if resectable , patients are generally treated with a pancreaticoduodenectomy ( whipple s procedure ) ( 3 ) .
we report a patient with a duodenal adenocarcinoma that was successfully resected by pancreas - sparing duodenectomy .
her past medical history was significant for hypertension , mild cerebral vascular accidents , atrial fibrillation , and coronary artery disease .
one week prior to transfer , she was intolerant of oral feeds , requiring parenteral feeds for nutrition .
bloodwork on admission were as follows : haemoglobin 12.6g / dl ; leukocyte count , 11500/mm3 ; creatinine 76 mol / l . a computed tomography ( ct ) scan revealed a mass in the duodenum measuring 6 x 3 cm .
an egd with biopsy was subsequently done and confirmed the diagnosis adenocarcinoma in the 2/3 part of the duodenum .
intraoperative images of pancreas - sparing duodenectomy : complete mobilization of duodenum and head of pancreas showing the tumour in the second / third portion of duodenum after being assessed by the general surgery , medicine and anaesthesia teams , the patient was consented for a laparotomy .
the ligament of treitz was incised and the proximal jejunum was passed beneath the superior mesenteric vessels to the right upper quadrant .
the proximal jejunum was transected using a gastrointestinal stapler . using sequential hemo - clips and silk ties ,
all feeding vessels were taken down from the uncinate process and ligated on the pancreatic side .
the proximal margin of the duodenum was transected at the level of the second portion , approximately 2 cm above the tumour , next to the ampulla of vater .
intraoperative images of pancreas - sparing duodenectomy : hand sewn , side to side , duodenojejunal anastomosis a hand sewn side - to - side anastomosis between the second portion of the duodenum and the jejunum was performed ( fig .
the anastomosis was sewn in two layers using a running and locking 3 - 0 pds stitch for the inner layer , followed by a 3 - 0 silk for a second layer .
simple interrupted 3 - 0 silk sutures were used to tack down the jejunum at the ligament of treitz .
a suction drain was placed in the proximity of the anastomotic site and the abdomen closed .
the operative time was three hours and the intraoperative blood loss was estimated to be 200ml .
intraoperative images of pancreas - sparing duodenectomy : completed anastomosis pathohistological analysis of the resected specimen revealed a low grade circumferential adenocarcinoma measuring 6.5 cm x 3.5 cm x 1.0 cm .
initially , her nasogastric tube was kept in place and her parenteral nutrition was maintained .
a postoperative upper gi series was done on day 6 and the anastomosis was in - tact ( fig .
after the contrast study , her suction drain was removed . at day 7 , the patient was tolerating a transitional diet . by day 9
, she was tolerating a full diet and discharged home . at her six month followup , the patient was doing well with no complaints .
duodenal adenocarcinomas are rare and account for just 0.3% of all gastrointestinal malignancies ( 1,2 ) . however , it is the most common neoplasm of the duodenum , accounting for 64% ( 4 ) . due to its non - specific symptoms ,
it is often not diagnosed until disease advanced . surgical resection with removal of all invaded tissues
is considered the best treatment , and in most instances a whipple s procedure is the treatment of choice for duodenal malignancies ( 3 ) .
small studies have shown that in select cases , pancreas - sparing partial duodectomy provides an acceptable morbidity and mortality rate for distal tumours located in the distal d3 or d4 when compared to pancreaticoduodenectomy ( 5 ) .
lymph node invasion is a very important indicator for long term survival , more important than tumour size , or local invasion ( 6,7 ) .
patients with lymph node metastases have 2-year survival rates of 30% , whereas patients those with no lymph node involvement have a 5-year survival rate of 72% ( p<0.05 ) ( 8) .
pancreas sparing duodenectomy decreases operative time , avoids resection of distal bile duct and pancreas , and circumvents the subsequent need for biliary - enteric and pancreatic - anastomoses , and thus decreases the morbidity significantly ( 9 ) .
segmental resection of distal duodenal tumours have been demonstrated to be a safe alternative to pancreaticoduodenectomy ( 10).with our patient who was of advanced age and had significant medical comorbidities , a pancreaticoduodenectomy procedure would likely have been poorly tolerated . however , since there was no evidence of lymphatic , vascular , or extra luminal invasion , it was felt that this patient was potentially curable with complete resection .
pancreas - sparing duodenectomy was successfully performed and an r0 resection was confirmed by pathology .
pancreas - sparing duodenectomy can be a safe alternative for d3-d4 duodenal tumours , particularly in select patients unlikely to tolerate a pancreaticoduodenectomy .
 a duodenal adenocarcinoma arising from the junction of the second and third portion of the duodenum , which was resected by pancreas - sparing duodenectomy , is reported . 
 the completely obstructing tumour was circumferential and measured 6.5 cm x 3.5 cm x 1.0 cm . there was no evidence of pancreas invasion , nor any lymph node metastasis . 
 pancreas - sparing duodenectomy was performed , with dissection of the pancreaticoduodenal lymph nodes . 
 the proximal duodenum was transected just distal to the ampula of vater and jejunum was transected just distal to the ligament of treitz . a hand - sewn side - to - side anastomosis for the duodenojejunostomy 
 was performed . 
 there were no postoperative complications . 
 pathology reported a duodenal adenocarcinoma resected with negative margins . 
 pancreaticoduodenectomy is the treatment of choice for a duodenal adenocarcinoma , however , pancreas - sparing duodenectomy may be a safe alternative for duodenal tumours not involving the 2nd portion , especially in elderly patients with multiple medical comorbidities . 
INTRODUCTION
CASE REPORT
DISCUSSION