Hybrid laparoscopic pancreas-preserving subtotal duodenectomy for suspected early duodenal cancer: A case report.

Introduction: Non-ampullary duodenal adenomas rarely show malignant potential. However, such adenomas located in the periampullary area are suspected of being malignant and require surgical treatment.

Presentation Of Case: A 75-year-old man presented with a 30-mm wide, endoscopically-unresectable laterally spreading tumor in the periampullary area. Biopsy showed a tubular adenoma; however, the size and color of the tumor strongly suggested malignancy. Therefore, a hybrid laparoscopic pancreas-preserving subtotal duodenectomy (HLPPSD) was performed. Laparoscopically, a Kocher maneuver was performed. The jejunum was divided 10 cm distal to the ligament of Treitz, and the duodenum was also divided at the supraduodenal-angle. The Shuriken method was applied, and the surgery converted to an open procedure. The common bile and pancreatic ducts were divided, and the subtotal duodenum and 10 cm of the jejunum were removed. Thereafter, the jejunal stump was hand-sutured to the duodenal stump. Cholangiojejunostomy and pancreatojejunostomy were performed under direct vision. Finally, an umbilicoplasty was performed. The histology revealed that the tumor was a carcinoma in situ.

Discussion: Endoscopic resection is the first-choice for duodenal adenoma suspected of malignant potential. When the endoscopically-unresectable tumor is located in periampullary area, pancreatoduodenectomy is generally selected because ampulla cannot be preserved. However, HLPPSD is an alternative option.

Conclusions: Non-ampullary duodenal adenomas can be malignant when the tumor is large and red. In these cases, HLPPSD can be useful; less invasive than conventional pancreaticoduodenectomy; leaves only a 3-cm, round scar, in addition to the laparoscopic port scars; and combines the benefits of both open and laparoscopic surgeries.