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Case Report | DOI: https://doi.org/10.31579/2690-1897/099
Department of Surgery, “Achillopoulio” General Hospital of Volos, Greece
*Corresponding Author: Athanasia Bamicha, Department of Surgery, “Achillopoulio” General Hospital of Volos, Greece
Citation: Athanasia Bamicha, Evangelos D. Lolis,Alexandra Pentheroudaki,Sotirios Rousogiannis,
(2022) Large bowel obstruction as an unusual presentation of pancreatic carcinoma J, Surgical Case Reports and Images 5(1); DOI: 10.31579/2690-1897/099
Copyright: © 2022, Athanasia Bamicha, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 25 September 2021 | Accepted: 25 October 2021 | Published: 05 January 2022
Keywords: pancreatic cancer, large bowel obstruction
Background: Large bowel obstruction due to pancreatic tail carcinoma is extremely rare. Case report: We present a case of large bowel obstruction and cecal perforation due to carcinoma of the tail of the pancreas.
Conclusion: Despite of the poor prognosis of the cases reported so far, our patient is alive and disease free 12 months after emergent aggressive surgical therapy and adjuvant therapy.
Large bowel obstruction is an unusual presentation of cancer of the pancreatic tail. Large bowel obstruction is a common surgical emergency. Common causes of large bowel obstruction are volvulus, diverticulitis, colorectal cancer and pelvic malignancies [1]. Large bowel obstruction due to pancreatic cancer is extremely rare despite the close anatomical relationship between the pancreatic tail and left colonic flexure. Only six relevant cases have been reported so far [2-6].
A 61 year-old male presented to the emergency department with abdominal distention and diffuse abdominal pain. He had persisting vomiting and nausea the last 10 hours .He hadn’t pass any stools or winds since the day before. He reported colicky pain and worsening constipation for the last 15 days. He had no other comorbidities and no previous laparotomies. Clinically, the patient’s abdomen had signs of diffuse peritonitis, he was hypotensive and suffered from acute renal failure. His inflammatory markers were raised. Abdominal x-ray revealed large bowel obstruction with an abrupt cut-off at the splenic flexure while the chest x-ray revealed free sub- diaphragmatic air.
After initial resuscitation, the patient underwent an emergent exploratory laparotomy. We encountered notably distended small and large bowel up to the splenic flexure and fecal peritonitis due to cecal perforation. A large mass was involving the tail of the pancreas, the splenic hilum and the splenic flexure causing total obstruction. We performed an extended right colectomy en block with distal pancreatectomy and splenectomy. Primary anastomosis was avoided so an end ileostomy was fashioned. Postoperatively, he suffered from a Clavien-Dindo II complication. He was discharged on the postoperative day 14.
The histopathology examination revealed a moderately differentiated pancreatic ductal adenocarcinoma with perineural infiltration pT3N1. No distant metastases were found following staging of the disease. The patient was treated with adjuvant chemo-radiotherapy. He is alive 12 months postoperatively and in his recent follow-up there is no sign of locoregional or distant recurrence.
Pancreatic carcinoma usually appears in the head of the pancreas and typically presents with weight loss and painless jaundice. Carcinoma of the tail of the pancreas is rarely symptomatic in early stages and presents as weight loss or indistinct abdominal pain [7]. Over 50% of the pancreatic tail carcinomas are stage IV at diagnosis.
Pancreatic tail carcinoma presenting as large bowel obstruction and perforation is extremely rare. In our review of the existing literature (Table 1) there are six published case reports so far [2-6]. All patients but one were male and mean age was 67.14 (48-92). All patients presented as emergencies and in four cases coexisted bowel perforation. Most of the patients underwent an urgent laparotomy. In two cases the patients had a damage control operation initially followedby definitive operationlater. Four of the patients, including ours, underwent a definitive laparotomy where extended pancreatic resection was performed. Most of the patients had a stoma formation instead of an anastomosis. One patient received only best supportive care. Prognosis is very poor. All six patients passed away within days to months from the surgery. This might be due to the significant morbidity and mortality of an urgent complex operation or might represent an aggressive behavior of the cancer [5]. Some authors imply that the treatment has palliative intent. Our patient is the only one who is still alive and disease-
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