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Pancreas-sparing duodenectomy for an obstructive adenocarcinoma of the duodenum.

INTRODUCTION

Adenocarcinomas account for the majority of neoplasms found in the duodenum (1,2). If resectable, patients are generally treated with a pancreaticoduodenectomy (Whipple's procedure) (3). We report a patient with a duodenal adenocarcinoma that was successfully resected by pancreas-sparing duodenectomy.

CASE REPORT

A 90-year-old female was transferred to our centre from a peripheral hospital. Her past medical history was significant for hypertension, mild cerebral vascular accidents, atrial fibrillation, and coronary artery disease. The patient had vomiting for more than 6 weeks. One week prior to transfer, she was intolerant of oral feeds, requiring parenteral feeds for nutrition. All vital signs were stable. Her abdomen was distended. She had epigastric tenderness, but no peritoneal signs. A nasogastric tube was inserted and 1.5 L of gastric fluid was immediately collected. Bloodwork on admission were as follows: haemoglobin 12.6g/dl; leukocyte count, 11500/[mm.sup.3]; creatinine 76 [micro]mol/L. A Computed Tomography (CT) scan revealed a mass in the duodenum measuring 6 x 3 cm. No enlarged lymph nodes were detected. An EGD with biopsy was subsequently done and confirmed the diagnosis adenocarcinoma in the 2nd/3rd part of the duodenum. Upon arrival to LHSC, her abdomen was distended. She had epigastric tenderness, but no peritoneal signs.

[FIGURE 1a OMITTED]

After being assessed by the general surgery, medicine and anaesthesia teams, the patient was consented for a laparotomy. A midline incision was done and there were no signs of metastatic disease. The duodenal tumour was palpable in the 2nd/3rd portion of the duodenum. The right colon was mobilized and a Kocher manouver was performed (FiG. 1a). The tumour was located a few centimetres distal to the ampula of Vater. There was no macroscopic invasion into adjacent vessels or structures. No lymph nodes were palpable. The ligament of Treitz was incised and the proximal jejunum was passed beneath the superior mesenteric vessels to the right upper quadrant. The proximal jejunum was transected using a gastrointestinal stapler. Using sequential hemo-clips and silk ties, the duodenum was carefully dissected and separated from the pancreatic head. All feeding vessels were taken down from the uncinate process and ligated on the pancreatic side. The proximal margin of the duodenum was transected at the level of the second portion, approximately 2 cm above the tumour, next to the ampulla of Vater. The specimen was then removed and sent for pathology.

[FIGURE 1b OMITTED]

A hand sewn side-to-side anastomosis between the second portion of the duodenum and the jejunum was performed (Fig. 1b and 1c). The anastomosis was sewn in two layers using a running and locking 3-0 PDS stitch for the inner layer, followed by a 3-0 silk for a second layer. Simple interrupted 3-0 silk sutures were used to tack down the jejunum at the ligament of Treitz. A suction drain was placed in the proximity of the anastomotic site and the abdomen closed. The operative time was three hours and the intraoperative blood loss was estimated to be 200ml.

[FIGURE 1c OMITTED]

Pathohistological analysis of the resected specimen revealed a low grade circumferential adenocarcinoma measuring 6.5cm x 3.5cm x 1.0 cm. The distance from the proximal duodenal cut line to the tumour was 2.2 cm. There was invasion through the muscularis propria, but the serosa was spared. Several mesenteric lymph nodes were identified and all were found negative for metastatic disease. No vascular invasion was identified.

[FIGURE 2 OMITTED]

The patient had an uneventful postoperative course. Initially, her nasogastric tube was kept in place and her parenteral nutrition was maintained. There were no clinical or biochemical signs of a pancreatic leak. A postoperative upper GI series was done on day 6 and the anastomosis was in-tact (Fig. 2). There were no leaks. After the contrast study, her suction drain was removed. At day 7, the patient was tolerating a transitional diet. By day 9, she was tolerating a full diet and discharged home. At her six month followup, the patient was doing well with no complaints. Oncology suggested no chemotherapy at the time.

DISCUSSION

Duodenal adenocarcinomas are rare and account for just 0.3% of all gastrointestinal malignancies (1,2). However, it is the most common neoplasm of the duodenum, accounting for 64% (4). Due to its non-specific symptoms, it is often not diagnosed until disease advanced. Surgical resection with removal of all invaded tissues is considered the best treatment, and in most instances a Whipple's procedure is the treatment of choice for duodenal malignancies (3).

Small studies have shown that in select cases, pancreas-sparing partial duodectomy provides an acceptable morbidity and mortality rate for distal tumours located in the distal D3 or D4 when compared to pancreaticoduodenectomy (5). Lymph node invasion is a very important indicator for long term survival, more important than tumour size, or local invasion (6,7). Patients with lymph node metastases have 2-year survival rates of 30%, whereas patients those with no lymph node involvement have a 5-year survival rate of 72% (P<0.05) (8).

Pancreas sparing duodenectomy decreases operative time, avoids resection of distal bile duct and pancreas, and circumvents the subsequent need for biliary-enteric and pancreatic-anastomoses, and thus decreases the morbidity significantly (9).

Segmental resection of distal duodenal tumours have been demonstrated to be a safe alternative to pancreaticoduodenectomy (10).With our patient who was of advanced age and had significant medical comorbidities, a pancreaticoduodenectomy procedure would likely have been poorly tolerated. However, since there was no evidence of lymphatic, vascular, or extra luminal invasion, it was felt that this patient was potentially curable with complete resection. Pancreas-sparing duodenectomy was successfully performed and an R0 resection was confirmed by pathology. The patient has since been doing very well. Pancreas-sparing duodenectomy can be a safe alternative for D3-D4 duodenal tumours, particularly in select patients unlikely to tolerate a pancreaticoduodenectomy.

REFERENCES

(1.) Egberts JH, Scharrer ML, Hinz S, Schafmayer C, Klomp HJ, Faendrich F, Tepel J. Small bowel cancer: single-centre results over a period of 12 years. Hepatogastroenterology. 2007; 54:129-34

(2.) Hu JX, Miao XY, Zhong DW, Dai WD, Liu W, Hu W. Surgical treatment of primary duodenal adenocarcinoma. Hepatogastroenterology. 2006; 53:858-62

(3.) Gonzalez GD, Evans EC. Primary adenocarcinoma of the duodenum. Am Surg. 1987; 53:174-9

(4.) Bilimoria KY, Bentrem DJ, Wayne JD, Ko CY, Bennett CL, Talamonti MS. Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg. 2009; 249:63-71

(5.) Eisenberger CF, Knoefel WT, Peiper M, Yekebas EF, Hosch SB, Busch C, Izbicki JR. Pancreas-sparing duodenectomy in duodenal pathology: indications and results. Hepatogastroenterology. 2004; 51:727-31

(6.) Bakaeen FG, Murr MM, Sarr MG, Thompson GB, Farnell MB, Nagorney DM, Farley DR, van Heerden JA, Wiersema LM, Schleck CD, Donohue JH. What prognostic factors are important in duodenal adenocarcinoma? Arch Surg. 2000; 135:635-41

(7.) Sarela AI, Brennan MF, Karpeh MS, Klimstra D, Conlon KC. Adenocarcinoma of the duodenum: importance of accurate lymph node staging and similarity in outcome to gastric cancer. Ann SurgOncol. 2004; 11:380-6

(8.) Declore R, Thomas JH, Forster J. Improving resectability and survival in patients with primary duodenal carcinoma. Am J Surg. 1993;166:626-30

(9.) Kaklamanos IG, Bathe OF, Franceschi D, Camarda C, Levi J, Livingstone AS. Extent of resection in the management of duodenal adenocarcinoma. Am J Surg. 2000; 179:37-41

(10.) Konishi M, Kinoshita T, Nakagohri T, Takahashi S, Gotohda N, Ryu M. Pancreas-sparing duodenectomy for duodenal neoplasms including malignancies. Hepatogastroenterology. 2007; 54:753-7

Authors: D Lam, KP Croome, R Hernandez-Alejandro

Location: London Health Sciences Centre, Ontario, Canada

Article Date: August 2012
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Article Details
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Author:Lam, D.; Croome, K.P.; Hernandez-Alejandro, R.
Publication:Journal of Surgical Case Reports
Article Type:Case study
Geographic Code:1CANA
Date:Aug 1, 2012
Words:1264
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