Ann Liver Transplant.  2021 Nov;1(2):187-193. 10.52604/alt.21.0019.

Pancreaticoduodenectomy for de novo ampulla of Vater cancer 15 years after living donor liver transplantation: Report of a case

• Na BG
• Hwang S
• Kim SM
• Yang G

• KMID: 2560871
• DOI: http://doi.org/10.52604/alt.21.0019

Abstract

De novo malignancy sporadically occurs in patients who undergo liver transplantation. We present a case of a 74-year-old patient who underwent pancreaticoduodenectomy (PD) for de novo ampulla of Vater cancer at 15 years after living donor liver transplantation (LDLT) for hepatitis B virus-associated liver cirrhosis. At 15 years after LDLT, elevation of liver enzyme levels led to diagnosis of de novo ampulla of Vater mass. We performed pylorus-resecting PD with extended pancreatic transection. Roux-en-Y choledochojejunostomy was performed to the remnant recipient-side proximal bile duct because active back bleeding from the bile duct stump was identified. The patient recovered uneventfully without complications. The surgical specimen showed a 2 cm-sized moderately differentiated adenocarcinoma arising from a tubular adenoma of the intestinal subtype at the ampulla of Vater. The extent of the tumor was pT1bN0M0, thus being stage IB. Adjuvant chemotherapy was not performed. The patient has been doing well for 3 months. The immunosuppressive regimen was switched from mycophenolate mofetil monotherapy to everolimus monotherapy. Our experience with this case suggests that PD can be eligibly performed after LDLT using duct-to-duct anastomosis.

Keyword

Duct-to-duct anastomosis; Living donor liver transplantation; De novo malignancy; Pancreaticoduodenectomy; Surgical complication

Figure

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  Figure 1 Peritransplant findings. (A) Pretransplant computed tomography shows liver cirrhosis with ascites. (B) Computed tomography taken 4 days after living donor liver transplantation using a modified right liver graft shows the usual posttransplant findings. (C) Direct tubogram taken at posttransplant 7 days through the external biliary drainage tube shows good patency of the two duct-to-duct anastomoses. (D) The explant liver shows advanced liver cirrhosis.

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  Figure 2 Preoperative findings and gross photographs of the tumor. (A) Initial computed tomography shows obstructing mass at the ampulla of Vater (arrow). (B) Magnetic resonance cholangiopancreatography shows dilatation of the common bile duct and the pancreatic duct with good patency of the double duct-to-duct anastomoses. (C) Endoscopic retrograde cholangiopancreatography shows a tubulovillous adenoma at the ampulla of Vater. (D) The surgical specimen shows a 2 cm-sized adenocarcinoma at the ampulla of Vater.

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  Figure 3 Intraoperative photographs of bile duct transection. (A, B) The common bile duct (CBD) is markedly dilated. (C) The dilated CBD was transected at the midway to observe the intraluminal status. (D) The proximal CBD (arrow) is transected at 1 cm away from the previous biliary anastomosis site.

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  Figure 4 Intraoperative photographs of biliary reconstruction. (A) The anterior wall of the remnant proximal bile duct opening is anchored with multiple double-arm 5-0 Prolenes. (B) The posterior wall of the remnant proximal bile duct opening is repaired with running sutures. Arrows indicate two graft duct openings. (C, D) Pancreaticojejunostomy and choledochojejunostomy are completed, leaving a redundant intervening jejunal loop for insertion of an omental tissue flap.

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  Figure 5 Intraoperative photographs after pancreaticoduodenectomy with extended pancreatic transection. Arrow and arrow head indicate the opening of the remnant proximal bile duct and the celiac axis, respectively.

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  Figure 6 Postoperative imaging study findings. (A) Simple abdomen X-ray shows insertion of multiple abdominal drains. (B) Computed tomography taken at postoperative 8 days shows the usual postoperative findings. (C, D) Computed tomography taken at 2 months shows the usual postoperative findings following pancreaticoduodenectomy. Arrows indicate an internal pancreatic stent tube.

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