcinoid syndrome
Junction of
cystic and
CBD
Junction of head
and neck of
pancreas
Junction of
2nd and 3rd
parts of
duodenum
(Passaro’s)
ZES is a condition caused by
gastrin-producing NET that
causes gastric acid
hypersecretion and peptic
ulcer disease
• 1-2/million
• 60%malignant
• 75%sporadic
• M>F
• Average age 50yrs, 5-10yrs earlier
in MEN-1
• 25% MEN-1
• medical control of gastric
acid hypersecretion
• PPI
• surgical resection of the
tumor
• >2.5cm
Treatment
Duodenal lymphomas are non-Hodgkin T-cell lymphomas. Usually indolent, slow-growing
course, although up to 30% of cases can become aggressive
6. Duodenal lymphomas
Risk factors
• H-Pylori
• Acquired Immunodeficiency Syndrome
• Inflammatory Bowel Disease
• Immunosuppression After Solid Organ
Transplantation
• Systemic Lupus Erythematosus
• Chemotherapy
• Presence of splenomegaly and lymphadenopathy helps distinguishing it from Crohn’s
disease
• Gastric outlet obstruction is uncommon.
whitish multi-nodular mucosal lesions around the
major papilla, with a diameter of 0.1-0.5 cm
Segmental nodular wall thickening or a large eccentric mass extending into adjacent tissues are typical
(producing circumferential wall thickening and irregular “aneurysmal dilatation” of the bowel lumen)
• GISTs arise from the interstitial cells of Cajal, which
are pacemaker cells for peristalsis located within the
myenteric plexus.
• <5% of GISTs affect the duodenum
• Duodenal GISTs seem to have a better prognosis
than GISTs occurring in the stomach or other
small-bowel regions
D4
Esophagogastroduodenoscopy view of duodenal GIST
GISTs express the CD117 (c-kit) protein, a tyrosine kinase growth factor receptor which
distinguishes GISTs from less common mesenchymal neoplasms
The predominant symptoms are GIB or anemia and abdominal pain or
discomfort
European Society for Medical Oncology (ESMO) in 2010
The mainstay of resectable primary D-GIST is complete surgical
resection with an adequate margin en bloc without breaching the
pseudo-capsule.
8. Adenocarcinomas
80% to 90% of all primary malignant duodenal tumors.
high risk
• Men > 50yrs
• Hereditary Nonpolyposis Colorectal
Cancer,
• Peutz-jeghers Syndrome
• Familial Adenomatous Polyposis
Nonspecific symptoms: abdominal pain, weight loss, nausea, vomiting,
occult gastrointestinal bleeding, pruritus, jaundice, and gastric outlet
obstruction
Location
• distal portion (3rd and
4th parts): 45%
• second part: 40%
• first part: 15%
Histopathologic subtypes of duodenal adenocarcinoma
Adapted from Ushiku et al
Periampullary adenocarcinomas occur with 2 cm of the major duodenal papilla and can cause bile and
pancreatic duct dilation, which is seen as the “double-duct sign”
Growth patterns
Infiltrative: commonly associated with pancreatobiliary-type periampullary
tumors.
Polypoid: typically seen in intestinal-type periampullary tumors.
Surgical Approach
Either laparoscopic and/or open!
General principle
• The 2nd part and periampullary: Pancreaticoduodenectomy (PD).
• The 1st, 3rd or 4th parts: Either PD or segmental resection (SR)
Most studies that compared outcomes of two approaches found no statistically significant difference in outcomes,
Cloyd et al 2015
• Patient age
• Distant metastasis
• Lymph status( metastasis, node ratio,
#harvested)
• High tumor grade, tumor (T) stage
• Margin status
• Lymphovascular or perineural invasion
Node category is one of the most powerful predictors of survival, and lymphovascular invasion is a
significant prognostic factor.
Kaplan–Meyer survival curves
Pancreaticoduodenectomy (PD)
Criteria
• No distant metastasis
• No radiographic evidence of portal
vein (PV) or (SMV) distortion
• Clear dissection planes around the
celiac axis, hepatic artery, and SM)
• No aortic or IVC involvement
• No tumor abutment of SMA
Complications
•Delayed gastric emptying,
• Pancreatic fistula,
• Postpancreatectomy hemorrhage
• Wound infection
•Intra-abdominal abscess
Types
• The classical Whipple (CW)"
• The "pylorus sparing pancreatoduodenectomy (PSD)
Involves:
• distal gastrectomy with removal of the pancreatic head, duodenum, first 15
cm of the jejunum, common bile duct, and gallbladder
It decreases the incidence of
postoperative dumping, marginal
ulceration, and bile reflux gastritis
A modification of the conventional
procedure, preserves the gastric
antrum, pylorus, and the proximal 2 to 3
cm of the duodenum, which is
anastomosed to the jejunum to restore
gastrointestinal continuity
Pylorus-preserving PD
pancreas-preserving total duodenectomy
Indicated in non-ampullaly benign or premalignant conditions confined to the duodenal mucosa usually
familial adenomatous polyposis, commonly the infrapapillary duodenal
lesions.
Reconstruction is by
a retrocolic isoperistaltic side-to-side
duodenojejunostomy
Mitchell Wket al World J Gastroenterol 2017; 23(23): 4252-426
Palliative surgery
Goals
• Relief of gastric outlet obstruction
• Relief of biliary obstruction
• Pain relief
Roux-en-y hepaticojejunostomy.
• Fagniez PL, Rotman N. Malignant tumors of the duodenum. In: Holzheimer RG, Mannick JA, editors. Surgical
Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK6953/
• Domenech-Ximenos B, Juanpere S, Serra I, Codina J, Maroto A. Duodenal tumors on cross-sectional
imaging with emphasis on multidetector computed tomography: a pictorial review. Diagn Interv Radiol.
2020 May;26(3):193-199. doi: 10.5152/dir.2019.19241. PMID: 32209505; PMCID: PMC7239371.
• Mitchell WK, Thomas PF, Zaitoun AM, Brooks AJ, Lobo DN. Pancreas preserving distal duodenectomy: A
versatile operation for a range of infra-papillary pathologies. World J Gastroenterol 2017; 23(23): 4252-4261
[PMID: 28694665 DOI: 10.3748/wjg.v23.i23.4252]
• Nakagawa K, Sho M, Fujishiro M, Kakushima N, Horimatsu T, Okada KI, Iguchi M, Uraoka T, Kato M,
Yamamoto Y, Aoyama T, Akahori T, Eguchi H, Kanaji S, Kanetaka K, Kuroda S, Nagakawa Y, Nunobe S,
Higuchi R, Fujii T, Yamashita H, Yamada S, Narita Y, Honma Y, Muro K, Ushiku T, Ejima Y, Yamaue H, Kodera Y.
Clinical practice guidelines for duodenal cancer 2021. J Gastroenterol. 2022 Dec;57(12):927-941. doi:
10.1007/s00535-022-01919-y. Epub 2022 Oct 19. PMID: 36260172; PMCID: PMC9663352.
• Chen ZM, Scudiere JR, Abraham SC, Montgomery E. Pyloric gland adenoma:An entity distinct from gastric
foveolar type adenoma. Am J Surg Pathol. 2009;33:186. - [PubMed] [Google Scholar]
• http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC1728018&blobtype=pdf
• Cloyd JM, Norton JA, Visser BC, Poultsides GA. Does the extent of resection impact survival for duodenal
adenocarcinoma? Analysis of 1,611 cases. Ann Surg Oncol. 2015 Feb;22(2):573-80. doi: 10.1245/s10434-014-
4020-z. Epub 2014 Aug 27. PMID: 25160736.

More Related Content

Similar to Duodenal neoplasms.pdf

Neuroendocrinal tumor of stomach and duodenum
Neuroendocrinal tumor of stomach and duodenumNeuroendocrinal tumor of stomach and duodenum
Neuroendocrinal tumor of stomach and duodenumanirudha doshi
 
Carcinoma stomach seminar
Carcinoma stomach seminarCarcinoma stomach seminar
Carcinoma stomach seminarRushabh Shah
 
Git j club secondaries.
Git j club secondaries.Git j club secondaries.
Git j club secondaries.Shaikhani.
 
Carcinoma of the GI Tract
Carcinoma of the GI TractCarcinoma of the GI Tract
Carcinoma of the GI TractPatrick Carter
 
Tumor small intestine
Tumor small intestineTumor small intestine
Tumor small intestinekansal007
 
Carcinoma colon-and-management
Carcinoma colon-and-managementCarcinoma colon-and-management
Carcinoma colon-and-managementshiv kishor
 
4. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx77777777777777777777774. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx7777777777777777777777JamesAmaduKamara
 
4. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx77777777777777777777774. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx7777777777777777777777JamesAmaduKamara
 
GASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptx
GASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptxGASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptx
GASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptxSelvaraj Balasubramani
 
CARCINOMA STOMACH.pptx
CARCINOMA STOMACH.pptxCARCINOMA STOMACH.pptx
CARCINOMA STOMACH.pptxarunabhasinha2
 
Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...
Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...
Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...European School of Oncology
 
Intraductal Papillary Mucinous Neoplasm of Pancreas.pptx
Intraductal Papillary Mucinous Neoplasm of Pancreas.pptxIntraductal Papillary Mucinous Neoplasm of Pancreas.pptx
Intraductal Papillary Mucinous Neoplasm of Pancreas.pptxmasoom parwez
 
Pancreatic Cystic Neoplasm
Pancreatic Cystic NeoplasmPancreatic Cystic Neoplasm
Pancreatic Cystic NeoplasmKIST Surgery
 
Carcinoma of stomach
Carcinoma of stomach Carcinoma of stomach
Carcinoma of stomach Meena Reddy
 
Recent advances in pancreatic pathology
Recent advances in pancreatic pathology Recent advances in pancreatic pathology
Recent advances in pancreatic pathology Appy Akshay Agarwal
 

Similar to Duodenal neoplasms.pdf (20)

Neuroendocrinal tumor of stomach and duodenum
Neuroendocrinal tumor of stomach and duodenumNeuroendocrinal tumor of stomach and duodenum
Neuroendocrinal tumor of stomach and duodenum
 
Carcinoma stomach seminar
Carcinoma stomach seminarCarcinoma stomach seminar
Carcinoma stomach seminar
 
Git j club secondaries.
Git j club secondaries.Git j club secondaries.
Git j club secondaries.
 
Carcinoma of the GI Tract
Carcinoma of the GI TractCarcinoma of the GI Tract
Carcinoma of the GI Tract
 
Tumor small intestine
Tumor small intestineTumor small intestine
Tumor small intestine
 
Gastric carcinoma
Gastric carcinoma Gastric carcinoma
Gastric carcinoma
 
Ampullary carcinoma
Ampullary carcinomaAmpullary carcinoma
Ampullary carcinoma
 
Colorectal Cancer
Colorectal CancerColorectal Cancer
Colorectal Cancer
 
Carcinoma colon-and-management
Carcinoma colon-and-managementCarcinoma colon-and-management
Carcinoma colon-and-management
 
4. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx77777777777777777777774. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx7777777777777777777777
 
4. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx77777777777777777777774. Gastric Cancer.pptx7777777777777777777777
4. Gastric Cancer.pptx7777777777777777777777
 
GASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptx
GASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptxGASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptx
GASTRIC CARCINOMA- EPIGASTRIC LUMPS- Abdominal Lumps.pptx
 
Liver hemangiona
Liver hemangionaLiver hemangiona
Liver hemangiona
 
CARCINOMA STOMACH.pptx
CARCINOMA STOMACH.pptxCARCINOMA STOMACH.pptx
CARCINOMA STOMACH.pptx
 
Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...
Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...
Rare Solid Cancers: An Introduction - Slide 10 - V. Kataja - Rare urological ...
 
Intraductal Papillary Mucinous Neoplasm of Pancreas.pptx
Intraductal Papillary Mucinous Neoplasm of Pancreas.pptxIntraductal Papillary Mucinous Neoplasm of Pancreas.pptx
Intraductal Papillary Mucinous Neoplasm of Pancreas.pptx
 
Carcinoid tumor
Carcinoid tumorCarcinoid tumor
Carcinoid tumor
 
Pancreatic Cystic Neoplasm
Pancreatic Cystic NeoplasmPancreatic Cystic Neoplasm
Pancreatic Cystic Neoplasm
 
Carcinoma of stomach
Carcinoma of stomach Carcinoma of stomach
Carcinoma of stomach
 
Recent advances in pancreatic pathology
Recent advances in pancreatic pathology Recent advances in pancreatic pathology
Recent advances in pancreatic pathology
 

Recently uploaded

97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAAjennyeacort
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxDr.Nusrat Tariq
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...narwatsonia7
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxNiranjan Chavan
 
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...sonalikaur4
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbaisonalikaur4
 
Radiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptxRadiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptxDr. Dheeraj Kumar
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...rajnisinghkjn
 
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original PhotosBook Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photosnarwatsonia7
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsMedicoseAcademics
 
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxbkling
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknownarwatsonia7
 
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls ServiceCall Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Servicesonalikaur4
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.ANJALI
 
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...rajnisinghkjn
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingNehru place Escorts
 

Recently uploaded (20)

97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptx
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptx
 
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
 
Radiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptxRadiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptx
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
 
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original PhotosBook Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes Functions
 
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptx
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
 
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls ServiceCall Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.
 
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
 
Epilepsy
EpilepsyEpilepsy
Epilepsy
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
 

Duodenal neoplasms.pdf

  • 1. Dr. Tim Wiyule Mutafya COSECSA General surgery resident Kamuzu Central Hospital, Malawi
  • 3.
  • 4. Sympathetic • Vagus nerve • Greater splanchnic nerves T5-T9 along PD arteries Parasympathetic • celiac and superior mesenteric plexus
  • 5.
  • 6.
  • 9. Non modifiable Modifiable Age > 60 M > F Inherited conditions • familial adenomatous polyposis • Lynch syndrome • Peutz-Jeghers syndrome • cystic fibrosis • Gardner’s Syndrome Intestinal disease • Chrons disease • Celiac disease • H-pylori- duodenal ulcer • Smocking • Alcohol • Diet • Hypegastrineamia
  • 10.
  • 11. Duodenal tumors are rare, ranging from benign lesions that can be managed by endoscopic resections to adenocarcinoma that will require surgery. They are usually asymptomatic. 90% are benign They are usually incidental finding during endoscopic examination. Adenomatous polyps are the most common benign lesions Primary malignant tumors of the duodenum represent 0.3% of all GIT tumors but up to 50% of small bowel malignancies. • Primary malignant tumors of the duodenum must be differentiated from malignant tumors of the ampulla, pancreas and common bile duct. • The most frequent tumor of the duodenum is adenocarcinoma
  • 12. Benign Malignant Epithelial • Adenoma polyps (tubular, villous, tubulovillous) • Brunner’s Gland Adenoma Primary • Adenocarcinoma • Lymphomas • Duodenal GIST • Leiomyosarcomas • Carcinoid Tumors • Gastrinomas, • Stromal Tumors. Mesenchymal • Leiomyoma • Leiomyoblastoma • Lipoma • Fibroma • Neurogenic Secondary • Ampulla • Pancreas • Biliary tree Anatomical/clinicopathological groups • Ampullary • non- ampullary
  • 13. They remain asymptomatic for long periods of time. The non-specific symptoms depend on the tumor size, location and complications arising from the tumor (eg: UGI bleeding and ulceration) Malignant symptoms • Abdominal pain (15 - 60% ) • Weight loss (30 - 59%) • Nausea and vomiting (25 - 30%) • Jaundice (20 - 30%) • GI bleeding (10 - 38%). • A palpable abdominal mass < 5%. Fagniez PL Et al
  • 14. Laboratory studies • FBC • Renal and liver function • Tumor markers • Fecal-occult blood Imaging • CXR & AXR • Barium swallow (1st part) • Abdominal USS • Esophagogastroduodenoscopy (+push enteroscopy) • Colonoscopy • CT and MRI with contrast • ERCP • Magnifying Endoscopy; narrow bind imaging (ME-NBI) Tumor markers Likely CEA Gastric CA 19-9 Pancreatic Calcitonin NET C-KIT(CD117) GIST LDH NHL MUC5AC and MUC6 Gastric type CDX2 and MUC2 Intestinal type 24hr-Urine serotonin carcinoind Clinical-Pathology • Biopsy • Cytology • IHC for phenotypes • Genetic typing
  • 15. Papillary: < 2cm from major papilla of duodenum Non-papillary: > 2cm and any location in duodenum Tumors are classified in relations to their anatomical relation to the papilla because: • Clinical symptoms • Origin of tumors • Staging of tumors • Treatment approach According to several studies, site, size, color, macroscopic type, and biopsy results are important assessment indicators for endoscopic diagnosis.
  • 16. Ampullary Tumors Primary Duodenal 1. Ampullary adenoma 2. Inflammatory myofibroblastic tumor 3. Gastrointestinal stromal tumor 4. Duodenal lipoma. 5. adenocarcinoma Difficult staging Can cause bile and pancreatic duct dilation, which is seen as the “double-duct sign”
  • 17. The tumors of this region are named periampullary adenocarcinomas, but the histologic type of these malignancies are an independent prognostic factors. Clinico-pathologic types Intestinal • Tall • Pseudostratified • oval nuclei • presence of mucin Pancreatic-biliary(poor prognosis) • Surrounded by a desmoplastic stroma • Cuboidal to low columnar epithelium • No pseudo stratification • The round nuclei. CK7 CK17 MUC1 CK20 CDX2 MUC2
  • 18.
  • 19.
  • 20. Node category is one of the most powerful predictors of survival Lymphovascular invasion is a significant prognostic factor. Distant metastases are identified at onset in > 50% of cases at diagnosis.
  • 21. Superficial Non-ampullary Duodenal Epithelial Tumors(SNADETs) The prevalence of non- ampullary primary duodenal tumors is 0.02%-0.5% of GI malignancies but Benign tumors are generally predominant. Both benign adenoma and cancer arise most frequently in the second portion of the duodenum, especially the periampullary area Most of the lesions are detected incidentally by endoscopic examinations but large lesions can cause obstructive symptoms or complaints related to tumor progression and metastasis. 60% of SNADETs occur in patients with familial adenomatous polyposis (FAP) + other genetic syndromes • when detected in a patient, an extra colonoscopy is strongly recommended
  • 22.
  • 23. Vienna Classification of Gastrointestinal Epithelial Neoplasia
  • 24. A simple endoscopic scoring system for SNADETs Kakushima N et al Endosc Int Open. 2017;5:E763. et al Used to differentiate between VCL 3 and VCL 4 or higher SNADETs A score ≥ 3 points indicated the histology of VCL 4 or higher, with sensitivity and specificity of 88% and 86%
  • 25. CDX2 and MUC2 markers MUC5AC and MUC6 marker Chen ZM et al Am J Surg Pathol. 2009;33:186 Gastric-type SNADETs show more aggressive biological behavior than intestinal-type SNADETs
  • 26. Duodenal adenomas are the most common type of polyp arising from the duodenum. They can occur within and outside of genetic syndromes. • Usually at 2nd and 3rd parts reflecting the exposure of duodenal mucosa to bile acids Histology- tubular 80-86% villous 5% tubulovillous(8-16%) • Villous adenomas • 15-25% malignant risk ( 40% > 4 cm in diameter) • 30-50% of ampullaly Villous adenomas are malignant • 20-25% of duodenal villous adenomas are malignant
  • 27. (A) (B) Stage II. (C) Stage III. (D) Stage IV.
  • 28. 2. Lipoma • The duodenum is the third most frequent site for lipomas in the gastrointestinal tract, after the colon and ileum. • Rare, being most common in elderly men. • They are often asymptomatic, but > 4 cm in diameter can cause symptoms such as abdominal pain, obstruction, or gastrointestinal bleeding due to pressure, intussusception, or ulceration • CT is reliable in its diagnosis, showing a lesion with smooth margins and typical negative Hounsfield values.
  • 29. • A rounded submucosal well-circumscribed mass with homogeneous enhancement in the absence of other lesions or metastases • Rarely occur in duodenum • No malignancy risk • Calcification and ulceration are more often seen with larger tumors. • Radiologic findings of leiomyoma are similar to other submucosal mesenchymal tumors being virtually impossible to differentiate a leiomyoma from GIST based on cross-sectional imaging alone, particularly if necrosis and ulceration are present. • Gastrointestinal bleeding is the main presenting symptom. 3. Leiomyomas
  • 30.
  • 31. 4. Brunner’s gland hamartoma • BGH represent about 5–10% of benign duodenal tumours1 and have an estimated incidence of <0.01%. • > 70% occurring in the proximal duodenum and a decreasing frequency occurring throughout the rest of the duodenum.4 • Brunner’s glands are located in the submucosa of the duodenum. They secrete an alkaline fluid containing mucin, which protects the mucosa from the acidic stomach contents entering the duodenum • It is suggested that hyperacidity or Helicobacter pylori may provoke proliferation of these protective glands • Brunner’s glands secrete urogastrone, which inhibits gastric acid secretion, and may have a protective role against peptic ulcer development
  • 32. It may be an incidental finding during an investigation but can also present acutely with hemorrhage or obstruction
  • 33. 1- 8% of GIT tumors, about 90% of duodenal NETs are located in the first and second parts. • 65% are G-cell tumors , and one-third are functional gastrinomas15% D-cell somatostatinomas, which occur exclusively in and around the papilla of Vater • nonfunctional serotonin-containing tumors (20%) • poorly differentiated neuroendocrine carcinomas (< 3%) • gangliocytic paragangliomas (< 2%). 5. Duodenal Neuroendocrine tumors (D-NETs) • Duodenal carcinoids have morphologic and functional similarities to pancreatic islet-cell tumors.
  • 34. carcinoid syndrome features Duodenal carcinoids represent less than 3% of all carcinoid tumors; most are sporadic, although they can also be associated with clinical syndromes such as multiple endocrine neoplasia type 1 (MEN-1) and neurofibromatosis type 1 (NF-1) Most carcinoid tumors are nonfunctional, so they present as bowel obstruction, abdominal pain, upper gastrointestinal bleeding, or when periampullary, as jaundice. Duodenal NETs rarely manifest with classic carcinoid syndrome
  • 35. Junction of cystic and CBD Junction of head and neck of pancreas Junction of 2nd and 3rd parts of duodenum (Passaro’s) ZES is a condition caused by gastrin-producing NET that causes gastric acid hypersecretion and peptic ulcer disease • 1-2/million • 60%malignant • 75%sporadic • M>F • Average age 50yrs, 5-10yrs earlier in MEN-1 • 25% MEN-1
  • 36.
  • 37. • medical control of gastric acid hypersecretion • PPI • surgical resection of the tumor • >2.5cm Treatment
  • 38. Duodenal lymphomas are non-Hodgkin T-cell lymphomas. Usually indolent, slow-growing course, although up to 30% of cases can become aggressive 6. Duodenal lymphomas Risk factors • H-Pylori • Acquired Immunodeficiency Syndrome • Inflammatory Bowel Disease • Immunosuppression After Solid Organ Transplantation • Systemic Lupus Erythematosus • Chemotherapy • Presence of splenomegaly and lymphadenopathy helps distinguishing it from Crohn’s disease • Gastric outlet obstruction is uncommon. whitish multi-nodular mucosal lesions around the major papilla, with a diameter of 0.1-0.5 cm
  • 39. Segmental nodular wall thickening or a large eccentric mass extending into adjacent tissues are typical (producing circumferential wall thickening and irregular “aneurysmal dilatation” of the bowel lumen)
  • 40. • GISTs arise from the interstitial cells of Cajal, which are pacemaker cells for peristalsis located within the myenteric plexus. • <5% of GISTs affect the duodenum • Duodenal GISTs seem to have a better prognosis than GISTs occurring in the stomach or other small-bowel regions D4
  • 42. GISTs express the CD117 (c-kit) protein, a tyrosine kinase growth factor receptor which distinguishes GISTs from less common mesenchymal neoplasms
  • 43. The predominant symptoms are GIB or anemia and abdominal pain or discomfort
  • 44. European Society for Medical Oncology (ESMO) in 2010 The mainstay of resectable primary D-GIST is complete surgical resection with an adequate margin en bloc without breaching the pseudo-capsule.
  • 45. 8. Adenocarcinomas 80% to 90% of all primary malignant duodenal tumors. high risk • Men > 50yrs • Hereditary Nonpolyposis Colorectal Cancer, • Peutz-jeghers Syndrome • Familial Adenomatous Polyposis Nonspecific symptoms: abdominal pain, weight loss, nausea, vomiting, occult gastrointestinal bleeding, pruritus, jaundice, and gastric outlet obstruction Location • distal portion (3rd and 4th parts): 45% • second part: 40% • first part: 15%
  • 46.
  • 47. Histopathologic subtypes of duodenal adenocarcinoma Adapted from Ushiku et al
  • 48. Periampullary adenocarcinomas occur with 2 cm of the major duodenal papilla and can cause bile and pancreatic duct dilation, which is seen as the “double-duct sign” Growth patterns Infiltrative: commonly associated with pancreatobiliary-type periampullary tumors. Polypoid: typically seen in intestinal-type periampullary tumors.
  • 50. General principle • The 2nd part and periampullary: Pancreaticoduodenectomy (PD). • The 1st, 3rd or 4th parts: Either PD or segmental resection (SR) Most studies that compared outcomes of two approaches found no statistically significant difference in outcomes, Cloyd et al 2015
  • 51. • Patient age • Distant metastasis • Lymph status( metastasis, node ratio, #harvested) • High tumor grade, tumor (T) stage • Margin status • Lymphovascular or perineural invasion
  • 52. Node category is one of the most powerful predictors of survival, and lymphovascular invasion is a significant prognostic factor. Kaplan–Meyer survival curves
  • 53.
  • 54.
  • 55. Pancreaticoduodenectomy (PD) Criteria • No distant metastasis • No radiographic evidence of portal vein (PV) or (SMV) distortion • Clear dissection planes around the celiac axis, hepatic artery, and SM) • No aortic or IVC involvement • No tumor abutment of SMA Complications •Delayed gastric emptying, • Pancreatic fistula, • Postpancreatectomy hemorrhage • Wound infection •Intra-abdominal abscess Types • The classical Whipple (CW)" • The "pylorus sparing pancreatoduodenectomy (PSD)
  • 56. Involves: • distal gastrectomy with removal of the pancreatic head, duodenum, first 15 cm of the jejunum, common bile duct, and gallbladder
  • 57. It decreases the incidence of postoperative dumping, marginal ulceration, and bile reflux gastritis A modification of the conventional procedure, preserves the gastric antrum, pylorus, and the proximal 2 to 3 cm of the duodenum, which is anastomosed to the jejunum to restore gastrointestinal continuity Pylorus-preserving PD
  • 58. pancreas-preserving total duodenectomy Indicated in non-ampullaly benign or premalignant conditions confined to the duodenal mucosa usually familial adenomatous polyposis, commonly the infrapapillary duodenal lesions. Reconstruction is by a retrocolic isoperistaltic side-to-side duodenojejunostomy Mitchell Wket al World J Gastroenterol 2017; 23(23): 4252-426
  • 59. Palliative surgery Goals • Relief of gastric outlet obstruction • Relief of biliary obstruction • Pain relief Roux-en-y hepaticojejunostomy.
  • 60.
  • 61. • Fagniez PL, Rotman N. Malignant tumors of the duodenum. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6953/ • Domenech-Ximenos B, Juanpere S, Serra I, Codina J, Maroto A. Duodenal tumors on cross-sectional imaging with emphasis on multidetector computed tomography: a pictorial review. Diagn Interv Radiol. 2020 May;26(3):193-199. doi: 10.5152/dir.2019.19241. PMID: 32209505; PMCID: PMC7239371. • Mitchell WK, Thomas PF, Zaitoun AM, Brooks AJ, Lobo DN. Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies. World J Gastroenterol 2017; 23(23): 4252-4261 [PMID: 28694665 DOI: 10.3748/wjg.v23.i23.4252] • Nakagawa K, Sho M, Fujishiro M, Kakushima N, Horimatsu T, Okada KI, Iguchi M, Uraoka T, Kato M, Yamamoto Y, Aoyama T, Akahori T, Eguchi H, Kanaji S, Kanetaka K, Kuroda S, Nagakawa Y, Nunobe S, Higuchi R, Fujii T, Yamashita H, Yamada S, Narita Y, Honma Y, Muro K, Ushiku T, Ejima Y, Yamaue H, Kodera Y. Clinical practice guidelines for duodenal cancer 2021. J Gastroenterol. 2022 Dec;57(12):927-941. doi: 10.1007/s00535-022-01919-y. Epub 2022 Oct 19. PMID: 36260172; PMCID: PMC9663352. • Chen ZM, Scudiere JR, Abraham SC, Montgomery E. Pyloric gland adenoma:An entity distinct from gastric foveolar type adenoma. Am J Surg Pathol. 2009;33:186. - [PubMed] [Google Scholar] • http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC1728018&blobtype=pdf • Cloyd JM, Norton JA, Visser BC, Poultsides GA. Does the extent of resection impact survival for duodenal adenocarcinoma? Analysis of 1,611 cases. Ann Surg Oncol. 2015 Feb;22(2):573-80. doi: 10.1245/s10434-014- 4020-z. Epub 2014 Aug 27. PMID: 25160736.