65. Serum amylase, bilirubin, and C-reactive protein (CRP) levels were not elevated. Gastroscopy showed choose size a reflux esophagitis, a massive distension of the stomach and the first part of the duodenum, respectively, and a stenosis of the second part of the duodenum, which could not be passed with the thin gastroscope. Abdominal MSCT depicted a fluid filled stomach and second segment of the duodenum (Figure (Figure1).1). The pancreatic head was enlarged, surrounding the second segment of the duodenum; no dilation of the main pancreatic duct and common bile duct was noticed. For further evaluation, an MRCP was done. This showed an aberrant pancreatic duct encircling the duodenum, linked to the main pancreatic duct (Figure (Figure2).2). No dilation of the common hepatic bile duct or the main pancreatic duct was evident.
Due to the annular pancreas, there was an obstruction at the level of the second segment of the duodenum. During surgery, we found a massively distended and elongated first segment with a conic stenosis of the second segment of the duodenum due to the annular pancreas (Figure (Figure3).3). A duodenojejunostomy was performed. There was no visible prestenotic tumor in the duodenum and the duodenal mucosa appeared to be normal. No tumor mass was palpated. The patient had an uneventful recovery and was discharged home with no complaints nine days later. After eight weeks, the patient was readmitted presenting with painless jaundice. She had no other complaints. No further weight loss was reported.
Laboratory investigations showed elevated total bilirubin (112 ��mol/L; reference range: 5-18) and alkaline phosphatases (178 U/L; reference range: < 104). An MRCP demonstrated dilatation of the common bile duct (Figure (Figure4).4). On explorative laparotomy, a hard mass was palpated in the pancreatic head region. The frozen section of one of several suspicious superior pancreatic lymph nodes revealed adenocarcinoma cells. A duodenopancreatectomy was performed. The tumor was clearly located in the duodenum, with infiltration of the surrounding structures (Figure (Figure5).5). No tumor was observed in the head of the pancreas. Pathological examination showed a poorly differentiated, infiltrating adenocarcinoma of the duodenum, surrounded by the incomplete annular pancreas (Figure (Figure5).5). The tumor stage was pT4, pN1 (8/12), G3, L0, V0, R0.
The tumor seemed to have arisen from the duodenal epithelium. Figure 1 Multislice computed tomography. A fluid filled stomach and enlargement of the pancreatic head (arrow) are detected, which encircles the second segment of the duodenum (dotted arrow). Figure 2 T2 weighted magnetic resonance cholangiopancreatography images depict Dacomitinib the aberrant pancreatic duct, which encircles the duodenum and connects with the main pancreatic duct (arrows).