En bloc Resection for Cancers of the Distal Bile Duct and the Appendix Invading the Duodenum Via Free Cecum Report of a Case

Abstract

A 71-year-old man presented with hemosiderinuria. He was suspected to have distal bile duct cancer and appendiceal cancer on CT. The cecum was located in the center of the abdomen. Appendiceal cancer abutted on the 3^rd portion of duodenum, superior mesenteric artery and vein (SMA & V), and jejunum, suggesting direct invasion. A biopsy from the distal bile duct revealed adenocarcinoma, and a biopsy from the cecum suggested low-grade appendiceal mucinous neoplasm. He was diagnosed with multiple primary cancers of distal bile duct cancer and advanced appendiceal cancer with free cecum and underwent surgery. We identified the distal bile duct tumor and the tumor of the appendix to have invaded the 3^rd portion of the duodenum. The jejunum and SMA & V could be separated from the appendiceal tumor. After complete mobilization of the duodenopancreas without separating the duodenum and appendix, multiple tumors were removed by en-bloc dissection of the duodenopancreas and right hemicolon. A case of advanced appendiceal cancer invading the 3^rd portion of duodenum, combined with distal bile duct cancer, is extremely rare. In the resection of multiple cancers including both cancer in the pancreatic head region and cancer with direct invasion of the duodenum, it is important to perform en-bloc resection with appropriate procedures not to impair oncological curability.