Simultaneous resection for synchronous double primary adenocarcinomas of the head of pancreas and rectum. Challenges and result of an aggressive surgical approach

Abstract

Introduction: Pancreatic ductal adenocarcinoma is a malignant disease with poor prognosis and high mortality due to its late presentation. Synchronous double primary tumours of the head of pancreas and rectum is a rare occurrence and scarcely reported in the literature. Case presentation: A 67-year-old man presented with fever for 10 days associated with anorexia and weight loss for three weeks. He denied abdominal pain, jaundice or altered bowel habit. His co-morbidities included diabetes mellitus and hypertension. Physical examination was unremarkable. His biochemistry showed obstructive jaundice features and non-reactive viral hepatitis infection. Abdominal sonography and contrasted tomography scan meanwhile revealed grossly dilated intra- and extra-hepatic bile ducts. The endoscopic ultrasound demonstrated distal common bile duct mass and fine needle biopsy was performed. A biliary stent was inserted via ERCP to relieve the biliary obstruction. Subsequently, a colonoscopy was performed following his positive fecal occult blood test which unveiled a polypoidal upper rectal mass. Biopsy of both the ductal and rectal lesions revealed adenocarcinoma. He underwent simultaneous pancreaticoduodenectomy and anterior resection but complicated by pancreaticojejunostomy leak postoperatively, which was treated conservatively. The final histology reaffirmed adenocarcinomas of pancreas and rectum. He recovered well and completed adjuvant chemotherapy with no tumour recurrence detected a year later. Conclusions: Simultaneous resection for synchronous double primary adenocarcinomas of the head of pancreas and rectum is an aggressive approach with considerable perioperative morbidity that necessitates multidisciplinary discussion. We report the surgical management of this rare case, discuss its challenges and present a review of the literature.