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Ampulloma in a patient with a history of Roux-en-Y gastrojejunal bypass
Ampuloma en paciente con antecedente de bypass gastroyeyunal en Y de Roux
Anna Curella,
Corresponding author
annacurell2@gmail.com

Corresponding author.
, Montse Adella, Concepción Gómez-Gavaraa, Elizabeth Pandoa, Xavier Merinob
a Servicio de Cirugía Hepatobiliopancreática y Trasplante Hepático, Hospital Universitari Vall d’Hebron, Barcelona, Spain
b Servicio de Radiodiagnóstico, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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Lab work showed predominantly direct hyperbilirubinemia &#40;total bilirubin 6&#46;83<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and direct bilirubin 4&#46;91<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; elevated cholestasis enzymes and Ca 19&#46;9 tumor marker 117&#46;6<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Abdominal computed tomography &#40;CT&#41; scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41; revealed a hydropic gallbladder and dilation of the intrahepatic bile duct and common bile duct &#40;23<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with a sudden change in caliber at the papilla of Vater&#44; with homogeneous increase in soft tissue&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Magnetic resonance cholangiopancreatography &#40;MRCP&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41; revealed a markedly dilated bile duct with an abrupt change in caliber in the distal&#47;pre-papillary common bile duct&#44; coinciding with the presence of a nodular lesion measuring 17<span class="elsevierStyleHsp" style=""></span>mm that was isointense on T1 and T2-weighted sequences&#44; showing restriction in diffusion sequences&#44; and which was slightly enhanced after the administration of intravenous contrast &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c and d&#41;&#44; as well as a lymphadenopathy in the bifurcation of the celiac trunk&#46; The differential diagnosis included ampullary carcinoma&#44; impacted lithiasis&#44; biliary cast&#44; pancreatic head cancer&#44; or papillitis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The case was discussed in the multidisciplinary committee&#44; at which time we decided to drain the bile duct by means of percutaneous transhepatic cholangiography &#40;PTHC&#41;&#44; and biopsies were taken&#46; The PTHC detected a large dilation of the intra- and extrahepatic bile duct with obstruction at the papilla&#59; past the obstruction&#44; an 8 F internal&#8211;external biliary drain tube was placed&#44; and the bile discharge was clean&#46; A biopsy was taken&#44; which was not conclusive as the sample consisted of fibromuscular tissue and glands without cytoarchitectural atypia&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient evolved favorably&#44; with improved pruritus and jaundice&#44; as well as lower bilirubin levels on follow-up studies&#46; We decided to try double-balloon enteroscopy for another biopsy&#44; but this was unsuccessful given the inability to reach the papilla endoscopically as a consequence of the previous of RYGB&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As it was impossible to rule out the presence of neoplasia&#44; and we had performed all the preoperative tests available at our hospital&#44; pancreaticoduodenectomy &#40;PD&#41; was proposed to the patient&#46; Thus&#44; PD was performed with an end-to-side duct-to-mucosa pancreaticojejunal anastomosis following the Blumgart technique and an end-to-side hepaticojejunal anastomosis &#40;using the distal segment of the old biliopancreatic limb from the RYGB in both cases&#41; as well as gastrectomy of the gastric remnant &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; During the postoperative period&#44; the patient presented infection of the surgical wound&#44; which required drainage and antibiotic therapy&#59; she was discharged on the 12th postoperative day&#46; The pathological study reported an infiltrating intestinal-type adenocarcinoma of ampullary-ductal origin &#40;G2 pT3bN0&#41;&#46; Currently under treatment with capecitabine&#44; the patient has had no evidence of disease 3 months after surgery&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with a history of RYGB pose great difficulty in diagnosing biliopancreatic diseases&#46; The presence of disease in the biliary limb may manifest abnormally because the intestinal tract has been modified&#46; Moreover&#44; the diagnosis of periampullary disease is also made difficult by the biliary limb&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> since it is necessary to initially reach the base of the loop during endoscopy&#44; and later ascend through the biliopancreatic limb to the papilla&#44; with the associated difficulties of the length and angles of the intestinal tract involved&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In our case&#44; double-balloon ERCP was attempted&#44; but the papilla could not be reached endoscopically&#46; There are other diagnostic possibilities<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to consider&#44; such as ERCP assisted by laparoscopy&#44; transgastric or transjejunal&#44; pediatric colonoscopes&#44; fluoroscopy-guided percutaneous gastrostomy or endoscopic ultrasound-guided gastrogastrostomy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; when considering surgical options&#44; it is important to take into account the difficulty posed by the post-RYGB anatomy for the resection and reconstruction performed during PD&#46; There are several technical options&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> but the evidence is limited&#44; and there is no clear consensus&#46; In our case&#44; we opted to use the old BPL for the reconstruction of pancreatic and biliary drainage&#44; which is a recommended technique<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> if the length of the BPL is sufficient&#44; since it avoids intestinal resections that would increase the possibility of postoperative malabsorption&#46; The gastrectomy of the remnant avoids<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the need for additional anastomoses&#44; with their possible associated complications&#44; as well as the future appearance of gastric disease&#44; both benign and malignant&#46; In this case&#44; initial ampullectomy was not considered because the lesion occupied the common bile duct&#44; contraindicating this approach&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to their altered anatomy&#44; patients who have previously undergone RYGB present significant difficulties both in the diagnosis and in the treatment of diseases of the hepatobiliary area&#46; However&#44; there are presently several minimally invasive diagnostic techniques that should be explored before subjecting these patients to a surgical procedure with high morbidity without a definitive diagnosis for a disease that could ultimately be benign&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This study has received no specific funding from public&#44; private or non-profit organizations&#46;</p></span></span>"
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