Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):373-380. 10.14701/ahbps.2020.24.3.373.

Retroduodenal resection of the extrahepatic common bile duct with in situ re-implantation of the main pancreatic duct:A report of two cases

• Hwang S
• Jung DH
• Ha TY

• KMID: 2505354
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.373

Abstract

Resection of the whole distal common bile duct (CBD) with in situ re-implantation of the main pancreatic duct can be a surgical option to avoid pancreaticoduodenectomy. in this study, we present two cases of cholangiocarcinomas with diffuse involvement of the extrahepatic CBD that was resected through a retroduodenal approach and re-implantation of the main pancreatic duct. The first case was a 70-year-old male patient with intraductal papillary neoplasm with invasive cholangiocarcinoma. He underwent retroduodenal resection of the whole CBD and in situ re-implantation of the main pancreatic duct. He was disease-free for 8 years, but tumor recurrence occurred at the hepaticojejunostomy site. This patient is currently undergoing chemoradiation therapy for treatment of recurrent lesions. The second case was a 71-year-old male patient with diffuse cholangiocarcinoma involving the whole extrahepatic CBD. He underwent medial sectionectomy, retroduodenal resection of the whole CBD and in situ re-implantation of the main pancreatic duct. He received postoperative chemoradiation therapy. He was disease-free for 3 years, but tumor recurrence occurred at the hepaticojejunostomy site. He passed away 4 years and 6 months after surgery. In conclusion, complete resection of the extrahepatic CBD through a retroduodenal approach with in situ re-implantation of the main pancreatic duct is feasible and less invasive than PD. Therefore, the proposed less-invasive approach can be an alternative procedure in selected patients requiring complete resection of the distal CBD.

Keyword

Ampulla of Vater; Bile duct resection; Retroduodenal approach; Pancreatoduodenectomy; Common bile duct

Figure

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  Fig. 1 Initial preoperative radiologic findings of Case 1. (A and B) Computed tomography scan shows multiple intraductal papillary masses in the extrahepatic bile duct and right intrahepatic duct with diffuse bile duct dilatation. (C) Magnetic resonance cholangiopancreatography shows intrahepatic duct stones and multiple intraductal lesions. (D) Endoscopic retrograde cholangiopancreatography with biopsy was performed.

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  Fig. 2 Schematic illustration of the retroduodenal resection of the whole extrahepatic bile duct (A) and in situ re-implantation of the main pancreatic duct (B) in Case 1. The dotted line and arrow denote the extent of bile duct resection and initial transection line, respectively (A). The tube indicates the internal pancreatic stent (B).

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  Fig. 3 Imaging study findings of Case 1 taken at 7 days (A), 1 year (B), 3 years (C) and 6 years (D) after the operation. The arrows indicate the internal pancreatic stent.

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  Fig. 4 Gross photographs of Case 1 specimen after bile duct resection showing intraductal papillary neoplasm with invasive cholangiocarcinoma.

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  Fig. 5 Imaging study findings of Case 1 showing tumor recurrence at 8 years after the operation. A recurrent tumor is visible at the hepaticojejunostomy site (A), and the pancreatic duct implantation site is intact (B). Magnetic resonance cholangiopancreatography shows intraluminal narrowing (C), thus percutaneous transhepatic biliary drainage was performed for biliary drainage (D).

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  Fig. 6 Initial preoperative radiologic findings of Case 2. (A and B) Computed tomography scan shows perihilar cholangiocarcinoma of Bismuth-Corlette type I. (C) Magnetic resonance cholangiopancreatography shows mass within the bile duct. (D) Endoscopic retrograde biliary drainage is performed for biliary drainage.

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  Fig. 7 Imaging study findings of Case 2 taken at 7 days (A and B), 1 month (C and D), and 2 years (E and F) after the operation. The arrows indicate the internal pancreatic stent, which was spontaneously removed before 2 years (F).

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  Fig. 8 Gross photographs of Case 2 specimen showing common bile duct adenocarcinoma.

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  Fig. 9 Imaging study findings of Case 2 showing tumor recurrence at 3-4 years after the operation. A recurrent tumor is visible at the left hepaticojejunostomy site (A and B). Percutaneous transhepatic cholangioscopy was performed to remove the intrahepatic stones from the left lateral segment (C). Percutaneous left portal vein embolization was performed (D). Cholangiohepatitis with abscess formation developed in the right liver (E). Finally, multiple intrahepatic recurrences occurred in the liver (F).

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