Pancreas-preserving duodenal resections vs pancreatoduodenectomy for groove pancreatitis. Should we revisit treatment algorithm for groove pancreatitis?

Table 1 Short- and long- term results of cystic dystrophy of the duodenal wall treatment (2004-2019)

Type of treatment	n	1Morbidity n (%)	Full pain control, n (%)	Steatorrhea, n (%)	New DM, n (%)
Conservative	12	5 (42%)	5 (42)	4 (33)	6 (50)
Draining OP	8	1/1 (12.5/12.5%)	2 (25)	2 (25)	2 (25)
DPPHR	6	1/2 (17/34%)	2 (33)
PD	44	12/7 (27/16%)	37 (84)	6 (14)	12 (31)
PPDR	15	4/1 (27/7%)	14 (93)

¹Postoperative complications are shown as minor/major (Dindo-Clavien I-II/III-IV).

DPPHR: Duodenum-preserving pancreatic head resection; PD: Pancreatoduodenectomy; PPDR: Pancreas-preserving duodenal resection; DM: Diabetes mellitus; Draining OP: Pancreatico- and/or cystoenterostomy.

Table 2 Demographic data and symptoms before and after pancreatoduodenectomy for cystic dystrophy of the duodenal wall, July 2020

No.	Age	Pain	Vomi-ting	Jaundice	Weight loss, kg	Weight gain after surgery, kg	Weight gain after surgery, %	PERT after surgery	Pain after surgery, status, events	Treatment before surgery, mo	Follow-up after surgery, mo, status, events
1	44	37.8	-	+	6	9	150	Yes	No, DM	72	188, NA
2	49	63	-		12	5	41	Yes	No, drinking, NDM	84	151, death of unknown cause
3	56	73.8	-		9	9	100	Yes	No, steatorrhea. Smoking, DM	54	166, death of MI
4	49	37.8	+	+	10	8	80	Yes	No, NDM	96	170, NA
5	55	81.3	+	+	12	6	50	Yes	31.5, drinking, NDM, steatorrhea	79	167, NA
6	52	73.8	-		12	9	75	Yes	No	50	162, NA
7	39	73.8	-		15	11	73	Yes	31.5, smoking, DM	60	167
8	43	63	+++		21	10	48	Yes	No	48	164
9	55	73.8	+++		18	13	72	Yes	No, smoking	38	162
10	39	63	++		17	12	71	No	No	60	156
11	57	73.8	-		6	6	100	Yes	No, NDM	8	69, death of unknown cause
12	40	73.8	-		11	8	78	Yes	No	36	155
13	51	77.5	-		10	6	60	Yes	37.8	36	152
14	61	81.3	++		8	6	75	Yes	No, steatorrhea, NDM	48	132, death of unknown cause
15	49	73.8	+++		14	8	57	Yes	37.8, NDM	72	147
16	48	77.5	++	+	12	7	58	Yes	31.5, drinking, smoking	31	147
17	40	63	+		13	7	54	No	no	60	141
18	53	77.5	-		7	7	100	Yes	no	48	129
19	59	31.5	+	+	13	9	69	Yes	No, steatorrhea	36	126
20	46	77.5	-		12	7	58	Yes	No	36	120
21	45	73.8	++		8	5	62.5	Yes	No, drinking	41	117
22	59	73.8	++		5	5	100	Yes	No	62	111
23	50	31.5	-		5	7	140	Yes	No, smoking	48	107
24	53	81.3	+++		16	9	56	Yes	No	66	105
25	47	37.8	++	+	10	8	80	Yes	No	54	103
26	44	63	-		10	7	70	Yes	No	48	101
27	46	63	+++		19	10	52	Yes	No, steatorrhea, NDM	36	97
28	51	63	+++		14	11	78.6	Yes	No	36	93
29	37	77.5	+++		15	9	60	No	No	40	93
30	54	73.8	++		10	8	80	Yes	No, DM	48	69, death of unknown cause
31	52	31.5	-	+	12	8	67	Yes	No, drinking, NDM	66	85
32	53	67.5	-		12	10	83	Yes	31.5	24	85
33	49	77.5	++		15	6	40	Yes	No, steatorrhea	12	79
34	46	81.3	+		13	9	69	Yes	No	9	69
35	48	37.8	++	+	15	10	67	Yes	No	16	69
36	50	63	++		14	9	64	Yes	No	32	69
37	51	81.3	-		7	6	86	Yes	No, smoking	39	60
38	58	31.5	-		11	8	73	Yes	No, NDM, smoking	42	57
39	54	37.8	-		12	8	67	Yes	No	30	52
40	49	73.8	++		8	6	75	Yes	No	36	45
41	47	77.5	++		7	6	86	Yes	No, DM	120	20
42	58	37.8	-		12	8	67	Yes	No, NDM	72	18
43	47	73.8	+		11	1	9	Yes	No, NDM	66	13
44	45	77.5	+++		21	5	23	Yes	No	63	6

Median preoperative follow-up was 42 mo (LQ-UQ: 36-60). All the patients, except two are males. Pain was assessed by the Izbicki score[38]. DM: Diabetes mellitus; NDM: New diabetes mellitus; PERT: Pancreatic enzyme replacement therapy; NA: Not by April 2020.

Table 3 Operative data and complications of pancreatoduodenectomy for cystic dystrophy of the duodenal wall (July, 2020)

No.	Procedure	Blood loss, mL	Time, min	Postop stay	Morbidity (Сlavien-Dindo)
1	pPD	130	290	16	Grade I, DGE A
2	pPD	150	310	11	No
3	pPD	50	230	14	No
4	PD	460	370	31	Grade IV, GI bleeding
5	pPD	500	350	18	Grade I, pneumonia
6	PD	120	305	10	No
7	pPD	150	290	10	No
8	pPD	100	280	10	Grade I, DGE A
9	PD	230	300	12	No
10	pPD	50	185	25	Grade III, POPF B
11	PD	100	340	12	No
12	pPD	100	270	14	No
13	pPD	130	220	15	Grade I, DGE A
14	pPD	140	280	16	Grade I, Lymphorrhea
15	pPD	50	270	11	No
16	PD	50	280	12	No
17	pPD	120	210	36	Grade III, POPF B, DGE B
18	pPD	70	225	10	No
19	PD	750	480	41	Grade III, ureter intraoperative trauma, DGE B
20	pPD	100	200	9	No
21	pPD	100	200	7	No
22	pPD	150	240	14	No
23	Nakao	100	330	27	Grade III, DGE B
24	pPD	50	230	16	Grade I, short-term bile leakage
25	pPD	50	280	11	No
26	Nakao	100	350	12	Grade I, DGE A
27	pPD	120	250	10	No
28	pPD	140	260	9	No
29	pPD	50	170	28	Grade III, POPF B, DGE B
30	Nakao	100	310	14	Grade I, short-term bile leakage
31	PD	120	290	12	No
32	Nakao	100	320	13	No
33	pPD	100	190	27	Grade III, DGE B
34	pPD	100	300	10	Grade I, lymphocele
35	PD	100	320	11	No
36	pPD	350	310	11	Grade I, wound infection
37	pPD	50	300	13	No
38	pPD	50	270	12	No
39	pPD	50	240	14	Grade I, DGE A
40	pPD	50	230	11	Grade I, POPF A
41	PD	100	230	10	No
42	pPD	150	410	12	No
43	PD	270	390	11	No
44	PD	250	440	10	No

PD: Pancreatoduodenectomy; pPD: Pylorus-preserving pancreatoduodenectomy; DGE A: Delayed gastric emptying A; GI: Gastrointestinal; POPF B: Postoperative pancreatic fistula grade B.

Table 4 Demographic data and symptoms before and after pancreas-preserving duodenal resections for isolated form of cystic dystrophy of the duodenal wall (pure form of groove pancreatitis), July 2020

No.	Age	Pain	Vomit	Jaundice	Weight loss, kg	Weight gain after surgery, kg	Weight gain after surgery, %	PERT after surgery	Pain after surgery, status, events	Treatment before surgery, mo	Follow-up after surgery, mo
1	53	31.5	+++	+	44	46	105	No	No	9.5	127
2	43	37.8	+++	+	21	18	86	No	No	10	124
3	47	62.5	-		18	16	89	No	No	13	118
4	45	81.3	+++		23	16	70	Yes	Pain 26.3, still drinking	7	116
5	41	62.5	+		11	8	73	No	No	11	110
6	46	62.5	+		9	8	89	No	No	8	108
7	28	67.5	-		5	3	60	No	No	8.5	104
8	30	73.8	-		6	8	75	No	No	9	103
9	56	77.5	-		14	10	71	No	No, smoking	10.5	101
10	40	68.8	+		12	8	67	No	No, smoking	12	98
11	44	81.3	-		7	8	114	No	No	13.5	97
12	52	37.8	+++		31	24	77	No	GI bleeding -DP 46 mo after surgery, no symptoms	11.5	89
13	29	77.5	+		6	8	86	No	No, smoking	11	68
14	62	68.8	+	+	11	11	100	No	No	5	65
15	55	77.5	++		21	12	57	No	No	7	31

All the patients were males. Pain assessed by the Izbicki score[38]. PERT: Pancreatic enzyme replacement therapy; GI: Gastrointestinal; DP: Distal pancreatectomy.

Table 5 Operative data and complications of pancreas-preserving duodenal resection, performed for isolated form of cystic dystrophy of the duodenal wall (July, 2020)

No.	PPDR	Blood loss, mL	Time, min	Postop stay, d	Morbidity (Сlavien-Dindo)
1	Intest pouch	150	280	14	No
2	Standard	200	310	15	No
3	DDA	50	250	21	Grade I, POPF A
4	Intest pouch	50	270	39	Grade IV, upper DJA leakage, converted in Roux-en-Y
5	Standard	100	270	12	No
6	DDA	50	260	18	Grade I, POPF A
7	Standard	50	220	12	No
8	Standard	150	245	12	No
9	Standard	100	235	11	No
10	Standard	100	200	17	Grade I, POPFA
11	Roux-en-Y	50	215	14	No
12	Standard	100	215	16	No
13	Roux-en-Y	50	195	15	No
14	Roux-en-Y	50	230	14	Grade I, POPF A
15	Roux-en-Y	50	225	16	No
	Mean value	87

PPDR: Pancreas-preserving duodenal resection; DDA: PPDR with duodeno-duodeno anastomosis reconstruction; DJA: Duodenojejunoanastomosis; Intest pouch: Pancreas-preserving duodenal resection with intestinal interposition reconstruction; Standard: Classical pancreas-preserving duodenal resection with one duodeno-jejuno anastomosis; Roux-en-Y: Pancreas-preserving duodenal resection with Roux-en-Y reconstruction; POPF: Postoperative pancreatic fistula.

Table 6 Pancreatoduodenectomy and pancreas-preserving duodenal resection for cystic dystrophy of the duodenal wall, comparison of demographic data and symptoms

Variables	PPDR	PD	P M-W value
n	15	44
Age, yr	45 (40-52)	49 (46-54)	0.09
Pain score	69 (62.5-77.5)	73.8 (63-73.8)	0.08
Weight loss, kg	12 (7.5-21)	12 (10.5-13)	0.52
Vomiting, n (%)	5 (33)	18 (41)	0.53
Jaundice, n (%)	3 (25)	8 (18)	1
Treatment before surgery, mo	10 (8-12)	45 (36-57)	01

¹Difference is significant.

All data are presented as Me (95%CI). PD: Pancreatoduodenectomy; PPDR: Pancreas-preserving duodenal resection.

Table 7 Pancreas-preserving duodenal resections and pancreatoduodenectomy for cystic dystrophy of the duodenal wall, comparison of intraoperative data and complications

Variables	PPDR	PD	P M-W value
n	15	44
Blood loss, mL	50 (50-100)	50 (100-125)	0.10
Time, min	235 (215-270)	275 (240-290)	0.05
Hospital stay, d	15 (13-17)	12 (11-14)	0.03
Morbidity (Clavien-Dindo > III), n (%)	1 (6)	6 (14)	0.67

PD: Pancreatoduodenectomy; PPDR: Pancreas-preserving duodenal resection.

Table 8 Pancreas-preserving duodenal resection vs pancreatoduodenectomy for cystic dystrophy of the duodenal wall, long term results

Variables	PPDR	PD	P M-W value
n	15	44
Weight gain, kg	10 (8-16)	8 (7-9)	0.01
Weight gain, %	77 (70-89)	69 (63-75)	0.03
Pain after surgery, n (%)	1 (6)	5 (11.4)	0.66
New DM, n (%)		12 (31)	0.001
PERT, n (%)	1 (6)	43 (98)	0.001
Follow-up, mo	89 (78-100)	105 (80-134)	0.15

¹Difference is significant.

All data are presented as Me (95%CI). PERT: Pancreatic enzyme replacement therapy; DM: Diabetes mellitus.

Table 9 Literature review of the largest series of cystic dystrophy of the duodenal wall treatment

Ref.	Year	CDDW patients (n)	Pure form of CDDW	Surgery1	PD2	PPDR2
Stolte et al[8]	1982	30	11 (37%)	30 (100%1)	30 (100%)	-
Jouannaud et al[4]	2006	23	0	14 (61%1)	10 (71%)	-
Rebours et al[5]	2007	105	30 (29%)	29 (28%)	17 (59%)	-
Tison et al[35]	2007	9	5 (56%)	9 (100%1)	9 (100%)	-
de Pretis et al[17]	2017	82	22 (27%)	57 (69.5%1)	51(89%)	-
Our data		82	18 (22%)	70 (85%)	42 (60%)	15 (21%)
Overall		331	86	209	159	15

¹% of all patients.

²% of all surgical procedures.

CDDW: Cystic dystrophy of the duodenal wall; PD: Pancreatoduodenectomy; PPDR: Pancreas-preserving duodenal resection.