Function-Preserving Laparoscopic Local Resection of Duodenal Papillary Adenomas

Summary

The present protocol describes a function-preserving laparoscopic resection technique with preoperative pancreatic and biliary stenting for duodenal papillary adenomas unsuitable for endoscopic removal. This approach ensures complete tumor excision, preserves duodenal function, minimizes complications, and achieves favorable postoperative outcomes in patients with a complex tumor presentation.

Abstract

Duodenal papillary adenomas, although rare, have significant potential for malignant transformation, necessitating precise intervention. Current surgical options for treating duodenal papillary adenomas include pancreaticoduodenectomy, endoscopic resection, and function-preserving laparoscopic resection. Although traditional pancreaticoduodenectomy has undergone substantial advancements in recent decades, it still carries a high risk of perioperative complications and mortality, making it a less preferred choice. Endoscopic resection is suitable for smaller tumors; however, it presents limitations when applied to larger tumors, potentially resulting in serious complications such as bleeding and perforation. In contrast, function-preserving laparoscopic resection of duodenal papillary tumors reduces the need for extensive organ resection or digestive tract reconstruction, thereby lowering surgical risks and better preserving digestive function. By combining preoperative placement of pancreatic duct and biliary stents with function-preserving laparoscopic resection, duodenal papillary adenomas not amenable to endoscopic removal were successfully resected without significant perioperative complications. The main procedures included preoperative placement of pancreatic duct and biliary stents; intraoperative mobilization of the descending duodenum through Kocherization; longitudinal incision of the anterolateral duodenal wall; incision along tumor margins to expose mucosal and submucosal layers; complete tumor resection along its base; and repair and reconstruction of the duodenal papilla and wall. Postoperative follow-up indicated good recovery and patient satisfaction. These findings suggest that function-preserving laparoscopic resection is a safe and feasible option for selected duodenal papillary adenomas.

Introduction

Duodenal papillary adenoma is a rare benign tumor. With the widespread adoption of endoscopic screening, the detection rate of duodenal papillary adenomas has increased in recent years. Duodenal papillary adenoma often presents with nonspecific symptoms in the early stages¹. As a precancerous tumor, it has the potential to progress to adenocarcinoma, posing significant challenges to patient treatment and survival.

Tumor resection remains the most effective treatment option. Currently, available surgical options include pancreaticoduodenectomy (PD), function-preserving local resection (LR), and endoscopic resection (ER) of duodenal papillary adenoma². Traditional PD is complicated and highly invasive, with the highest risk of perioperative complications and mortality³. With advancements in minimally invasive techniques and function-preserving concepts, the less invasive LR of tumors has become possible⁴. This procedure integrates the benefits of surgical resection with a simplified surgical procedure that significantly reduces the risk of surgical complications and loss of function; in addition, it can be converted to PD if malignant lesions are detected. ER is the least invasive option and has advanced rapidly in recent years, with continually expanding indications. Although ER is comparable to surgery in terms of overall survival, it is associated with a higher rate of incomplete resection and postoperative recurrence. For ER, LR, and PD, the pooled R0 resection rates were 76.6%, 96.4%, and 98.9%, respectively; adverse events were 24.7%, 28.3%, and 44.7%; and recurrence rates were 13.0%, 9.4%, and 14.2%, respectively^5,6.

Current evidence suggests that ER is the preferred option if an R0 resection can be achieved. If this is not feasible, the LR option should be considered. However, PD is recommended for patients with adenocarcinoma (AC) beyond the pT1a N0 stage⁷. Although ER is frequently chosen as the primary treatment, further research is needed to identify the most suitable cases compared with those of LR. Especially for patients with larger tumors (>3 cm) or central duodenal involvement, ER is less effective, often requiring multiple procedures and posing significant risks of serious complications such as bleeding and perforation⁸. In this situation, LR may be more appropriate because of its inherent advantages: organ/function preservation (avoiding PD morbidity), minimally invasive nature (laparoscopic benefits), and utilization of established surgical principles familiar to hepatopancreatobiliary surgeons. These characteristics increase its accessibility and generalizability in clinical practice^9,10,11. Nevertheless, relevant reports remain limited. This is partly attributable to the anatomical complexity of the duodenal ampulla and partly due to the technical challenges associated with the procedure.

This article reports how duodenal papillary adenomas that are not feasible to remove endoscopically can be resected laparoscopically at this center. The procedure commenced with the preoperative placement of the pancreatic duct and biliary stents. After adequate mobilization of the descending portion of the duodenum with kocherization¹², longitudinal duodenotomy was performed to localize the tumor and the duodenal papilla. After the complete resection of the tumor along its base, the duodenal papilla and duodenal wall were repaired and reconstructed. The primary objective of this procedure is to preserve the function of the duodenal papilla while completely excising the tumor. In addition, it helps minimize surgical trauma and enhances surgical safety.

The patient, a 52-year-old female, was admitted to the Department of Gastroenterology due to recurrent chest tightness and pain lasting for over a year. A preadmission gastroscopy revealed a duodenal papillary mass measuring approximately 3 cm x 2 cm, characterized by a rough surface. Biopsy pathology revealed a low-grade adenoma. The patient had a history of breast cancer, and was treated with surgery, radiotherapy, and chemotherapy ten years prior. A physical examination revealed no apparent positive signs. Preoperatively, the patient's CA19-9, CA-125, and CEA levels and liver and kidney function test results were within the normal range. A CT and MRI scan revealed a nodular mass in the duodenal papilla region, which exhibited homogeneous enhancement on contrast imaging. MRI revealed that the sizes of the prepapillary common bile duct and pancreatic main duct were 5 mm and 3 mm, respectively. The patient first underwent an endoscopic resection on February 20, 2024. During the procedure, the mass was observed to extend significantly below the duodenal papilla, with its lower portion reaching the horizontal segment of the duodenum. This complication makes endoscopic resection challenging and increases the risk of bleeding and perforation. The endoscopic method was unsuccessful in removing the tumor. The patient was subsequently transferred to the department for surgical resection of the tumor. Preoperative placement of the pancreatic duct and biliary stents was performed on February 23, 2024. Laparoscopic resection with reconstruction of the duodenal papilla was performed on February 26, 2024. Postoperative pathology confirmed the presence of villous tubular adenoma with focal high-grade intraepithelial neoplasia (occupying approximately 25%-30% of the tumor volume) and excluded adenocarcinoma in the adenoma (Figure 1). The patients recovered without complications, and their pancreatic duct and biliary stents were removed 30 days after the operation.

Protocol

The operation was routine and conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Meizhou People's Hospital. Informed consent was obtained from the patient's authorized representatives. Details of the reagents and equipment used are listed in the Table of Materials.

1. Patient selection

1. Apply the following inclusion criteria: benign duodenal papillary adenomas, adenomas exhibiting local malignancy without lymph node metastasis, and patients unable to tolerate pancreaticoduodenectomy.
2. Apply the following exclusion criteria: advanced malignant tumors with potential lymph node metastasis and diffuse duodenal ulcers.

2. Preoperative preparation, operative position, and anesthesia

1. Instruct patients to abstain from food for 6 h and refrain from consuming any liquids for 2 h before surgery. Ensure adherence to preoperative protocols, including fasting, stent placement, and imaging assessments. Confirm compliance through regular clinical evaluations and patient-reported adherence.
2. Place the patient in a supine position with the head elevated and tilted 30 degrees to the left. The primary surgeon should be on the right side of the patient.
3. Perform endotracheal intubation and general anesthesia¹³(following institutionally approved protocols). After completing the necessary assessments, administer sedatives, followed by general anesthesia.
   1. Once unconscious, use a laryngoscope to insert an endotracheal tube through the mouth and into the trachea. Connect the tube to a ventilator to assist with breathing. Monitor anesthetic effects and depth of anesthesia by assessing the level of consciousness and vital signs.

3. Surgical procedure

1. Review CT and MRI scans to evaluate the location and adjacent anatomical relationships.
2. Make a vertical 1.5 cm incision below the navel using a scalpel. Establish pneumoperitoneum with a Veress needle. Once pneumoperitoneum is achieved, insert a 12 mm trocar and introduce the laparoscope.
3. Place four additional trocars in the following positions: a 5 mm trocar in the right anterior axillary line, a 5 mm trocar in the left anterior axillary line, a 12 mm trocar in the right midclavicular line at the level of the umbilicus, and a 12 mm trocar in the left midclavicular line at the level of the umbilicus (see Figure 2).
4. Examine the intraperitoneal organs and peritoneal surface, confirming the absence of significant adhesions and masses.
5. Use an ultrasonic knife combined with an electrocautery hook to perform Kocherization 12 to expose the pancreatic head and the second and third parts of the duodenum. Confirm that no tumors are present on the serosa of the duodenum.
   NOTE: Observe complete exposure of the anterior surface of the inferior vena cava and left renal vein, confirming adequate mobilization for tension-free anastomosis.
6. Create a unilateral suture using 3-0 antimicrobial sutures in the seromuscular layer. Retract the duodenum to the patient's left side.
7. Perform a longitudinal duodenotomy approximately 2.5 cm in length using tissue scissors in the mid-portion of the descending duodenum.
   1. Identify the ampulla of Vater by locating the emergence points of the pancreatic duct/biliary stents within the intestinal lumen (visible as protruding stent tips surrounded by concentric mucosal folds).
   2. Identify the exophytic gray-white broad-based soft tumor protruding into the intestinal lumen.
   3. Confirm the positions of the biliary stent and pancreatic duct stent by: (1) visualizing stent tips protruding from the papillary orifices at 11-1 o'clock (bile duct) and 5 o'clock (pancreatic duct), surrounded by concentric mucosal folds; (2) applying gentle traction to observe resistance-free retraction (<5 mm), followed by spontaneous repositioning, indicating secure anchoring without migration.
8. Resect the duodenal tumor by dissecting it in the submucosal plane using an ultrasonic knife combined with an electrocautery hook at 3 o'clock, continuing until the ampulla of Vater is reached (Figure 3).
   NOTE: When the inferior tumor margin is adjacent to the ampulla of Vater, retract the pancreatic duct stent to fully expose the tumor base while avoiding direct contact with the sphincter complex. During the procedure, gentle traction is applied to the biliary stent to dynamically confirm the CBD opening position, ensuring the preservation of anatomical integrity.
9. Send the resected tumor for frozen section pathological examination immediately to exclude malignancy and confirm clear resection margins.
10. Suture and reconstruct the ampulla of Vater using interrupted sutures with 5-0 absorbable antimicrobial sutures (Figure 4).
    1. Alternately retract the pancreatic and biliary stents to clearly expose the openings of the common bile duct (CBD) and main pancreatic duct (MPD). Perform layered closure and separately suture the mucosal and muscular layers to ensure precise ductal orifice alignment without stenosis.
       NOTE: Ensure ductal mucosa-to-duodenal mucosa coaptation under 3× laparoscopic magnification by visualizing: (1) bile flow from the CBD stent orifice upon gentle liver compression; (2) clear pancreatic juice secretion from the MPD orifice. Test patency via stent irrigation without resistance.
11. Insert a nasogastric tube for postoperative nutritional support.
    NOTE: If nasogastric tube placement is unsuccessful, use an endoscope for assistance.
12. Suture the duodenum using interrupted, two-layer techniques with 3-0 absorbable sutures.
13. Rinse the abdominal cavity with saline. Place a drain in the foramen of Winslow. Close the incision with sutures and terminate the operation.

4. Postoperative management

1. Administer low-flow oxygen following the operation.
2. Maintain fasting and provide parenteral nutrition. Initiate a liquid diet on the seventh postoperative day, and gradually transition to a regular diet. Provide guidance on turning and exercising in bed starting on the first postoperative day.
3. Administer octreotide, inhibit gastric acid secretion, provide antibiotics, ensure hemostatic treatment, administer analgesics, and deliver albumin therapy.
4. Monitor plasma bilirubin and amylase levels on the 2^nd, 4^th, and 8^th postoperative days.

Results

The operation was completed in 320 min with 20 mL of intraoperative hemorrhage without the need for a perioperative transfusion. The preoperatively placed pancreatic and bile ducts provided excellent guidance for the localization and reconstruction of the duodenal papilla during the operation. There were no significant short-term complications, including severe pancreatitis, cholangitis, abdominal infections, or leakage from the pancreas or bile ducts. The patient initiated nasogastric feeding with a glucose-saline solut...

Discussion

Currently, the use of PD in treating duodenal adenomas is gradually declining, with ER or LR becoming the preferred treatment option^14,15. These procedures theoretically facilitate a more minimally invasive and safer removal of tumors while preserving the function of the duodenal papilla. However, inappropriate selection of indications may result in disastrous outcomes for patients, including severe postoperative complications such as perforation or bleeding, the...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Biliary stent	Boston Scientific	M00539260
Dissecting forceps	KANGJI	ZP485RB 330mm×Φ5
Drainage tube	Kang-Li	QH-F28
Duodenoscope	Olympus Medical Europa	TJF-260V
Endoscope	Olympus Medical Europa	CHF-BP260
Grasping forceps	KANGJI	ZP531RB 330mm×Φ5
Guidewire	Boston Scientific	M0055614
Hurricane RX Biliary Balloon Dilatation Catheter	Boston Scientific	M00535900
Laparoscope	OptoMedic	OPTO-CA214K
Laparoscope	Flocare	CH10-130
Normal Saline 3000 mL	Ke-Lun	3000ml:27g
Pancreatic stent	Cook Medical	SPSOF-5-7
Suction and Irrigation	KANGJI	Φ5/Φ10×330mm
Suture	ETHICON	VCP784D
Suture	ETHICON	5-0 PDS VIOLET 1x30" (75cm) RB-2 DA
Ultrasonic knife	An-He	AH-600