Duodenojejunostomy treatment of groove pancreatitis-induced stenosis and obstruction of the horizontal duodenum: A case report

Abstract

Background: Groove pancreatitis (GP) is a rare condition affecting the pancreatic groove region within the dorsal-cranial part of the pancreatic head, duodenum, and common bile duct. As a rare form of chronic pancreatitis, GP poses a diagnostic and therapeutic challenge for clinicians. GP is frequently misdiagnosed or not considered; thus, the diagnosis is often delayed by weeks or months. The treatment of GP is complicated and often requires surgical intervention, especially pancreatoduodenectomy.

Case summary: A 66-year-old man with a history of long-term drinking was admitted to the gastroenterology department of our hospital, complaining of vomiting and acid reflux. Upper gastrointestinal endoscopy showed luminal stenosis in the descending part of the duodenum. Abdominal computed tomography showed slight exudation in the descending and horizontal parts of the duodenum with broadening of the groove region, indicating local pancreatitis. The symptoms of intestinal obstruction were not relieved with conservative therapy, and insertion of an enteral feeding tube was not successful. Exploratory laparoscopy was performed and revealed a hard mass with scarring in the horizontal part of the duodenum and stenosis. Intraoperative frozen section analysis showed no evidence of malignancy, and side-to-side duodenojejunostomy was performed. Routine pathologic examination showed massive proliferation of fibrous tissue, hyaline change, and the proliferation of spindle cells. Based on the radiologic and pathologic characteristics, a diagnosis of GP was made. The patient presented with anastomotic obstruction postoperatively and took a long time to recover, requiring supportive therapy.

Conclusion: GP often involves the descending and horizontal parts of the duodenum and causes duodenal stenosis, impaired duodenal motility, and gastric emptying due to fibrosis.

Keywords: Case report; Duodenal obstruction; Duodenal stenosis; Duodenojejunostomy; Groove pancreatitis.

Figure 1

Abdominal plain computed tomography, axial view. A: Abdominal plain computed tomography (CT) showed gastric retention (yellow arrow) and a nodule (35 mm × 23 mm) in the anterior wall of the pylorus (red arrow); B-D: Abdominal CT showed slight exudation in the descending and horizontal parts of the duodenum with broadening of the groove region, indicating local pancreatitis around the pancreatic head (green arrows) and gastric retention (yellow arrows).

Figure 2

Abdominal plain computed tomography, coronal view. A-D: An irregular nodule was found in the descending part of the duodenum with no clear demarcation (green arrows); A, C and D: Images showed abdominal aortic wall calcification (red arrows) and partial calcified endometrium inward migration.

Figure 3

Magnetic resonance cholangiopancreatography. A and B: Images showed a normal bile duct and pancreatic duct and gastric retention (yellow arrows).

Figure 4

Upper gastrointestinal endoscopy. A-D: The descending part of the duodenum showed slight edema and obvious luminal stenosis.

Figure 5

Magnetic resonance cholangiopancreatography. A and B: Magnetic resonance cholangiopancreatography showed duodenal wall thickening with exudation (green arrows).

Figure 6

Postoperative iodine hydrography. A-B: Images showed obstruction of the anastomotic stoma (green arrows) and no visualization of the distal small intestine and colon.

Figure 7

Postoperative upper gastrointestinal endoscopy. A and B: Images showed congestion of the anastomotic stoma (green arrows); C and D: Images showed stenosis of the efferent loop (yellow arrows).

Figure 8

Histopathological findings of the intraoperative biopsy (hematoxylin and eosin; 20 ×). A: Representative specimens showing massive proliferation of fibrous tissue and hyaline change (green arrows); B: Representative specimens showing interstitial hemorrhage (green arrows); C: Representative specimens showing chronic inflammatory cell infiltration (green arrows); D: Representative specimens showing proliferation of spindle cells (green arrows).

Figure 9

Postoperative iodine hydrography at 3 mo after surgery. A-B: Images showed that iodine water could enter the jejunum (green arrows) via the horizontal part of the duodenum.