Pancreas-sparing and superior mesenteric artery first approach in duodenal adenocarcinoma of the fourth portion of duodenum: A case report

INTRODUCTION: Peroperative assessment of resectability in pancreas-sparing duodenectomy for distal duodenal (D3-D4) adenocarcinoma is challenging for surgeons. PRESENTATION OF CASE: We report a 68-year-old man with biopsy-proven adenocarcinoma of the fourth portion of duodenum which had been diagnosed with upper endoscopy and CT. A pancreas-sparing duodenectomy with loco-regional lymph node resection using the superior mesenteric artery first approach was performed. DISCUSSION: Adenocarcinoma of the fourth portion of duodenum is rare. It has non-specific symptoms. The diagnosis is difficult and is frequently delayed. Surgery is the only chance of cure. After peroperative assessment of resectability, with intraoperative ultrasound, complete exposition of the duodenum and entire dissection of the superior mesenteric artery (SMA) using the artery-first approach technique should be done to assess for tumor resectability, which should include the possibility of complete lymphadenectomy of the mesenteric root. If technically feasible, a pancreas-sparing resection should be preferred to avoid pancreatectomy-related morbi-mortality. The aim of the surgery is a R0 resection which has a 5-year survival rate between 25% and 75%. CONCLUSION: Artery-first approach of the SMA should be considered by surgeons in adenocarcinoma of the distal duodenum to identify any contra-indications to proceed further.