Adenocarcinoma of the third and fourth portions of the duodenum: results of surgical treatment

HYPOTHESIS: To verify the adequacy of duodenal segmentectomy after intestinal derotation in the treatment of primary adenocarcinoma of the third and fourth portions of the duodenum. DESIGN: A retrospective review of the surgical management of patients who underwent derotation of the third and fourth portions of the duodenum was undertaken to determine long-term outcome. SETTING: Departments of surgery in 3 university hospitals. PATIENTS: Between January 1, 1980, and December 31, 2000, 47 patients with primary adenocarcinoma of the third and fourth portions of the duodenum were surgically treated at 3 different institutions. MAIN OUTCOME MEASURES: Details of primary surgery were abstracted from clinical records of the original hospital referral. Postoperative clinical course and long-term outcome were evaluated by a review of the hospital records and follow-up. RESULTS: The results of a barium swallow test series was positive in 38 cases (80.8%) and esophagogastroduodenoscopy was primarily diagnostic in 30 patients (63.8%). In all cases duodenal segmentectomy was attempted. Twenty-two patients underwent palliative gastrojejunal bypass and in 9 patients pancreaticoduodenectomy was performed. In 16 cases duodenal segmentectomy was performed after intestinal derotation. Anastomoses were performed manually in all cases. Fifteen of the resected patients died of recurrent disease. A median (SD) disease-free survival of 36 (23.6) months (range, 6-85 months) was observed. The median (SD) overall survival was 37.5 (23.9) months (range, 11-85 months), the overall 5-year survival rate was 23% (11 patients), and the actuarial 5-year survival rate was 51% (24 patients). CONCLUSIONS: Duodenal segmentectomy associated with intestinal derotation was shown to be a straightforward, safe procedure for the treatment of the primary adenocarcinoma of the third and fourth portions of the duodenum. This surgical procedure should be preferred to pancreaticoduodenectomy because it is associated with negligible rates of morbidity and mortality, while allowing for satisfactory margin clearance and adequate lymphadenectomy.     

Anterior transposition of the third part of the duodenum for the treatment of superior mesenteric artery syndrome

A 14-year-old adolescent girl with superior mesenteric artery syndrome was referred to us after failure of conservative management. Anterior transposition of the duodenum was performed and appears to be safe for permanently circumventing the duodenal obstruction seen in superior mesenteric artery syndrome, even in a pediatric population.     

Diverticula of the third portion of the duodenum

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1. A case of diverticulum of the third portion of the duodenum is presented.     

Adenocarcinoma of the duodenum: factors influencing long-term survival

This single-institution retrospective analysis reviews the management and outcome of patients with surgically treated adenocarcinoma of the duodenum. Between February 1984 and August 1996, fifty-five patients with adenocarcinoma of the duodenum underwent surgery at The Johns Hopkins Hospital. Univariate analysis was performed to identify possible prognostic indicators. Curative resection was performed in 48 patients (87%): 35 of these patients (73%) underwent a pancreaticoduodenectomy (PD), whereas 27% (n = 13) underwent a pancreas-sparing duodenectomy (PSD). Patients undergoing PD were comparable to those undergoing PSD with respect to demographic factors, presenting symptoms, and tumor pathology. The remaining 13% of patients (n = 7) were deemed unresectable at the time of surgery and underwent biopsy and/or palliative bypass. PD was associated with an increase in postoperative complications when compared to PSD (57% vs. 30%), but this difference was not statistically significant. One perioperative death occurred following PD (mortality 2.9%), The overall 5-year survival rate for the 48 patients undergoing potentially curative resection was 53 %. Negative resection margins (P <0.001), PD (P <0.005), and tumors in the first and second portions of the duodenum (P <0.05) were favorable predictors of long-term survival by univariate analysis. Nodal status, tumor diameter, degree of differentiation, and the use of adjuvant chemoradiation therapy did not influence survival. These data support an aggressive role for resection in patients with adenocarcinoma of the duodenum Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

Anterior transposition of the third part of the duodenum in the management of chronic duodenal compression by the superior mesenteric artery

Transposition of the third part of the duodenum anteriorly to the superior mesenteric vessels was performed in ten patients with chronic duodenal obstruction due to compression by the superior mesenteric artery (SMAS). Follow-up evaluation showed that all the patients (a) had complete relief of their preoperative symptoms, (b) could tolerate normal diet postoperatively and (c) gained weight rapidly following surgery. There were no major complications or deaths among the patients so treated. The Author feels that this technique is more direct approach, aimed at permanently circumventing the obstruction for these groups of patients selected on the basis of the radiological, pathological and operative findings. The success encountered with the patients so treated would seem to confirm this impression.     

Leiomyosarcoma of the duodenum]

The paper reports the case of a patient with leiomyosarcoma of the duodenum who underwent radical duodenocephalopancreatectomy and survived for 22 months after the operation. Following a review of the international literature on the topic, the diagnostic procedures and prognostic criteria of this uncommon tumour are discussed. In conclusion, leiomyosarcoma always presents considerable problems of diagnosis even with the aid of biopsy and only surgery can lead to recovery in a limited number of cases.     

Carcinoids of the first part of the duodenum.

Three cases of duodenal carcinoid tumour are described and the histology of this type of tumour is discussed. Two of the patients have been followed up for 8 years. No further complications related to the tumours have been observed.     

Adenocarcinoma of the duodenum associated with skin neurofibromatosis and Caroli's disease

A case of primary adenocarcinoma of the duodenum associated with Recklinghausen's disease and Caroli's disease provides the opportunity to review the literature. Malignant tumours of the duodenum are extremely rare and even rarer is their association with R's and Caroli's diseases. It should not be forgotten that in Recklinghausen's disease gastro-intestinal involvement is possible. Caroli's disease is diagnosed anatomopathologically. Surgical resection remains the sole satisfactory treatment when the tumour has not spread locally or at a distance. If it has, treatment must be palliative.