A case of wedge resection of duodenum for massive gastrointestinal bleeding due to duodenal metastasis by renal cell carcinoma
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Gastrointestinal bleeding due to duodenal metastasis from renal cell carcinoma is extremely rare. Several previous reports have shown that embolic therapy or pancreatoduodenectomy (radical surgical resection) could be effective in controlling this type of clinical complication. Management is entirely dependent on the general condition and concurrent metastases at other sites. Optimizing the therapeutic strategies thus deserves further discussion and exploration.
In this report, we describe a patient with severe co-morbidities who underwent successful palliative wedge resection of duodenum and direct duodenal wall defect repair without reconstruction of duodeno-jejunostomy for acute upper digestive tract hemorrhage caused by duodenal metastasis from renal clear cell carcinoma.
The patient recovered uneventfully and did not experience rebleeding and frequent vomiting after surgery. Since then (1.5 years) he has had no evidence of rebleeding.
Gastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities, and for palliative treatment.
KeywordsGastrointestinal bleeding Wedge resection Metastasis Renal clear cell carcinoma
Epidermal growth factor receptor
Renal cell carcinoma
Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies, and is the third most frequent urologic malignancy after prostate and bladder cancer. Additionally, nearly 25% to 50% will develop metastatic disease metachronously after surgical treatment of the primary renal mass. While the most common sites of metastasis are the lung, bone, liver, adrenal, and brain, some unusual sites have also been reported including the iris, thyroid, breast, urinary bladder, epididymis, small bowel, pancreas, spleen, gallbladder, and ampulla[3, 4]. Acute upper gastrointestinal hemorrhage due to duodenal metastasis from RCC is a rare event. To the best of our knowledge, there have been a few reports in which embolic therapy or pancreatoduodenectomy have been employed to stop bleeding from RCC duodenal metastasis. Both methods are proved to be useful in controlling upper gastrointestinal bleeding from this cause[2, 5]. Embolization is a less invasive surgery but the RCC metastasis may re-bleed after treatment. On the other hand pancreatoduodenectomy offers control of bleeding and cure of duodenal metastasis but in these patients morbidities from the procedure may be excessive. In other words, such surgical therapy could not only stop bleeding but also remove the duodenal metastatic tumor, in spite of high risk of morbidity especially for those patients suffering from cachexia to go through the surgical procedure. Here, we present a case of successful management of duodenal bleeding caused by metastasis from RCC by a wedge resection of duodenum with an excellent long-term outcome.
Preoperative diagnostics and medical history
A 56-year-old man was referred to us with a diagnosis of presumed duodenal carcinoma.
The patient had undergone right nephrectomy in 2005 for renal clear cell carcinoma (pT2, pV0, pN0: stage II). The postoperative course was uneventful and no adjuvant therapy was given. During the 5-year follow-up, fecal occult blood test had been carried out as a routine test. No signs of tumor recurrence were detected during the follow-up with annual abdominal ultrasonography, and the physical examination was unremarkable.
Results and discussion
Postoperative clinical course and histopathology
RCC metastasis to the duodenum is a rare event, accounting for 7.1% of all small bowel metastases[6, 7]. Duodenal metastasis from RCC may present with abdominal pain, nausea, weight loss, jaundice, anemia, gastrointestinal bleeding, duodenal obstruction, perforation and duodenal intussusceptions. It can occur at any time after nephrectomy, and is indistinguishable from other gastrointestinal diseases. If there are specific mucosal changes in the duodenal lumen, the diagnosis can be made by gastroscopy. The diagnosis should be considered in any patient with upper gastrointestinal bleeding or obstructive symptoms and with right-sided renal tumor or radical nephrectomy in the past (even if metastasis of renal cell carcinoma cannot be definitely diagnosed in routine duodenal biopsy at gastroscopy). There have been several reports on the use of stanniocalcin 2 (STC2) as a marker for the diagnosis of duodenal metastasis from RCC. Results from these studies indicate that STC2 may indeed be useful in determining the postoperative risk stratification of those patients.
A Kocher maneuver is performed to assess the anatomic relationship between the lesion and the bile duct and head of the pancreas. The ampulla of Vater is carefully identified and preserved during the resection process.
The lesion is carefully dissected away from the inferior vena cava and retroperitoneal structures. Vascular anastomotic devices and an adequate supply of blood should be present.
Clear surgical margins of 1 or 2 cm are obtained .
A longitudinal incision and transverse suturing of the duodenum is performed to prevent stricture of the duodenum.
A patent distal jejunum is present.
In conclusion, gastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities (severe anemia, hypoalbuminemia, and incomplete duodenal obstruction), and for palliative treatment.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
All authors of this article are clinically highly experienced surgeons who are regularly involved with interdisciplinary treatment decisions for patients with massive gastrointestinal bleeding due to cancer metastasis or post-hepatitis liver cirrhosis, encompassing up-to-date interventional, chemotherapeutic, and surgical approaches, in one of the largest department of hepatobiliary surgery in southwest of China.
We wish to thank Professor Fang-Ping Huang (Imperial College London) for assisting in the preparation of this manuscript. We would also like to thank Medjaden Bioscience Limited for assisting in the preparation of this manuscript.
- 2.Chung PH, Srinivasan R, Linehan WM, Pinto PA, Bratslavsky G: Renal cell carcinoma with metastases to the gallbladder: four cases from the National Cancer Institute (NCI) and review of the literature. Urol Oncol. 2012, 30: 476-481. 10.1016/j.urolonc.2010.04.010.PubMedCentralCrossRefPubMedGoogle Scholar
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