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35. Probst A, Freund S, Neuhaus L, etal. Complication risk despite preventive endoscopic measures in patients undergoing endoscopic mucosal resection of large duodenal adenomas.
Endoscopy. 2020;52(10):847–55. https://doi.org/10.1055/a- 1144- 2767.
36. Spadaccini M, Fugazza A, Frazzoni L, etal. Endoscopic papillectomy for neoplastic ampullary lesions: a systematic review with pooled analysis. United European Gastroenterol
J. 2020;8(1):44–51. https://doi.org/10.1177/2050640619868367.
37. Tianle M, Jang EJ, Zukerberg LR, etal. Recurrences are common after endoscopic ampullectomy for adenoma in the FAP syndrome. Surg Endosc. 2014;28(8):2349.
C. Vozzo and A. Faulx
Chapter 13
Surgical: Transduodenal Resection (Open
vs Minimally Invasive)
AnnPolcari, AramRojas, andMelissaE.Hogg
Introduction
The duodenum is the most common location of small intestinal tumors [1]. Lesions
in the duodenum pose a challenge for the surgeon, given the complex anatomic relation to the pancreas, liver, and biliary system (Fig.13.1). Choosing a method for
resection of a duodenal lesion is nuanced; it requires an understanding of the tumor’s
biology, location within the duodenum, size, and proximity to the ampulla of Vater.
Distinguishing between benign and malignant lesions and the likelihood for lymph
node involvement is key for decision-making, as malignant adenocarcinomas
require a pancreatoduodenectomy (Whipple procedure) due to the high risk of
lymph node metastasis. Benign lesions, pre-malignant lesions, small neoplastic
lesions with low likelihood of lymph node metastasis, and low-grade tumors that do
not metastasize to lymph nodes, on the other hand, are often amenable to less extensive and thus less invasive operations in experienced hands.
Of note, there are no evidence-based consensus guidelines regarding the role of
transduodenal resections for masses of the duodenum. It is widely accepted that
benign lesions of the duodenum, especially ampullary tumors, should be resected to
avoid obstruction. However, the operations are technically challenging and thus
require an experienced surgeon. Halsted was the rst to describe the open
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 78409- 5_13.
A. Polcari
University of Chicago, Chicago, IL, USA
A. Rojas · M. E. Hogg (
NorthShore University HealthSystem, Evanston, IL, USA
e-mail: MHogg@Northshore.org
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_13
*)
203© The Author(s), under exclusive license to Springer Nature
204
Fig. 13.1 Pancreas
anatomy and relations
A. Polcari et al.
transduodenal ampullectomy (TDA) in 1899, but the procedure was largely abandoned as the pancreatoduodenectomy became the gold standard for resecting duodenal and ampullary cancers [2]. Transduodenal resections remained appealing for
benign lesions, given the morbidity associated with the Whipple procedure, but
existed as a primarily open operative technique. Though attempted laparoscopically
in 2003, the lack of articulating instruments and 2D visualization associated with
laparoscopic surgery limited the uptake of the minimally invasive technique [3].
More recently, the advancement of minimally invasive procedures for gastroenterologists and surgeons, alike, has changed the landscape for resection of duodenal
tumors. Advanced endoscopy is now an accepted tool for resecting small, supercial duodenal tumors. Robotic-assisted surgery has enabled increased opportunity
of minimally invasive approaches for transduodenal resection of ampullary and
duodenal masses. The rst robotic-assisted transduodenal ampullectomy was successfully completed in 2015 and has since become a widely accepted approach to
resecting amenable benign duodenal lesions; exibility of the instruments and
improved ergonomics for the surgeon make the robotic approach more enticing [3].
Of course, every surgeon should know when to choose the appropriate technique—whether endoscopic, open, minimally invasive, or a hybrid—in addition to
considering the full spectrum of procedures—from mucosal resections to the
Whipple procedure—based on tumor characteristics and individual patient factors.
In this chapter, we will focus on the management of duodenal tumors amenable to
transduodenal resection. We will discuss both the technique for transduodenal
wedge resections and surgical ampullectomy.
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
205
Duodenal Masses Amenable toTransduodenal Surgery
The lesions typically considered for transduodenal resection are nonadenocarcinomas. Incidence of these tumors has been growing, likely due to the
increased use of endoscopy to assess upper gastrointestinal symptoms. On these
exams, hyperplastic polyps are frequently found, but are usually small and amenable to endoscopic resection.
Benign Tumors
There are several mesenchymal-derived benign tumors found in the duodenal submucosa, which can be excised via a transduodenal approach. Leiomyomas, derived
from smooth muscle layers within the bowel wall, are often discovered during
workup for anemia in middle-aged men—ulceration of the tumor’s overlying
mucous membrane can cause bleeding [1]. These tumors should be biopsied to rule
out leiomyosarcoma, which is malignant and when small is amenable to transduodenal resection. Lipomas, which arise from the fatty submucosa of the small bowel
wall, are also found in the duodenum. Lipomas are typically initially asymptomatic
and are usually discovered after progressing to duodenal obstruction [1]. A welldened mass of blood vessels found in the submucosa of the duodenum is the hemangioma. As one might assume, hemangiomas can cause signicant bleeding, which
ultimately leads to their diagnosis [1]. Lymphangiomas have been described, as
well, though these tumors are rare. A host of neuron-derived tumors can also exist
in the duodenum’s wall and require resection, including neurobromas (most common), schwannomas, and gangliomas.
Genetic Syndromes
Patients with familial adenomatous polyposis (FAP) syndrome and Peutz-Jeghers
disease often develop polyps in the duodenum. Patients with FAP typically develop
adenomas found in the more distal duodenum; these patients require regular surveillance as these polyps can lead to cancer [1]. The hamartomas developed in PeutzJeghers disease are usually benign and the duodenum is a rare location for these
lesions [1]. Given small bowel lesions occur early in life in patients with these
genetic conditions, young adults with duodenal polyps or tumors should be further
evaluated specically for these syndromes.
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A. Polcari et al.
Pre-Malignant Tumors
The most common benign tumor found in the duodenum are adenomas, typically
located in D2 and therefore amenable to transduodenal resection. Adenomas are
derived from the epithelium. They are categorized as serrated, tubular, tubulovillous, and villous. These tumors can be sporadic, occur in inherited polyposis syndromes, or are derived from Brunner’s glands. Adenomas have been proven to
progress to cancer, so early excision is paramount. Large adenomas, especially,
should be considered for removal via transduodenal resection, as endoscopic biopsy
often misses portions of the polyp containing carcinoma in situ. Transduodenal
resection is accepted for adenomas that display carcinoma in situ on biopsy.
Low-Grade Malignancies
Gastrointestinal stromal tumors (GISTs), which arise from the interstitial cells of
Cajal and are distinguished by c-kit mutations, can also grow intramurally and
obstruct the duodenal lumen or ulcerate through the mucosa and bleed; surgical
resection is required for these tumors [4]. It is well accepted that GISTs can be
removed via transduodenal surgical techniques, both wedge resection and ampullectomy (Supplementary Videos 13.1 and 13.2).
Another rare duodenal tumor requiring resection and potentially amenable to
transduodenal resection is a neuroendocrine tumor (NET). These comprise <3% of
all duodenal tumors but are increasingly found as abdominal imaging modalities
improve. NETs can be aggressive tumors; however, small (<2cm), well- differentiated
Grade 1 periampullary NETs without evidence of lymph node metastasis can be
resected via transduodenal resection.
Please refer to Chap. 11 for more in-depth discussion on benign, pre-malignant,
and malignant duodenal neoplasms.
Indications forTransduodenal Resection
Alternatives
Adenocarcinomas of the duodenum are straightforward—tumors with biopsy or
imaging-proven disease greater than Tis (carcinoma in situ) require a pancreatoduodenectomy. This is largely driven by the possibility of upstaging on nal pathology,
especially given the high risk of lymph node invasion. Please refer to Chaps. 19, 20,
and 21 for in-depth review of open, laparoscopic, and robotic
pancreatoduodenectomy.
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
207
Resection of other duodenal masses, on the other hand, is less cut-and-dry due to
the variety of local excision techniques available. Duodenal masses of the descending portion of the duodenum (D2) are most often amenable to endoscopic and transduodenal approaches. Please refer to Chap. 12 for a more in-depth review of
endoscopic duodenal resection. Non-cancerous and some cancerous lesions of the
proximal duodenal segment (D1) and those that are infra-ampullary (in D3 and D4)
typically require a more extensive resection such as the partial sleeve duodenectomy
(PSD) [5]. This operation, like transduodenal approaches, can be completed open,
laparoscopic, or robotically and is pancreas-sparing, but requires proximal small
bowel reconstruction. Also, D1 and D3 lesions on the antimesenteric surface of the
duodenum are amenable to a wedge resection. Please refer to Chap. 14 for more
in-depth review of segmental duodenal resection (open vs MIS). For this chapter,
we will focus on surgical options for D2 lesions.
Inclusion Criteria
Currently, the literature suggests that endoscopic mucosal resections (EMR), endoscopic submucosal dissections (ESD), or endoscopic papillectomy be reserved for
benign lesions <2cm in size; there should be no more than high-grade dysplasia on
preoperative biopsy of the lesion, and it should not extend beyond the papilla into
the common bile or pancreatic ducts [6, 7]. Some studies have reported mandatory
transduodenal resection only after the tumor has reached 4cm in size [6]. However,
the primary goal of operative intervention is to achieve complete pathologic resection. Thus, if a lesion cannot be resected en bloc endoscopically, a transduodenal
approach should be employed instead [2]. In fact, transduodenal resection is indicated for tumor recurrence or lack of clear margins after endoscopic resections.
Lesions that reach the muscularis propria of the duodenal wall, encompass more
than one-third of the duodenum circumference, or incorporate the common bile and/
or pancreatic duct are reasons to perform a pancreatoduodenectomy. Of note, endoscopic resections can be considered as a palliative approach for patients who are
poor surgical candidates.
Once a transduodenal operation is deemed appropriate, selection of the approach
is largely contingent upon the proximity of the tumor to the ampulla [8]. A transduodenal wedge resection, in which the tumor is removed with a full-thickness portion
of the duodenal wall, is possible if there is a clear margin between the lesion and the
ampulla. This is most often done for D2 lesions on the antimesenteric wall of the
duodenum located at least 2cm from the ampulla. True periampullary lesions may
require a transduodenal mucosal resection to avoid a full-thickness wedge that
encroaches on the ampulla. A lesion that involves the common bile and/or pancreatic ducts within the ampulla necessitates a transduodenal ampullectomy.
An interesting new hybrid approach, called laparoscopic and endoscopic cooperative surgery (LECS), has been recently described by Hiki etal. and was tested
in 12 patients by Ichikawa et al. [9, 10]. During this procedure, both ESD and
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A. Polcari et al.
laparoscopy are performed together. LECS is reserved for resection of nonampullary tumors with the goal of reducing the common complications related to
ESD. For example, the ESD resection bed is oversewn laparoscopically to avoid
hemorrhage and leak after perforation. While we do not describe this technique in
detail in this chapter, it appears to be a safe and feasible option for nonampullary tumors.
Preoperative Planning
Surgical options for a patient with a duodenal tumor are largely dependent on ndings during the preoperative workup, which typically consists of an upper endoscopy with biopsy, endoscopic ultrasound (EUS), computed tomography (CT) scan,
and/or magnetic resonance imaging with cholangiopancreatography (MRI/MRCP).
CT scan can be better to optimize understanding of vasculature and MRCP can be
helpful to better depict the common bile duct (CBD and pancreatic duct. Both are
not usually necessary and is surgeon preference.
Upper endoscopy is key in determining location of the tumor, particularly with
respect to the ampulla and the physical characteristics of the tumor, such as size and
shape (Fig.13.2). Biopsy of the lesion during upper endoscopy is also essential in
determining the required operative intervention. If the tumor is benign, such as an
adenoma with features of dysplasia, or only contains carcinoma in situ, a
Fig. 13.2 GD Endoscopy showing duodenal mass (green arrow)
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
209
pancreatoduodenectomy may be avoided. It is often essential to get a second endoscopy as the rst one may not completely delineate (1) mesenteric vs. antimesenteric
location, (2) circumference of the wall involved, (3) proximity to the ampulla with
pictures, and (4) complete size with measurements. If possible, requesting video
footage of or being present during the preoperative endoscopy is recommended.
Tattooing is not always helpful as this can disperse and enter the abdominal cavity widely.
Upper endoscopic ultrasound is important in identifying lymph node metastasis
for cancerous lesions and is also extremely valuable in determining whether benign
lesions can undergo endoscopic resection versus a transduodenal approach. EUS
can evaluate the depth of invasion into the duodenal wall, as well as extension into
the CBD or pancreatic duct for ampullary lesions (Fig.13.3). Ultimately, it determines the approach by which a lesion is considered resectable.
CT (Fig.13.4) and MRI/MRCP (Fig.13.5) can further assist in decision-making
by providing a map of the tumor and its association to the common bile and pancreatic ducts, in addition to revealing any local anatomic variations.
a
b
Fig. 13.3 (a) Endoscopic ultrasound showing duodenal mass (green arrow). (b) Eus in patient
with tumor of the Ampulla
Fig. 13.4 CT scan showing duodenal mass (green arrow)
210
Fig. 13.5 Magnetic resonance imaging with cholangiopancreatography
Fig. 13.6 ERCP
A. Polcari et al.
A few groups have reported using preoperative ERCP to place a stent in the CBD
to assist in identication of the ampulla prior to duodenotomy during a minimally
invasive transduodenal resection. The stent can help precisely target the duodenotomy using intra-operative ultrasound. This step is surgeon-dependent and not
required preoperatively. However, it may be useful for ampullary tumors causing
obstruction or in patients who are at high risk for cholangitis while awaiting surgery.
When a patient presents with jaundice, a pause is necessary before considering an
ampullectomy due to concern for malignancy. Careful attention should be paid to
MRCP to look for stones, to EUS for identication of small masses, and to cholangiogram on ERCP to identify stricture (Fig. 13.6). It is possible to present with
jaundice for benign etiologies, but one must perform due diligence.
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
211
Always consent the patient for a possible Whipple procedure. With careful
workup and planning and in experienced hands this hopefully would not be necessary, but in the event that all the anatomy cannot be appropriately delineated or the
reconstruction could compromise the lumen or the ducts, then a Whipple may be the
safest option. In the setting of an adenoma, always discuss the possibility the tumor
will be upstaged on nal pathology and another operation may be necessary.
Surgical Techniques andOutcomes
Open Transduodenal Submucosal andWedge Resection
1. The patient should be positioned supine on the operating table with both arms
out at 90 degrees.
2. After intubation and initiation of general anesthesia, a nasogastric tube and uri-
nary catheter should be placed in addition to pneumatic compression devices
for DVT prophylaxis. Patient should be prepped according to hospital protocol.
3. Both a generous midline incision and right subcostal incision are acceptable. A
midline incision is recommended for patients who may require adhesiolysis due
to prior surgical history.
4. Palpate the liver and inspect the rest of the peritoneum to rule out evidence of
metastatic disease.
5. After the surgeon’s preferred self-retaining retractor is placed, mobilize the
hepatic exure of the colon.
6. Perform an extensive Kocher maneuver to expose the entirety of D2—lysing
the duodenum’s retroperitoneal attachments from the foramen of Winslow to
the Ligament of Treitz and posteromedial to the root of the superior mesenteric
artery (SMA). The posterior wall of the duodenum should be visible after completion of this maneuver.
7. Physically palpate the duodenal wall in a bimanual fashion to identify the target
lesion and the ampulla. TIP: For small tumors that may not be easily palpable,
Hashimoto etal. describe a preoperative duodenoscopy with clip placement on
the duodenal mucosa opposite the tumor to assist in determining the site of
duodenotomy [11]. It is important to limit insufation to avoid extensive dilation of the small bowel. Additionally, carbon dioxide insufation may assist in
limiting bowel distension.
8. At this time, stay sutures may be placed through the duodenal wall lateral to the
lesion and planned site of duodenotomy in order to maintain adequate exposure
throughout the operation. TIP: A laparotomy sponge can be placed behind the
duodenum to facilitate positioning prior to making the duodenotomy.
9. Using cautery, make a 2–4cm longitudinal duodenotomy on the antimesenteric
border of D2, opposite the lesion.