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.
Up to now there have been several similar cases reporting acute upper gastrointestinal hemorrhage due to duodenal metastasis from RCC. Currently management is entirely dependent on the general condition and concurrent metastases at other sites[8
]. Although immediate life-saving treatment requires emergency arteriography and arterial embolization[5
], complications including rebleeding, gastrointestinal ischemia, and non-target embolization are relatively encountered[8
]. Moreover, the duodenal obstruction is not solved by using embolization at all. Additionally, the patient was admitted by the department of gastroenterology for 20 days. For the reason of incomplete duodenal obstruction, the patient could not eat food, even in a liquid form. Anemia, hypoproteinemia, and frequent vomiting were not relieved by using medications and supportive care (like fluids, parenteral nutrition, and blood transfusion). The family of the patient could not continue to bear the economic burden and even prepared to abandon the treatment. According to the patient’s clinical conditions (gastrointestinal bleeding with incomplete duodenal obstruction) and economic situation, emergent surgical intervention to stop bleeding and relieve obstruction of the duodenum is the preferred choice. In terms of the surgical treatment of duodenal carcinoma, the most conventional and effective surgical method is pancreatoduodenectomy. Surgical resection of solitary metastatic renal cell carcinoma has resulted in 5-year survival rates from 35% to 50%, and a 5-year disease-free survival rate of 5% to 23%[11
]. However, because of the complications and surgical massive trauma associated with this procedure and the poor condition of the patient, a less aggressive and palliative treatment was selected without treating the pancreatic tail, in order to minimize the complications and improve the quality of life. Therefore, a segmental, palliative full-thickness wedge resection of duodenum was emergent undertaken. This procedure can be performed safely if basic principles are followed:
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.