Laparoscopic Distal Gastrectomy for Duodenal Adenocarcinoma Located in a Duodenal Bulb Diverticulum: Report of a Rare Case

Abstract

Introduction: Duodenal adenocarcinomas are relatively rare. We report here a particularly rare case of duodenal adenocarcinoma that arose within a duodenal bulb diverticulum and was successfully managed surgically.

Case presentation: A 70-year-old woman presented to us with a history of duodenal bulb ulceration and a diverticulum in the same area diagnosed by esophagogastroduodenoscopy. Routine endoscopic examination revealed an elevated lesion growing from within the diverticulum to outside of it. Examination of a biopsy specimen resulted in a diagnosis of well-differentiated adenocarcinoma. Computed tomography failed to detect any lesions in the duodenal bulb. No enlarged lymph nodes or distant metastases were found. Fluoroscopic examination revealed a pool of contrast suggestive of a diverticulum in the duodenal bulb on the anal side of the pyloric ring. Thus, the clinical stage according to the TNM Classification based on the 8th edition of the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC 8th edition) was T1N0M0: Stage I. Endoscopic resection was not feasible because the tumor's origin was within the diverticulum. Furthermore, surgical local resection was considered not to be feasible because of the tumor size and location. We performed laparoscopic distal gastrectomy, D1+ lymph node dissection, and Roux-en-Y reconstruction. The patient was discharged on the 10th postoperative day and is currently on outpatient follow-up with no evidence of recurrence 1 year postoperatively.

Conclusions: We report here a rare case of an adenocarcinoma arising within a duodenal bulb diverticulum. We successfully performed a laparoscopic distal gastrectomy, this procedure being considered the optimal surgical approach for this patient.

Keywords: distal gastrectomy; duodenal adenocarcinoma; duodenal bulb diverticulum.

Fig. 1. Findings of esophagogastroduodenoscopy. (A) An elevated lesion (yellow arrowheads) spread from within the diverticulum (red arrowhead) to the surrounding area. (B) The image shows the relationship between the pyloric ring (red arrowhead) and the tumor (yellow arrowhead). It can show that the tumor is located just on the anal side of the pyloric ring. (C) Narrow-band imaging (NBI) mode. The disturbed vascular structure (yellow arrowheads) suggests the presence of a malignant tumor.

Fig. 2. Findings of computed tomography. Computed tomography scan image. No lesions were detected in the duodenal bulb (yellow arrowhead).

Fig. 3. Findings of gastric fluoroscopic examination. A pool of contrast (yellow arrowheads) suggestive of a diverticulum in the duodenal bulb on the anal side of the pyloric ring (red arrowhead).

Fig. 4. Intraoperative findings. (A) Findings at the start of surgery. A diverticulum (yellow arrowheads) was observed in the anterior wall of the duodenal bulb. (B) Findings of No. 6 lymph node dissection. The right gastroepiploic artery (yellow arrowheads) were dissected at the root. The red arrowheads are the preserved gastroduodenal artery. (C) To expose the duodenal dissection line, a branch of the superior pancreaticoduodenal artery (yellow arrowheads) was dissected and separated from the pancreatic head. (D) The duodenum was dissected on the anorectal side of the diverticulum (yellow arrowheads) while observing with an intraoperative endoscope.

Fig. 5. Operative specimen. (A) Macroscopic findings. A tumor (yellow arrowhead) is located in the duodenal bulb. R0 resection was achieved. (B) Enlarged macroscopic findings (yellow arrowheads). (C) Photomicrograph of hematoxylin and eosin-stained specimen showing atypical cells in the area indicated by the blue arrowheads, extending from within the diverticulum (red arrowhead) to outside of it. (D) Photomicrograph of specimen immunostained with desmin (red arrowheads) showing that there is an intrinsic muscular layer.