A Rare Case of Advanced Duodenal Cancer Infiltrating the Head of Pancreas and the Mesocolon of the Hepatic Flexure

Abstract

Background Primary small bowel carcinoma is a very rare tumor, with non-specific symptoms that usually cause a delay in diagnosis and, consequently, a negative outcome. Duodenal carcinoma is on its own an uncommon tumor of the intestinal tract. Our case presented further local advancement with infiltration of the hepatic flexure mesocolon. En-block pancreaticoduodenectomy plus right hemicolectomy or Colo-Pancreatico- Duodenectomy (cPD) is feasible in highly selected patients if performed by experienced surgeons. Case presentation We are introducing the case of a 48 y/o male patient presenting with a dull pain of the lower abdomen and dark stools (melena) in the recent episodes of defecation; considerable weight loss; jaundice (total bilirubin level 10 mg/dL). In the radiologic investigations, IV contrast CT of the abdomen revealed the presence of a 7.7 cm x 8.5 cm mass of duodenum (D3) which infiltrates the head of pancreas as evidenced by homogeneous contrast enhancement. The pancreatic duct of Wirsung was dilated, 4.4 mm. Gastroduodenoscopy visualizes a non-circumferential ulcerative proliferation. Exploratory laparotomy was performed. Intraoperatively we encountered the presence of local progression of the primary duodenal lesion into head of the pancreas, the mesocolon of the hepatic flexure with infiltration of the right colic vessels. Colo-Pancreatico-Duodenectomy (cPD) and Whipple’s procedure was performed, with Blumgart type pancreatico-jejunal and ileo-colic anastomoses. Discussion En-block pancreaticoduodenectomy plus right hemicolectomy or Colo-Pancreatico-Duodenectomy (cPD) is feasible in highly selected patients if performed by experienced surgeons. The most common indication of cPD is locally advanced pancreatic head cancer that directly invades the colon or mesocolon, followed by locally invaded colon cancer at the duodenum and/or pancreatic head. The cPD procedure is rarely performed in gastrointestinal surgery. This is due to its complexity, difficulty, and high risks. In certain acute situations, cPD is the efficacious path forward. Conclusion Following a careful evaluation plan, along with necessary consults for accompanying disorders, the indications for colo-pancreatico-duodenectomy were clearly set for this patient with locally advanced duodenal adenocarcinoma infiltrating the pancreas head and hepatic flexure mesocolon. Our experience highlights the importance of meticulous and experienced perioperative care to minimize complications and mortality. Keywords: General surgery, Duodenal cancer, Whipple procedure, colo-pancreatico-duodenectomy, cPD, Blumgart pancreatico-jejunal anastomosis DOI: 10.7176/ALST/95-01 Publication date: November 30 th 2022