Partial Resection of the Pancreatic Head and Duodenum for Management of Carcinoma of the Ampulla of Vater: A Case Report

Case Report

A 57-year-old woman presented with spontaneous pain in the right upper quadrant of the abdominal region of one year's duration, which was aggravated after meals. She had repeated chills and fever but did not report nausea, vomiting or jaundice. She had been hospitalized three times before because of acute pancreatitis, gallbladder stones, and cholecystitis.

On physical examination, the patient's body temperature (rectal) was 36.5 to 37.3°C, heart rate was 78 beats/min, and blood pressure 120/90 mmHg. The skin and tunica dura of the patient were not stained yellow. There were no swollen superficial lymphoid nodes. The abdomen was flat and soft without a gastrointestinal pattern, peristaltic waves or varicose vein. The patient felt a slight tenderness in the upper right quadrant without rebound tenderness or muscle tonus. The liver and spleen were not touched below the costal margin. Bowel sound was 2 to 3 min.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1.

Contrast-enhanced computed tomography image showing a periampullary tumour, expansion of the bile and pancreatic ducts, gallbladder stones and cholecystitis.

Laboratory examination revealed that blood cell counts, blood and urine amylase, as well as the tumor markers carbohydrate antigen (CA) 19-9, carcinoembryonic antigen (CEA) and α-fetoprotein (AFP) were all normal. The patient had abnormal liver function tests: total protein=69.79 g/l (65-85 g/l), total bilirubin=24.9 μmol/l (3.2-23.5 μmol/l), direct bilirubin=5.8 μmol/l (0-8μmol/l), γ-glutamyl transpeptidase=1076 IU/l (10-60 IU/l), alkaline phosphatase=637 IU/l (45-125 IU/l), glutamic oxaloacetic transaminase=45 IU/l (15-40 IU/l), glutamic-pyruvic transaminase=46 IU/l (9-50 IU/l), and glutamic acid=5.46 mmol/l (0-14 mmol/l). Serum lipase increased to 566 IU/l (50-120 IU/l).

Contrast-enhanced computed tomography (CT) showed the presence of a tumour in the periampullary region and the expansion of pancreatic bile duct, gallbladder stones and cholecystitis (Figure 1). Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreaticography (MRCP) showed gallstones, cholecystitis and biliary obstruction. The obstruction plane was located in the ampulla, and there was abnormal signal at the end of the common bile duct (Figure 2). Moreover, common bile duct stones inside the pancreas, bile duct expansion, and atrophy of the pancreas (especially the tail of the pancreas) were noted. Chronic inflammation was initially suspected, although a tumor could not be excluded. A duodenoscopy was then performed, which revealed a papillary neoplasm, measuring 2.5×3 cm, in the descending duodenum. Pathological analysis of the duodenoscopic biopsy suggested with carcinoma of the ampulla of Vater.

After this diagnosis was established by imaging and duodenoscopy, a surgery was planned. The tumour was not at an early stage, and local excision may result in inadequate removal of the tumour. Given that the patient had significantly atrophied pancreatic tail, the resection of the whole head of the pancreas might have seriously impaired pancreatic exocrine and endocrine secretion. Dense adhesions involving mesenteric blood vessels, the portal vein, and the pancreas would also have made resection of the whole pancreatic head and duodenum difficult. For these reasons, partial resection of the pancreatic head and duodenum was performed.

An incision was made through the upper right rectus abdominis muscle to open the abdominal cavity. About 100 ml of pale yellow ascites was noted. Adhesions involving the greater omentum, hepatic flexure of the colon transverse colon and liver were visible. The adhesions were separated to expose the liver, hepatoduodenal ligament, and duodenum. No metastatic nodules were found in the liver, pelvis, small intestine or colon. A Kocher's incision was made. After mobilizing the head of the pancreas and the duodenum, a mass measuring about 3.0×2.5 cm was noted in the descending duodenum; the tumour did not invade the duodenal seromuscular layer. Due to repeated pancreatitis, there were severe adhesions involving the superior mesenteric vein, portal vein, and hepatoduodenal ligament. The hepatoduodenal ligament, proper hepatic artery, and common hepatic artery were mobilized to expose the gastroduodenal artery, which was then ligated and cut. The common hepatic artery, celiac trunk and hepatoduodenal ligament lymph nodes were excised, and the distal duodenum was transected and closed. Subsequently, a 60% distal gastrectomy was performed. At 2.0 cm right to the superior mesenteric vein, the head of the pancreas was partly resected. The superior pancreaticoduodenal artery from the gastroduodenal artery and the inferior pancreaticoduodenal artery branch from the superior mesenteric artery were sutured and ligatured without dissection of the superior mesenteric vein and portal vein in the rear of the neck of the pancreas, while preserving the integrity of the uncinated process of the pancreas. The gallbladder, extrahepatic biliary tract transected at the common hepatic duct, distal stomach, and duodenum were excised together with the subtotal resection of the pancreatic head. Reconstruction of the digestive tract was then performed. The jejunum was transected 30 cm below the Treitz ligament. The distal jejunum was lifted to carry out a duct-to-mucosa pancreaticojejunostomy. A 4-mm silicone tube was placed in the main pancreatic duct, and an end-to-side choledochojejunostomy was performed at 10 cm from the pancreaticojejunostomy. A side-to-end gastrojejunostomy was then performed 10 cm below the Treitz ligament, followed by a side-to-side jejunojejunostomy performed 40 cm under the choledochojejunostomy. Finally, the mesangial hiatus was closed (Figure 3).

• Download figure
• Open in new tab
• Download powerpoint

Figure 2.

Magnetic resonance cholangiopancreaticography image showing gallstones, cholecystitis, and biliary obstruction. The obstruction plane is located in the ampulla, and there is abnormal signal at the end of the common bile duct.

Postoperative pathology revealed well-to-highly differentiated adenocarcinoma. The tumor invaded the duodenum muscle layer and involved the common bile duct mucosa (Figure 4). Gastric, pancreatic and duodenal resection margins were all free of tumour cells. No metastases was found in number 4, 6, 8, 9, 12, or 13 group of lymph nodes.

Postoperative recovery of the patient was smooth. After 16 days of hospitalization, she was discharged and received regular outpatient follow-up. Fourteen months postoperatively, CT examination showed no recurrence or metastasis (Figure 5), and routine blood tests, tumor markers CA19-9, AFP, and CEA, liver function tests, blood glucose, and blood and urine amylase were all within normal ranges.