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Indian Journal of Surgery, Vol. 68, No. 3, May-June, 2006, pp. 174 Case Report Carcinoma of the fourth part of the duodenum Mallika Tewari, Ajay K. Khanna* Department of Surgical Oncology and *General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP, India Code Number: is06056 Abstract Primary carcinoma of the duodenum is uncommonly encountered. This is a report of a 45-year-old gentleman who was admitted to our unit with a one-month history of upper abdominal distention. Barium study revealed a narrowed segment of the fourth part of duodenum. A hard stenosing growth was found in the fourth part of duodenum, at laparotomy. He was treated by distal segmental resection and regional lymphadenectomy, that relieved his symptoms. He is asymptomatic and recurrence free at one year follow up.Keywords: Carcinoma duodenum, segmental resection Primary carcinoma of duodenum is rare, accounting for only 0.35% of all gastrointestinal carcinomas, and carcinoma of the fourth part of the duodenum constitutes approximately 10% of duodenal carcinomas.[1] Due to infrequency of the condition, there remains diagnostic and therapeutic uncertainty, and thus diagnosis is often made late. CASE REPORT A 45-year male presented with a one-month history of bloating of abdomen and vomiting after meals. Examination revealed upper abdominal distension and visible peristalsis. A narrowed segment in the fourth part of duodenum was seen in barium meal follow through study. The patient developed frank intestinal obstruction, and an emergency laparotomy had to be performed. A hard stenosing growth was found in the fourth part of duodenum, with dilated proximal part of duodenum. There were no surrounding enlarged lymphnodes. The growth was resectable, with no local invasion or distant spread. Distal segmental resection with regional lymphadenectomy was performed, followed by primary anastomosis. The patient had an uneventful postoperative course. Histopathology revealed moderately differentiated adenocarcinoma with areas of papillary differentiation and mucin secretion. The tumor had transmural invasion. The resected margins were free with no lymphnode involvement.DISCUSSION Nearly 45% of all adenocarcinomas of the small bowel arise within the duodenum. Approximately 15% of these are in the first part of duodenum, 40% in the second portion, and 45% are in the distal duodenum.[2] The median age of these patients is 60 years, although our patient was younger. The most common presenting symptom is upper abdominal pain related to partial duodenal obstruction.[2] Our patient also had features suggestive of upper intestinal obstruction. Diagnosis is usually suspected from the upper gastrointestinal series, as was with this patient. Hypotonic duodenography may improve the diagnostic yield. Histologic confirmation can be obtained preoperatively in most patients by upper gastrointestinal endoscopy, with total duodenoscopy. Patients with tumors of third and fourth portions of duodenum often undergo complete resection with segmental duodenectomy and primary anastomosis. Most authors suggest that outcome in duodenal carcinoma depends on resectability, lymphnode involvement, and histological grade.[2] On the other hand, some hold the view that metastasis to lymphnodes, advanced tumor stage, and positive resection margins are associated with decreased survival in patients with duodenal adenocarcinoma.[3] Tumor size, grade, and location within the duodenum have no impact on survival.[3] The outcome appears favorable in this patient, in view of complete segmental resection with no lymphatic spread, and a moderately differentiated tumor. There is no clear cut evidence in literature that supports that pancreaticoduodenectomy results in superior survival than segmental resection.[4] Infact, Wellner et al[5] support the fact that radical resection of tumors in distal duodenum, even by segmental resection, provides a more favorable prognosis for duodenal carcinoma than for pancreatic tumors. Kaklamanos et al[6] reviewed the records of 63 patients treated for duodenal adenocarcinoma from 1979 to 1998, and compared the perioperative outcome, patient survival, and extent of lymphadenectomy in patients who underwent pancreaticoduodenectomy and segmental resection. They concluded that segmental duodenal resection for patients with duodenal adenocarcinoma was associated with acceptable postoperative morbidity and long-term survival, and that the clearance of lymphnodes is comparable to pancreaticoduodenectomy.[6] Our patient had an uneventful postoperative course, and is asymptomatic and recurrence- free at one year post surgery. The role of postoperative adjuvant therapy is still unclear, and efforts are underway with 5-fluorouracil- based chemotherapy regimens. CONCLUSION Primary carcinoma of distal duodenum is rare, and diagnosis is often late. The disease should be suspected, even if symptomatology is poor. Segmental resection with regional lymphadenectomy, if feasible, offers a good treatment option for patients with carcinoma of distal duodenum.References
Copyright 2006 - Indian Journal of Surgery |
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