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

tINTRODUCTION: Peroperative assessment of resectability in pancreas-sparing duodenectomy for distalduodenal (D3-D4) adenocarcinoma is challenging for surgeons.PRESENTATION OF CASE: We report a 68-year-old man with biopsy-proven adenocarcinoma of the fourthportion of duodenum which had been diagnosed with upper endoscopy and CT. A pancreas-sparing duo-denectomy with loco-regional lymph node resection using the superior mesenteric artery first approachwas 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 peroperativeassessment of resectability, with intraoperative ultrasound, complete exposition of the duodenum andentire dissection of the superior mesenteric artery (SMA) using the artery-first approach technique shouldbe done to assess for tumor resectability, which should include the possibility of complete lymphadenec-tomy of the mesenteric root. If technically feasible, a pancreas-sparing resection should be preferredto avoid pancreatectomy-related morbi-mortality. The aim of the surgery is a R0 resection which has a5-year survival rate between 25% and 75%.CONCLUSION: Artery-first approach of the SMA should be considered by surgeons in adenocarcinoma ofthe distal duodenum to identify any contra-indications to proceed further.© 2018 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an openaccess article under the CC BY-NC-ND license