1. Department of General Surgery, Upper Gastrointestinal Unit,
LAPAROSCOPIC RIGHT HEMICOLECTOMY WITH WEDGE EXCISION OF DUODENUM FOR LOCALLY ADVANCED HEPATIC FLEXURE ADENOCARCINOMA AND SUBTOTAL GASTRECTOMY FOR GASTRIC OUTLET OBSTRUCTION FROM CHRONIC GASTRIC ULCER STRICTURE.
B. C. Toh and J. Rao
Department of General Surgery, Upper Gastrointestinal Unit,
Tan Tock Seng Hospital, Singapore.
Introduction :
Figure 2: Upper Endoscopy showed chronic ulcer with stricture causing gastric outlet obstruction.
Surgical treatment for locally advanced colonic hepatic flexure adenocarcinoma with direct invasion to duodenum is a challenging case even to skilled surgeon. The standard surgical treatment includes right radical hemicolectomy with en bloc pancreaticoduodenectomy.1 However, in selected case, right radical hemicolectomy with enbloc wedge excision of duodenum is a feasible option as it enhances early recovery and reduces morbidity. We present an unusual case of patient presented with symptoms of gastric outlet obstruction with chronic gastric ulcer stricture with locally advanced hepatic flexure tumour with direct invasion to duodenum who underwent successfully minimal invasive surgery.
Results :
Patient underwent laparoscopic right hemicolectomy with wedge excision of duodenum with Subtotal Gastrectomy Bilroth II reconstruction. Four 10-12mm Ports placed at supraumbilical, suprapubic, right and left iliac fossa region and another two 5mm working ports at right and left upper outer quadrant. Standard Right Hemicolectomy performed with wedge excision of duodenum. Primary closure of duodenotomy performed laparoscopically with V-loc suture. It was followed by Subtotal gastrectomy Bilroth II reconstruction. Total operating time was five hours with intra-operative blood loss about 200ml. Postoperatively, patient was started on oral feeding from Day 4. Patient was discharged well on post-operative Day 7. Final histology showed poorly differentiated adenocarcinoma with pT4bN0 ( 0/20 Lymph Node positive). Tumour penetrated to the surface of the visceral peritoneum (serosa) and directly invaded adjacent subserosal soft tissue of the duodenum. Proximal, distal and circumferential margins were negative. Histology of subtotal gastrectomy showed chronic inflammation. Patient subsequently completed adjuvant chemotherapy. Follow-up PET-CT scan one year later do not show any evidence of recurrent malignancy.
Materials and Methods :
A 73 years old lady presented with symptoms of vomiting and change in bowel habit. She underwent upper endoscopy that showed chronic gastric ulcer stricture causing gastric outlet obstruction. Biopsy was taken that showed chronic gastritis. She also underwent colonoscopy which showed hepatic flexure tumour. CT-scan of abdomen and pelvic showed locally advanced hepatic flexure tumour with duodenum invasion. There were no liver or lung metastases lesions.
Figure 1 : CT-scan of abdomen and pelvic showed gastric outlet obstruction and hepatic flexure of circumferential mural thickenning mass.
Figure 3: Right Hemicolectomy and Subtotal Gastrectomy Specimen.
Conclusion:
Laparoscopic Right Hemicolectomy with wedge excision of duodenum for locally advanced hepatic flexure adenocarcinoma and Subtotal Gastrectomy with Bilroth II reconstruction for chronic gastric ulcer stricture is safe and feasible in selected case. The oncological outcome may not be inferior to standard open approach and yet to be proven.
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Yang W, Li S, Zhang L and et al. Chin. Surgical treatment and prognosis of cancers of hepatic flexure of colon invading the duodenum in 65 patients. Ger. J. Clin. Oncol. 2011;10:166.