Pancreaticoduodenectomy with Preservation of a Prior Hepaticojejunostomy for Ampullary Carcinoma: A Case Report.

INTRODUCTION: Pancreaticoduodenectomy (PD) can be technically challenging in patients who previously underwent biliary reconstruction, particularly hepaticojejunostomy. The optimal strategy for managing a prior hepaticojejunostomy during PD has not been well established.

CASE PRESENTATION: A woman in her 70s developed ampullary carcinoma 10 years after diversion surgery for pancreaticobiliary maljunction. She had previously undergone laparoscopic extrahepatic bile duct resection with hepaticojejunostomy. Subtotal stomach-preserving pancreaticoduodenectomy was planned. Intraoperatively, dense adhesions were observed around the hepaticojejunostomy, and the previous bile duct transection had been performed near the hepatic duct bifurcation. Resection of the existing anastomosis was considered technically risky because it might have resulted in multiple small biliary openings and increased operative complexity. Therefore, the hepaticojejunostomy was preserved based on intraoperative findings. Reconstruction was completed using a single jejunal limb for pancreaticojejunostomy and gastrojejunostomy. The operative time was 430 min, and blood loss was 192 mL. The postoperative course was uneventful. Pathological examination revealed well-differentiated tubular adenocarcinoma of the ampulla of Vater (pT1aN0M0, Stage IA) with negative margins. The patient remains recurrence-free 6 months after surgery.

CONCLUSIONS: Careful intraoperative assessment is important when determining whether a prior hepaticojejunostomy should be preserved during PD. Preservation may represent a reasonable option when re-dissection around the hepatic hilum is technically hazardous.