Laparoscopic duodenojejunostomy for malignant stenosis as a part of multimodal therapy: A case report

INTRODUCTION

Patients with recurrent or metastatic cancer have poor prognosis, and chemotherapy has a pivotal role in their survival[1-3], especially in highly malignant disease such as pancreatic cancer (PC). When patients with unresectable malignancies require surgery for symptom relief, selection of a minimally invasive procedure allows faster recovery and thus quicker induction of chemotherapy.

Laparoscopic duodenojejunostomy (LDJ) has become the standard surgical procedure for superior mesenteric artery syndrome (SMAS) due to its sufficient short- and long-term outcomes in terms of safety and symptom relief[4,5]. However, there are only a few reports about LDJ for malignant stenosis[6] and its indication remains uncertain.

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We report a successful case of LDJ as palliative care in a patient with unresectable malignant stenosis around the duodenojejunal flexure caused by recurrent PC (rPC). The postoperative course was uneventful, and early food consumption and induction of chemotherapy were achieved. Hence, we think this method is valuable for the multimodal therapy of unresectable malignancies.

CASE PRESENTATION

Chief complaints

A 77-year-old woman presented with upper right abdominal distension and recurrent vomiting.

Computed tomography on admission revealed a soft tissue mass dorsal to the stomach and nearby duodenojejunal flexure. We found a dilated duodenum and collapsed jejunum (Figure 1). Upper gastrointestinal examination showed a dilated duodenum, limited extensibility of the stomach and no gastrografin passage through the duodenojejunal flexure (Figure 2A). Upper gastrointestinal endoscopy revealed stricture at the duodenojejunal flexure due to intraluminal stenosis but revealed no mucosal surface changes (Figure 2B), and a nasogastric tube was placed to decompress the stomach and duodenum (Figure 2C).

History of present illness

The patient had a history of PC treated with distal pancreatectomy withresection of the transverse colon 7 mo ago. She presented with upper right abdominal distension and recurrent vomiting since 1 d ago and was admitted to our institution as an emergency.

History of past illness

She underwent distal pancreatectomy withresection of the transverse colon for PC.

Personal and family history

Prognosis of rPC after initial curative resection is poor and similar to that ofmetastatic PC[1-3]. However, new anticancer agents and multiagent chemotherapy have improved overall survival (OS). The median OS for patients with rPC treated by chemotherapy is 10-14 mo compared to 3 mo without treatment[3], indicating the significant role of chemotherapy in prolonging the survival of these patients. In terms of our patient, she gained 10 mo survival, comparable to previous reports.

Physical examination

Blood pressure 134/90 mmHg, heart rate 82 beats/min, respiration rate 12 breaths/min and body temperature 36.2 °C were noted upon arrival. The upper right abdomen was distended but soft and there was no abdominal pain.

除了以上專家之外，會議還邀請了清華大學土木工程系教授博士生導師王元清、核工業工程研究設計有限公司副所長潘國偉、中建鋼構有限公司技術管理部總經理陳振明、水利部水工金屬結構質量檢驗測試教授級高工靳紅澤分別做了“基于斷裂力學的含裂紋或類裂紋缺陷的鋼構件安全性評定技術研究”、“核電站核島安裝施工管理軟件焊接模塊介紹”、“建筑鋼結構中歐美標準焊接技術及應用”、“涉外水電工程采標情況”的演講，演講內容緊緊圍繞主題，對各自行業的相關焊接技術、標準都非常翔實的報告，深受代表好評。

Laboratory examinations

Creatinine and blood urea nitrogen were elevated to 2.21 mg/dL (normal range: 0.65-1.1 mg/dL) and 28 mg/dL (normal range: 8-20 mg/dL), respectively. Tumor marker carbohydrate antigen 19-9 markedly increased to 6191 U/mL (normal range: 0-45 U/mL).

Imaging examinations

1) 在足尺PHC管樁上安裝多種測試元件，在黏性土地基上進行靜壓樁沉樁過程及沉樁后休止期樁身軸力、樁土界面側壓力及孔隙水壓力的現場測試試驗，通過試驗了解樁身及樁土界面的受力狀態，并形成可推廣的試驗方法.

FINAL DIAGNOSIS

Malignant stenosis of the duodenojejunal flexure caused by local recurrence of PC.

The patient was placed in the open-leg supine position and a 4-port procedure (Figure 3A) was performed with the operator on the left side of the patient. Laparoscopic findings revealed a dilated duodenum, no gastric mobility and no peritoneal metastasis. With upward traction on the transverse colon, the second and third portions of the duodenum were exposed and mobilized (Figure 4A). We chose the third portion and jejunum about 30 cm anal to the Treitz ligament for anastomosis (Figure 4B and 4C). A side-to-side DJ was performed in an antiperistaltic manner using a stapling device (Signia with 45 mm purple reload; Covidien Japan, Tokyo, Japan) (Figure 4C). The common entry hole was closed with a continuous absorbable V-Loc suture (Covidien Japan) (Figure 4D). The operating time was 90 min with trivial bleeding. No drain was placed. Intraoperative findings are summarized in Figure 3.

TREATMENT

注意力的集中是指運動技能表現類的運動員在完成整套難度系數較高的動作時所需要的因素，也是進入流暢狀態的運動員所應具備的特征。

研究高壓鹽水層形成機理，須從盆地演化的角度分析高壓鹽水層存在的古環境，在此基礎上研究高壓鹽水層的沉積體系和斷裂體系，以異常壓力為動力，在沉積儲層的控制下分析斷層對油水的控制關系，建立初步的理想模型，總結高壓鹽水層的形成機理。

OUTCOME AND FOLLOW-UP

Postoperative course was uneventful. Oral fluid intake and food consumption were started on postoperative day (POD) 2 and 7, respectively. Upper gastrointestinal examination on POD 5 showed good patency of the anastomosis (Figure 5). The patient was discharged on POD 9, followed by induction of outpatient chemotherapy (nab-paclitaxel + gemcitabine) started on POD 30.

Six months later, (7 mo after the operation), chemotherapy was terminated due to disease progression and the patient’s desire for best supportive care. Although she died of PC 10 mo after the operation, she could tolerate food consumption until just before her death.

The obstruction site in our patient resembled that of SMAS since it was located in the duodenojejunal flexure, and so we thought that LDJ could be a suitable method. As mentioned before, stiffness of the stomach makes GJS a difficult choice. Fortunately, rapid symptom relief and induction of chemotherapy was achieved, thus the selection of LDJ over GJS was an acceptable decision.

Surgical intervention was essential for symptom relief and induction of chemotherapy. Gastrojejunal bypass was thought to be difficult due to the stiffness of the stomach, so we chose to perform DJ. A minimally invasive procedure was necessary for rapid recovery. LDJ was performed 9 d after admission. Decompression of the duodenum with nasogastric tube (Figure 2C) and correction of dehydration by total parenteral nutrition were performed preoperatively.

DISCUSSION

A single-center case series of LDJ, although for SMAS[4,5,7-11], showed no mortality, no anastomotic leaks, short length of stay and no recurrence of symptoms (Table 1). With such results, LDJ has been considered to be safe, efficacious and minimally invasive, and has become the standard surgical procedure for SMAS.

Gastrojejunostomy (GJS) used to be performed for SMAS. However, GJS is no longer considered to be a suitable method for SMAS since it has been associated with insufficient duodenal decompression, peptic ulcer, bile gastritis and blind loop syndrome[4,9,10]. LDJ, in contrast, provides more sufficient duodenal decompression and a more natural and physiological route for food passage.

信息的統計解析設計主要針對的是統計解析監管邏輯方面，其使用的方式為創建數據分析函數、計算統計函數、搜索查詢函數及信息傳輸函數等。此外，在此功能的設計過程中，系統管理工作者在搜索數據的時候，首要工作就是發出信息搜索請求，然后信息會直接傳遞到頁面，再通過搜索條件，將最終所需要的數據返還回來。

趙 闖 男，1978年出生于河北辛集.現為解放軍信息工程大學導航與空天目標工程學院副教授，主要研究方向為雷達信號處理.

The patient had no specific family history.

Improvement in quality of life (QOL) is also crucial in the multimodal therapy of cancer patients[12-15]. LDJ had a significant role in our patient by enabling oral food intake until the last few days of her life. High QOL is associated with better prognosis in patients receiving chemotherapy[12-14], although psychological distress can interfere with treatment[15]. We also believe that improving QOL is particularly important for patients with poor prognostic disease, and the fact that symptom relief and ability to eat were maintained in our patient shows that LDJ can have a significant role in palliative care of patients with obstruction around the duodenojejunal flexure due to unresectable malignant diseases such as lymphoma, PC, gastrointestinal tumor and peritoneal dissemination.

However, the indication for LDJ for unresectable malignancies remains uncertain since reports of LDJ performed on malignant stenosis are scarce[6]. LDJ is a method of palliative care, and so the absence of postoperative complications is crucial for prolonging survival of cancer patients by means of chemotherapy[16,17]. Preoperative management such as decompression of the duodenum with a nasogastric tube and correction of dehydration, electrolyte balances and nutrition are essential for avoiding complications such as anastomotic leakage. Chang[4] argues the importance of preoperative workup in LDJ for SMAS, and we think this can also apply for cancer patients as well.

To our knowledge, this is the first report on the role of LDJ as a part of a multimodal therapy for unresectable cancer. Many anticancer agents expected to prolong survival have been developed to date[18], and the role of minimally invasive surgery that preserve QOL will become increasingly significant. We expect more reports on cases of LDJ for malignant obstructions and hope that this procedure will be an acceptable treatment option for patients with unresectable malignant obstruction around the duodenojejunal flexure.

CONCLUSION

LDJ is thought to be a valuable method of palliative care and as a part of multimodal therapy for patients with unresectable malignant stenosis around the duodenojejunal flexure. By preserving QOL, this procedure is expected to be a bridge to chemotherapy for unresectable malignancies.

第一，手工書籍制作需要實現內容與形式的統一。傳統的書籍設計課程，在編輯和排版等環節的訓練上常常忽略了書籍內容和形式的結合，這使得幾乎所有書籍的形式都采用通用型，忽視了設計者的個性和創新，自然不能帶給閱讀消費者嶄新而難忘的閱讀體驗。

FOOTNOTES

Murakami T wrote the manuscript; Matsui RY made the manuscript revision; All authors issued final approval for the version to be submitted.

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

The authors declare that they have no conflict of interest.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Japan

Teppei Murakami 0000-0003-2621-4210; Yugo Matsui 0000-0001-9442-2279.

Chang KL

Kerr C

Chang KL