Management of Duodenal Involvement During Retroperitoneal Lymph Node Dissection for Germ Cell Tumors

OBJECTIVE To describe patient characteristics and outcomes after duodenal repair during postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and to identify treatment and management patterns. METHODS The Indiana University Testis Cancer database was used to identify all patients who underwent simultaneous partial duodenectomy and PC-RPLND from 1983 to 2013. Patient records were reviewed to describe patient and tumor characteristics, type of duodenal restoration, postoperative management, and complications. RESULTS Of the 2223 PC-RPLND performed during the study period, we identified 39 patients who underwent simultaneous duodenectomy, with 1 patient requiring 2 duodenal procedures for a total of 40 duodenal procedures. The postchemotherapy median tumor mass size was 8.95 (2.5-17) cm. Fifty percent of cases were standard PC-RPLND; the remainders were redo, desperation, or late relapse cases. Preoperative gastrointestinal symptoms were present in 21% of patients and included bowel obstruction (8%) or gastrointestinal bleeding (13%). Retroperitoneal pathology consisted of teratoma (48%), cancer (33%), and necrosis (20%). Duodenal involvement was managed with primary duodenorrhaphy (68%), duodenojejunostomy (18%), duodenoduodenostomy (13%), or pancreaticoduodenectomy (3%). Starting in the year 2000, duodenostomy and gastrostomy tubes were no longer used. The most common postoperative complication was ileus (45%) with a 3% duodenal fistula rate. CONCLUSION Duodenal tumor involvement during PC-RPLND is most commonly managed with primary duodenorrhaphy after partial duodenectomy with an acceptable duodenal fistula rate. The routine use of duodenostomy or gastrostomy tubes is not recommended. (C) 2016 Elsevier Inc.