A case of primary adenocarcinoma of the third portion of the duodenum resected by laparoscopic and endoscopic cooperating surgery

Abstract

Introduction: We report a case of primary adenocarcinoma in the third portion of the duodenum (D3) curatively resected by laparoscopic and endoscopic cooperating surgery (LECS).

Presentation of case: A 65-year-old woman had a routine visit to our hospital for a follow-up of rectal cancer resected curatively 2 years ago. A routine screening gastroduodenal endoscopy revealed an elevated lesion of 20mm in diameter in the D3. The preoperative diagnosis was adenoma with high-grade dysplasia; however, suspicion about potential adenocarcinoma was undeniable. Curative resection was performed by LECS. Pathological examination revealed intramucosal adenocarcinoma arising from normal duodenal mucosa. The tumor was stage I (T1/N0/M0) in terms of the tumor, nodes, metastasis (TNM) classification. LECS for duodenal tumor has seldom been reported previously, and this is the first report of LECS for primary adenocarcinoma in the D3. The transverse mesocolon was removed from the head of pancreas to expose the duodenum, and the accessory right colic vein was cut; this was followed by the Kocher maneuver for mobilization of the lesion site.

Discussion: LECS enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing. Thorough mobilization of the mesocolon and pancreas head is essential for this procedure because it facilitates correct resection and suturing.

Conclusion: LECS is a feasible treatment option for duodenal neoplasms, including intramucosal adenocarcinoma, even though it exists in the D3.

Keywords: Duodenal adenocarcinoma; Duodenum; Laparoscopic and endoscopic cooperating surgery.

Fig. 1

Gastroduodenoscopy. (A) Gastroduodenoscopy in white-light. A 20 mm sessile tumor in the third portion of the duodenum was shown. (B) Endoscopic narrow-band imaging showed a rough micro surface pattern. (C) Chromoendoscopy revealed that the tumor was spreading laterally (arrow).

Fig. 2

Hypotonic duodenography showed an elevated lesion on the lateral side of the third portion of the duodenum.

Fig. 3

The trocar arrangement. A 12 mm trocar was placed in the umbilicus as a camera port. Two 5 mm trocars were placed in the left lateral upper quadrant (operation port). One 5 mm trocar and one 12 mm trocar were placed in the right upper quadrant (operation port).

Fig. 4

Operative procedures. (A) Mobilization of the transverse colon. The accessory right colic vein is seen (arrow). (B) Head of pancreas (arrowhead) is dissected from the retroperitoneum. (C) The transmitting light of the endoscope indicated that the tumor sight could be seen in the laparoscopic view. (D) Full-thickness excision approximately two-thirds circumference around the tumor is finished endoscopically and the tumor is inverted into abdominal cavity (arrow).

Fig. 5

Hematoxylin-eosin staining. Intramucosal adenocarcinoma with increasing nuclear pleomorphism and loss of polarity is shown.