Duodenal Adenocarcinoma in a Patient with Partial Intestinal Malrotation

Li, William T.; Sethi, Shruti; Christopher, Adrienne N.; Koganti, Deepika; Yeo, Charles J.

doi:10.1089/pancan.2018.0005

Cited by 4 publications

(6 citation statements)

References 9 publications

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“…Malrotation is a congenital intestinal gestational disorder that affects not only the positioning of the midgut but also its vascular supply, and sometimes the ligament of Treitz is in abnormal position or even absent. It is generally a disease of childhood, but it can have significant implications later in adult surgeries as well, and sometimes it can cause recurrent abdominal pain and volvulus [ 6 – 8 ], but it rarely presents with a gastrointestinal neoplasm [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Pancreaticoduodenectomy in a patient with intestinal malrotation and distal cholangiocarcinoma: a case report and review of the literature

Arabi¹,

Abdoun²,

Ali³

et al. 2020

J Med Case Reports

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Background A combination of intestinal malrotation and distal cholangiocarcinoma is considered a rare condition and poses some difficulties in surgical management. We present a case of a patient with asymptomatic nonrotation of the midgut with a concomitant distal cholangiocarcinoma who underwent successful pancreaticoduodenectomy. Case presentation A 52-year-old Sudanese man presented to our hospital with progressive painless jaundice associated with dark urine, pale stool, and itching for the last 2 months. He had no other complaint or significant previous medical history apart from being an ex-smoker. His clinical examination revealed a palpable gallbladder and scratch mark. His other systems were unremarkable. His blood test results showed a normal complete blood count, elevated total bilirubin (mainly direct bilirubin), elevated alkaline phosphatase, and normal cancer antigen 19-9 and carcinoembryonic antigen. Ultrasound, computed tomography of the abdomen, and magnetic resonance cholangiopancreatography showed a dilated intrahepatic and extrahepatic biliary system down to the distal part, where the lumen was obstructed by a periampullary mass measuring 2.4 by 2.1 cm. The patient’s gallbladder was distended. He had no liver metastases or ascites and few lymph nodes. Inversion of the superior mesenteric artery and superior mesenteric vein but no invasion was seen, and malrotation of the bowel was observed with the large bowel on the left side and the small bowel to the right of the abdomen. Endoscopic retrograde cholangiopancreatography showed a fleshy ampulla that was stented. Laparotomy showed malrotation, with the duodenum straight on the right side of the midline, and Ladd’s band crossed the second portion of the duodenum. The vessels were approached from the lateral side meticulously after kocherization of the duodenum and pancreas, dissection along an extended portion of the superior mesenteric artery to assure preservation of the superior mesenteric artery and branches going to the jejunum, Ladd’s procedure, division of the jejunum 10 cm below the uncinate process of pancreas, and modified pancreaticoduodenectomy were performed, and anastomoses were performed in the standard fashion. The patient had an uneventful postoperative course, started oral feeding after 5 days, and discharged to home on day 10 for regular follow-up. Histopathology confirmed distal cholangiocarcinoma, and the patient was referred for further oncological management. Conclusions Pancreaticoduodenectomy can be safely performed in patients with intestinal malrotation with some modifications of the standard approach. Meticulous dissection after preoperative identification of vascular anomaly and a lateral approach are of great help to reduce morbidity.

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Section: Discussionmentioning

confidence: 99%

Pancreaticoduodenectomy in a patient with intestinal malrotation and distal cholangiocarcinoma: a case report and review of the literature

Arabi¹,

Abdoun²,

Ali³

et al. 2020

J Med Case Reports

View full text Add to dashboard Cite

show abstract

“…These relations need to be studied in detail preoperatively on the imaging studies to avoid such intraoperative difficulties. 2 3 11…”

Section: Discussionmentioning

confidence: 99%

“…Also, the anastomosis will be paracolic and mobilization of hepatic flexure and cecum may be avoided in these cases. 2 3 5 11…”

Section: Discussionmentioning

confidence: 99%

“…Thus, in these cases with intestinal malrotation, the key principles are to perform an accurate preoperative imaging to identify the anomalies present, plan a surgical approach based on the variations present which may be different from the conventional sequence of steps while performing PD, and perform careful adhesiolysis to avoid intestinal devascularization. 5 11 12 A useful technique is to follow each vessel to its origin to identify its variation before division of the vessel to avoid ischemia to critical structures in PD. Jejunal division may need modification to create a tension free anastomosis.…”

Section: Discussionmentioning

confidence: 99%

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Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases

et al. 2021

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Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.

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“…However, no report on the reconstruction procedure was found. We conducted a review of literature that included Japanese studies by searching the PubMed database, and we found reports on a total of 16 patients with intestinal malrotation who underwent pancreaticoduodenectomy (Table 1) [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. None of the 16 patients developed any complication associated with reconstruction.…”

Section: Discussionmentioning

confidence: 99%

Pancreaticoduodenectomy with malrotation following reoperation due to torsion of efferent loop: a case report

et al. 2020

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Background Malrotation is a congenital anomaly during the development of the embryonic intestine. Although it is generally considered a pediatric surgical condition, it can have significant implications for adult surgery in terms of reconstruction. Case presentation The patient was an 85-year-old man with pancreatic cancer and intestinal malrotation. He underwent pancreaticoduodenectomy with modified Child’s reconstruction. Because the ascending colon and efferent loop twisted easily, we fixed the ascending colon to the abdominal wall. Thereafter, right twist and stenosis of the efferent loop occurred. On the 22nd day after the initial surgery, detorsion and Braun anastomosis were performed for efferent loop fixation. Postoperative oral intake was good, and the patient was discharged from our hospital on the 24th day after the reoperation. Conclusions This is a rare case of pancreaticoduodenectomy with malrotation following reoperation due to a complication after Child’s reconstruction. In similar cases of intestinal malrotation, it is important to consider avoiding coaxial positioning of intestinal parts and an upper abdominal space while selecting a reconstruction method.

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Duodenal Adenocarcinoma in a Patient with Partial Intestinal Malrotation

Cited by 4 publications

References 9 publications

Pancreaticoduodenectomy in a patient with intestinal malrotation and distal cholangiocarcinoma: a case report and review of the literature

Pancreaticoduodenectomy in a patient with intestinal malrotation and distal cholangiocarcinoma: a case report and review of the literature

Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases

Pancreaticoduodenectomy with malrotation following reoperation due to torsion of efferent loop: a case report

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