What are the techniques for duodenal mass resection?

Duodenal Mass Resection Techniques

Endoscopic resection is the preferred first-line approach for duodenal adenomas and masses, as it is less morbid, resource-intensive, and expensive than surgery, with technique selection based on lesion size: cold snare for lesions <20 mm and hot snare endoscopic mucosal resection (EMR) for lesions >20 mm. 1

Endoscopic Resection Techniques

For Small Lesions (<20 mm)

• Piecemeal cold snare resection is the technique of choice for flat duodenal adenomas <20 mm, as it mitigates postprocedural bleeding risk while remaining effective with minimal recurrence risk. 1, 2
• This approach is particularly appropriate for patients with significant comorbidities and flat nonbulky lesions. 1

For Larger Lesions (>20 mm)

• Conventional hot snare EMR should be used for duodenal adenomas >20 mm or those with large Paris subtype Is (pedunculated) components. 1, 2
• Thermal ablation of the post-EMR margin should be performed to reduce recurrence risk to <2-5%. 1, 2

Critical Safety Considerations for Endoscopic Resection

• Postprocedural bleeding risk is significantly higher in the duodenum compared to other gastrointestinal sites, typically occurring within the first 48 hours, with risk proportional to lesion size. 1, 2
• For lesions >3 cm, bleeding risk exceeds 25% and may be life-threatening with hemodynamic compromise, though endoscopic hemostasis is generally effective after resuscitation. 1
• Careful evaluation of the post-resection defect is critical to identify duodenal perforation, which if unrecognized and untreated may be life-threatening and often mandates surgery. 1, 2

Surgical Resection Techniques

Indications for Surgery

Surgery is indicated when endoscopic resection is not feasible, for tumors with deep submucosal invasion (T1b), for neuroendocrine tumors ≥2 cm, or for lesions with concerning features. 2

Surgical Options by Location and Complexity

For Proximal Duodenal Lesions (D1-D2)

• Transduodenal local excision with or without lymph node sampling is appropriate for localized neuroendocrine tumors ≥2 cm. 2
• When primary repair or resection with primary anastomosis is not possible in the first or proximal second duodenal portion, antrectomy with gastrojejunostomy and duodenal stump closure is an option. 1

For Distal Duodenal Lesions (Beyond Ampulla)

• Roux-en-Y duodeno-jejunostomy can be performed for injuries or lesions located distal to the ampulla. 1
• When the ampulla or distal common bile duct is involved, re-implantation into healthy adjacent duodenum or reconstruction with a Roux-en-Y jejunal limb is an option if adjacent tissue loss is minimal. 1

For Extensive Duodeno-Pancreatic Involvement

• Pancreatoduodenectomy (Whipple procedure) is required when the duodenum and/or pancreatic head are severely devitalized or devascularized. 1
• Both classic Whipple procedures and pylorus-preserving pancreatoduodenectomy (PPPD) are options, with PPPD showing advantages in postoperative quality of life and body weight maintenance without compromising survival. 1, 3
• Pancreas-preserving total duodenectomy (PPTD) is a safe alternative for duodenal adenomatosis, avoiding pancreatic head resection while providing high quality of life and eliminating the need for pancreatic enzyme substitution. 4

Trauma-Related Resection Principles

For traumatic duodenal injuries requiring resection:

• Primary two-layer repair is recommended for all injury grades when feasible, including grades IV and V, with tension-free transverse repair after complete exposure and removal of devitalized tissue. 5
• Nasogastric tube placement for proximal decompression should accompany primary repair. 1, 5
• Duodenal diverticulization and triple tube decompression are no longer advocated, and routine pyloric exclusion should be avoided as it shows no improvement in morbidity or mortality. 1, 5
• When primary repair is not possible, segmental resection with primary duodeno-duodenostomy should be performed. 1, 5

Post-Resection Management

Surveillance After Endoscopic Resection

• Initial endoscopic surveillance should occur at 6 months after complete resection of duodenal adenomas. 1, 2
• Recurrence is often scarred and may require avulsion techniques rather than conventional snare resection. 1, 2

Nutritional Support After Surgical Resection

• A feeding jejunostomy may be considered in patients with severe duodenopancreatic injuries requiring resection and reconstruction, though jejunostomy-related complications occur in up to 7% of patients. 1
• Total parenteral nutrition may be required in 37-75% of patients with complex duodenal resections. 1

Key Clinical Pitfalls to Avoid

• Do not assume all duodenal polyps are neoplastic: Non-neoplastic lesions like Brunner gland hamartomas and gastric heterotopia do not require resection unless symptomatic or bleeding. 1, 2
• Do not discharge patients immediately after large duodenal resections: The high bleeding risk (>25% for lesions >3 cm) necessitates appropriate monitoring for at least 48 hours. 1, 2
• Do not delay surgical intervention when indicated: Late diagnosis and treatment are associated with increased morbidity and mortality, with complication rates significantly higher when operative management is delayed beyond 24 hours. 5
• Avoid extraluminal drains unless required for associated injuries, as their placement correlates with increased leak rates. 5