ORIGINAL ARTICLE
Laparoscopic Partial Sleeve Duodenectomy (PSD)
for Nonampullary Duodenal Neoplasms
Avoiding a Whipple by Separating the Duodenum from the Pancreatic Head
John Andrew Stauffer, MD,* Massimo Raimondo, MD, Timothy A. Woodward, MD, Ross F. Goldberg, MD,*
Steven P. Bowers, MD,* and Horacio J. Asbun, MD*
Objective: To learn the clinical outcome of patients undergoing lapa-
roscopic partial sleeve duodenectomy (PSD) for lesions, which require
sleeve resection of the duodenum. Traditionally, these lesions require en
bloc excision of the head of the pancreas performed in an open fashion.
Methods: A retrospective review of medical records of patients with
nonampullary large or circumferential duodenal lesions, which were
not amenable to endoscopic or local resection for complete removal,
was performed. Characteristics, complications, and technical details
were analyzed.
Results: Ten patients (5 men and 5 women; mean age, 70 years) with
duodenal lesions including adenoma (n = 5), adenocarcinoma (n = 2),
lymphangiolipoma (n = 1), leiomyoma (n = 1), and neuroendocrine tumor
(n = 1) were included. All patients underwent a laparoscopic approach
with either a proximal PSD (n = 3) or distal PSD (n = 7) after separation of
the duodenum from the pancreatic head. Reconstruction was carried out
by a side-to-side duodenojejunostomy (n = 7), end-to-side duodenoje-
junostomy (n = 2), or gastrojejunostomy (n = 1). Mean length of stay was
5.6 days, and complications were 20%.
Conclusions: Laparoscopic PSD seems to be a safe and easily
applicable technique for treatment of duodenal lesions not involving
the ampulla, which requires separation of the duodenum from the
pancreas head with sleeve resection of the duodenum and subsequent
reconstruction.
Key Words: pancreaticoduodenectomy, duodenum, Whipple, adenoma
(Pancreas 2013;42: 461Y466)
D uodenal lesions are common, and their diagnosis has be-
come more prevalent, with an increase in screening upper
endoscopic examinations over the past decade. Advanced en-
doscopic techniques such as endoscopic mucosal resection have
allowed for a minimal invasive approach to smaller noncancer-
ous lesions, when found at a favorable location within the du-
odenum.1 Larger lesions that encompass a significant portion of
the circumference and those in an unfavorable location are
usually not amenable to endoscopic mucosal resection or wedge
resection. For those lesions, the most commonly practiced ap-
proach has been to perform a pancreaticoduodenectomy (PD).
However, this treatment may be considered too aggressive for
benign and premalignant lesions that otherwise would not re-
quire a pancreatic head resection or a total duodenectomy for
oncologic reasons.
From the Departments of *General Surgery, and Gastroenterology and
Hepatology, Mayo Clinic, Jacksonville , FL.
Received for publication February 22, 2012; accepted June 6, 2012.
Reprints: John Andrew Stauffer, MD, Division of General Surgery, Mayo
Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
(e-mail: stauffer.john@mayo.edu).
This study was not supported by any funding or grant.
The authors declare no conflict of interest.
Copyright * 2013 by Lippincott Williams & Wilkins
Pancreas & Volume 42, Number 3, April 2013
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In the last decade, however, there have been multiple
publications regarding partial sleeve duodenectomy (PSD) for
many different nonampullary duodenal lesions.1Y8 These pro-
cedures were performed using open techniques and were asso-
ciated with less morbidity than PD, with the added advantage of
preservation of duodenal function. Dissection of the supra- or
infra-ampullary medial wall of the duodenum off the head of the
pancreas is difficult owing to their close association and
common blood supply9 but can clearly be performed. This
requires meticulous dissection of the duodenum from the
pancreatic head and has been described even for ampullary
lesions requiring total duodenectomy with pancreaticojeju-
nostomy.10,11 Recently, advanced laparoscopic techniques have
been used for duodenal and pancreatic pathology, which require
more complex dissection and gastrointestinal reconstruction
techniques. These techniques can be used for patients with be-
nign nonampullary duodenal neoplasms to not only spare the
patient the morbidity of a PD or total duodenectomy but also of
an open incision. Only 2 case reports exist in the literature re-
garding this minimal access approach with sleeve resection of the
duodenum for duodenal pathology.12,13 This report describes
indications, technique, and outcome for benign and selected
malignant nonampullary duodenal lesions requiring separation
of the proximal or distal duodenum from the pancreatic head for
PSD who would have otherwise needed a PD or total duode-
nectomy for complete resection.
MATERIALS AND METHODS
A retrospective review of a prospectively maintained da-
tabase was conducted to assess the patients who underwent
pancreatic preserving duodenectomies over the period from
August 2008 to October 2011. All patients were evaluated by
diagnostic endoscopy with finding of a duodenal lesion. Indi-
cations for surgery include all fit patients who were found to have
nonampullary duodenal lesions, which were unable to be ade-
quately resected by endoscopic mucosal techniques or by any
other endoscopic means. The lesions were first assessed for a
limited local duodenal wall resection by endoscopic or radio-
graphic modalities. If a limited resection would not provide for
an adequate margin or subsequent duodenal lumen, then the
patient was considered for a segmental sleeve resection. Patients
undergoing a laparoscopic segmental duodenectomy without
need for reconstruction/reimplantation of the pancreatic and
common bile duct opening were included in the study. The
patients identified were studied in detail, and all clinical and
pathologic details were entered into a standard database for re-
view. A proximal PSD resection with reconstruction was per-
formed for those lesions found proximal to the ampulla, whereas
a distal PSD resection with reconstruction was performed for
those lesions found distal to the ampulla (Figs. 1Y3).
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Stauffer et al
FIGURE 1. Tumor location (A) and PSD procedure with
reconstruction method (B) for patient 1.
Technique
A preoperative endoscopy is performed to mark the location
of the lesion. The level of the proximal and distal margins of the
lesion is tattooed with India ink on the antipancreatic side of the
duodenum using an endoscopic approach.
For the laparoscopic approach, a Hasson trocar is placed at
the umbilicus to obtain pneumoperitoneum and later enlarged for
specimen extraction. Three additional accessory ports are placed
(Fig. 4). A window is created in the gastrocolic omentum, and the
lesser sac is entered. The stomach is separated from the trans-
verse colon to an extent necessary to have adequate access to the
duodenal and pancreatic head area. The hepatic flexure of the
colon is widely mobilized. The cephalad portion of the ascending
colon is also mobilized, exposing the duodenum.
For supra-ampullary lesions, the pyloric region and proxi-
mal duodenum are separated from its posterior attachments up to
FIGURE 2. Tumor location (A) and PSD procedure with
reconstruction method (B) for patients 2 and 3.
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Pancreas & Volume 42, Number 3, April 2013
FIGURE 3. Tumor location (A) and PSD procedure with
reconstruction method (B) for patient 4 through 10.
the level of the pancreatic head (Fig. 5A). After the right gas-
troepiploic vessels have been transected, a plane is developed
behind the duodenum approximately 2 to 3 cm from the pylorus;
and for pyloric preserving procedures, the duodenum is stapled
and divided at this level. The duodenum is then gradually sep-
arated from the head of the pancreas using ultrasonic shears. A
meticulous dissection is performed from cephalad to caudad
retracting the divided end of the duodenum laterally, keeping it
under constant traction. The extent of dissection is guided by the
preoperative tattoo markings. The goal is to obtain a negative
margin and, when possible, to preserve the ampulla intact. Not
infrequently, the duodenum can be stretched to obtain more
distance from the ampulla once its proximal portion has been
freed from the head of the pancreas. A clamp or the stapler itself
is placed at the planned site of transection and an intraoperative
cholangiogram (IOC) is obtained to confirm that the ampulla is
FIGURE 4. Trocar placement for laparoscopic PSD.
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Pancreas & Volume 42, Number 3, April 2013 Laparoscopic Partial Sleeve Duodenectomy (PSD)

FIGURE 5. Intraoperative image of a submucosal tattoo marking adenoma of the proximal duodenum after dissecting the duodenal
from the pancreatic head (A) and intraoperative fluoroscopic cholangiogram image with endoscopic stapler in place before transection
proximal to the ampulla (B). D, duodenum; P, head of pancreas; C, cholangiogram catheter; arrow, gastroduodenal artery.

not being harmed (Fig. 5B). The duodenum is then divided. The
reconstruction is done through either an antecolic loop gastro-
jejunostomy (Fig. 1B) or an antecolic loop duodenojejunostomy
approximately 15 to 20 cm from the ligament of Treitz (Fig. 2B).
For infra-ampullary lesions, the duodenum is completely
exposed and a wide Kocher maneuver is performed extending to
the ligament of Treitz. The ligament of Treitz is opened from the
patients right side to free the fourth portion of the duodenum
and to allow the passing of the proximal jejunum behind the
mesenteric vessels toward the right. The proximal jejunum is
transected with a stapler, and the mesentery of the distal duo-
denum and jejunum is ligated with ultrasonic coagulation. A
meticulous dissection with ultrasonic coagulation that progres-
sively separates the distal duodenum from the pancreatic head is
performed as described for supra-ampullary lesions. In similar
manner, the goal is to obtain a clear margin without damaging the
ampullary region. A clamp or the stapler is placed at the planned
site of transection (Fig. 6A), and an IOC is also obtained before
division of the duodenum as described previously (Fig. 6B).
Alternatively, an upper endoscopy can be performed intrao-
peratively with the clamp in place to assess margins and am-
pullary integrity. The latter, however, seems to be less accurate
and more cumbersome and is reserved for patients in which
performing IOC is not feasible. The reconstruction is performed
in a side-to-side functional end-to-end duodenojejunostomy on
the antipancreatic edge of the duodenum (Fig. 3B).
For both supra- and infra-ampullary resections, the amount
of duodenum resected is limited to the minimum extent needed to
obtain adequate clear margins. The goal is also to preserve du-
odenal function. A cholecystectomy is performed for both types
of PSD to obtain cholangiogram imaging to assess distance to the
ampulla. The cholangiogram will ensure no encroachment upon
the ampulla by duodenal division either above or below the level
of the ampulla.
RESULTS
Ten patients were identified to have undergone a laparo-
scopic PSD after meeting inclusion criteria from August 2008 to
October 2011. Age, sex, segment of resected duodenum, re-
construction methods, indications, length of stay, and postop-
erative outcomes are given in Table 1. A 4- or 5-trocar technique
was used for all laparoscopic procedures except for case 4 in
which a hand port was inserted owing to the size of the primary
tumor. Intraoperative cholangiogram, upper endoscopy, and
intraoperative ultrasound were used in 9, 3, and 1 procedure,
respectively. Mean operative time was 274 minutes (range,
181Y425 minutes). All specimens were examined with the sur-
geon and an experienced pathologist (Fig. 7), and duodenal
margins were negative on all cases, with a mean of 0.9 cm (range,
0.2Y2 cm). Inpatient morbidity and mortality was 20% and 0%,
respectively. Patient 2 was a nonambulatory patient preopera-
tively with significant comorbidities who remained significantly
deconditioned after surgery and was discharged to a skilled
nursing facility. Patient 4 experienced a transient amylase-rich
leak from her concomitant pancreatic uncinate process resection,
which was treated conservatively with delayed removal of an

FIGURE 6. Intraoperative image of a submucosal tattoo marking adenoma of the infra-ampullary duodenum after dissecting the
duodenum and pancreatic head (A) and intraoperative fluoroscopic cholangiogram image with endoscopic grasper in place
before transection distal to the ampulla (B). (D, duodenum: P, head of pancreas; arrow, ampulla).

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Stauffer et al Pancreas & Volume 42, Number 3, April 2013

TABLE 1. Patients Age, Sex, Duodenal Segment Resected, Reconstruction Method, Final Pathology, Length of Stay (LOS), and
Postoperative Complications for 10 PSDs

Complications
Number Age/Sex Duodenal Segment Reconstruction Final Pathology LOS After Surgery
1 70 F Proximal duodenectomy Stapled loop BII gastrojejunostomy 5-cm tubular 3 None
(D1/D2) including adenoma
distal gastrectomy
2 77 F Pylorus-preserving Hand-sewn loop duodenojejunostomy 3.5-cm tubulovillous 8 Medical
proximal duodenal adenoma deconditioning
resection (D1/D2)
3 78 M Pylorus-preserving Hand-sewn loop duodenojejunostomy 2-cm 6 None
proximal duodenal neuroendocrine tumor
resection (D1/D2)
4 19 F Distal duodenectomy Stapled side-to-side duodenojejunostomy 8.5 cm 9 DGE, pancreatic
(D3/D4) and uncinate lymphangio-lipoma fistula
process resection
5 90 M Distal duodenectomy Stapled side-to-side duodenojejunostomy Grade 2, T1b duodenal 5 None
(D3/D4) adenocarcinoma
6 77 M Distal duodenectomy Stapled side-to-side duodenojejunostomy 5-cm 8 None
(D3/D4) tubulovillous adenoma
7 75 M Distal duodenectomy Stapled side-to-side duodenojejunostomy 6.5-cm 4 None
(D3/D4) tubulovillous adenoma
8 79 F Distal duodenectomy Stapled side-to-side duodenojejunostomy 2.4-cm leiomyoma 3 None
(D3/D4)
9 84 M Distal duodenectomy Stapled side-to-side duodenojejunostomy Grade 2, T3 duodenal 6 None
(D3/D4) adenocarcinoma
10 49 F Distal duodenectomy Stapled side-to-side duodenojejunostomy 5-cm 4 None
(D3/D4) tubulovillous adenoma
BII indicates Billroth II; D1, first-portion duodenum; D2, second-portion duodenum; D3, third-portion duodenum; D4, fourth-portion duodenum;
DGE, delayed gastric emptying; GIST, gastrointestinal stromal tumor; HGD, high-grade dysplasia.

operatively placed drain. Her delayed gastric emptying (DGE) dissection of the duodenum from the pancreatic head and has
was managed with a temporary course of parenteral nutrition. been performed with good outcomes. The technical principles
All patients underwent a postoperative gastrograffin upper GI learned from laparoscopic total duodenectomy14 was carried
study (Figs. 8A, B) within 1 to 4 days of surgery, which were all over to facilitate the performance of segmental duodenectomy
negative for leaks. Mean length of hospitalization was 5.6 days. with preservation of the pancreatic head. The latter has the ad-
There were no biliary complications or evidence of pancreatitis vantage of the absence of need for a bilio/pancreatic recon-
seen in the postoperative or follow-up period. There have been no struction and its associated morbidity when the lesions do not
recurrences detected in the follow-up period with a mean follow- involve the ampulla.
up of 11.3 months (range, 0.8Y31.6 months). When performing proximal PSD, one must be cognizant of
the minor papilla which will enter the duodenum more proximal
DISCUSSION
Traditionally, PD has been the most commonly practiced
procedure for large duodenal neoplasms of benign or prema-
lignant nature that are not amenable to endoscopic excision. The
procedure has been performed based on the old dictum that
separation of the duodenum from the head of the pancreas is
technically complex and inherent to significant bleeding. With
surgical techniques available today, including magnification and
a variety of energy devices, dissecting the duodenum away from
the pancreatic head seems not only feasible but also readily
possible. In experienced hands, this seems to be accomplished
without significant difficulty. Furthermore, it is felt that the
learning curve to perform this dissection is relatively quick for
the surgeons with experience in pancreatic surgery and mini-
mally invasive techniques.
Dissection of the duodenum and head of pancreas including FIGURE 7. Gross pathology picture of a 5-cm tubulovillous
the ampullary has been widely described for total duodenectomy adenoma after distal duodenectomy (patient 10).
in patients with familial adenomatous polyposis.10,11 It has been Proximal margin (M) was 0.8 cm from the lesion, which was
the authors experience that when feasible, a laparoscopic ap- noted to be approximately 3 cm distal to the ampulla by
proach to this procedure allows for a more facile and precise preoperative endoscopy.

464 www.pancreasjournal.com * 2013 Lippincott Williams & Wilkins

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Pancreas & Volume 42, Number 3, April 2013
FIGURE 8. Postoperative gastrograffin swallow study for proximal duodenal resection with reconstruction (A) and infra-ampullary
resection with reconstruction (B). Pylorus (asterisk) and anastomosis (arrowhead) are marked.
on the medial wall of the duodenum for those patients with
pancreas divisum. It is recommended that preoperative cho-
langiopancreatography imaging be considered prior to proxi-
mal PSD. However, the advantages of the magnified view
afforded by laparoscopy include the ability to recognize small
structures such as the minor papilla and avoid injury during the
dissection. If this anatomic abnormality is encountered, one must
be willing to convert the procedure to perform a PD or accept the
risk of pancreatic leak or pancreatitis from a ligated minor duct.
Limitations to the procedure are the rarity of its need.
Generally, duodenal lesions are amenable to localized resection
either endoscopically or by local duodenal wedge resections
which maintain an adequate lumen. Lesions which require a
sleeve resection are uncommon and often may also involve the
ampulla. In addition, this procedure would be inappropriate
treatment for lesions that are diffuse throughout the duodenum,
such as the polyps seen in FAP patients. Preoperative endoscopic
ultrasound or frozen pathology showing invasive disease would
most likely warrant the surgeon to perform a more definitive
resection such as a PD with an adequate surrounding lympha-
denectomy. In our series, 2 patients were known to have inva-
sive carcinoma of the distal portion of the duodenum. However,
owing to their very advanced age (84 and 90 years old) and
comorbidities, we felt that a PSD would be a better treatment
than a PD while still allowing for a limited periduodenal lymph
node clearance.
It is the authors experience that it is frequent to find that the
distance between the lesion and the ampulla reported on en-
doscopy is varied when the duodenum is freed from the head of
the pancreas and manually stretched away from the ampulla. This
step can potentially gain significant additional proximal du-
odenal margin and is done to facilitate the safe placement of the
dividing stapler device. It is, however, paramount to identify the
site where the ampulla enters into the duodenum, and this can be
done preferentially with the use of intraoperative cholangiog-
raphy. For patients in whom an IOC cannot be performed owing
to a prior cholecystectomy, intraoperative ultrasound examina-
tion maybe of aid. For resections below the ampulla, intrao-
perative EGD can also be used.
The postoperative morbidity for this procedure is mini-
mal, and recovery is generally rapid. Our patient with the most
significant complication also underwent a partial resection of
the parenchyma of the pancreatic head owing to its involve-
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Laparoscopic Partial Sleeve Duodenectomy (PSD)
ment with the mass, resulting in a pancreatic fistula, which
was successfully treated with conservative management. This
complication should generally be quite rare, as the disturbance
of the pancreatic parenchyma is minimal if the dissection plane
is kept close to the duodenal serosa during separation of the
duodenum from the pancreas.
CONCLUSIONS
Laparoscopic PSD seems to be a feasible treatment alterna-
tive for localized nonampullary adenoma or other tumors, which
would otherwise require PD or total duodenectomy for complete
removal. With the combination of minimal access techniques and a
limited duodenal resection procedure, PSD may allow patients
with multiple comorbidities with certain duodenal pathology to
undergo appropriate resection who would not otherwise be a
candidate for a major pancreaticoduodenal resection. Separation of
the duodenum from the head of the pancreas can safely be per-
formed, which, although it requires advanced laparoscopic skills,
seems to be safe and readily feasible. Gastrointestinal recon-
struction can be carried out as described with minimal morbidity,
good functional outcomes, and low risk for recurrence.
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