A case of wedge resection of duodenum for massive gastrointestinal bleeding due to duodenal metastasis by renal cell carcinoma

Abstract

Background: Gastrointestinal bleeding due to duodenal metastasis from renal cell carcinoma is extremely rare. Several previous reports have shown that embolic therapy or pancreatoduodenectomy (radical surgical resection) could be effective in controlling this type of clinical complication. Management is entirely dependent on the general condition and concurrent metastases at other sites. Optimizing the therapeutic strategies thus deserves further discussion and exploration.

Methods: In this report, we describe a patient with severe co-morbidities who underwent successful palliative wedge resection of duodenum and direct duodenal wall defect repair without reconstruction of duodeno-jejunostomy for acute upper digestive tract hemorrhage caused by duodenal metastasis from renal clear cell carcinoma.

Results: The patient recovered uneventfully and did not experience rebleeding and frequent vomiting after surgery. Since then (1.5 years) he has had no evidence of rebleeding.

Conclusions: Gastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities, and for palliative treatment.

Figure 1

Gastroscopy showing a mass in the descending portion of the duodenum with mucosal ulcerations and focal hemorrhage. The whole lumen of the duodenum was occupied by the tumor, and the duodenal papilla cannot be visualized.

Figure 2

Upper GI meal barium showing a filling-defect in the descending and the horizontal portion of the duodenum. The mucous membrane was not smooth, and there was limited dilatation.

Figure 3

Abdominal computed tomography showed a 2.0 cm enhancing mass in the pancreatic tail. According to CT arterial phase, the pancreatic mass revealed enhancing lesions.

Figure 4

Tumor invasion of the descending duodenum with mucosal ulcerations and focal hemorrhage. The ampulla of Vater was not affected, but part of the duodenum was tightly adherent to the surrounding tissue, including the inferior vena cava and retroperitoneal space.

Figure 5

Gross appearance of the resected tumor.

Figure 6

(A) Immunohistochemical staining by renal cell carcinoma (RCC) (original magnification, ×400). (B) Immunohistochemical staining by Cytokeratin 18 (CK18) (original magnification, ×400). (C) Hematoxylin and eosin (HE)-staining showing polygonal cells with clear cytoplasm and relatively uniform nuclei, some of them exhibiting prominent nucleoli (original magnification, ×400).