Retroduodenal resection of ampullary carcinoid tumor in a patient with cavernous transformation of the portal vein

Pancreaticoduodenectomy for pancreatic head cancer with cavernous transformation of the portal vein: a case report

Background

Cavernous transformation of the portal vein (CTPV) due to extrahepatic portal vein obstruction is a rare vascular anomaly. Since its symptoms usually appear in childhood, most of the adult cases are detected unexpectedly with other diseases. Only a few reports have described surgical difficulties in patients with CTPV. We report a case of pancreatic head cancer with CTPV in a patient who underwent pancreaticoduodenectomy.

Case presentation

A 77-year-old man with epigastric and back pain was referred to our hospital. Computed tomography revealed a tumor in the pancreatic head and a CTPV near the hepatic hilum. CTPV consisted of two main collateral vessels connected by multiple surrounding small vessels. Also, portal vein obstruction was observed near the hepatic hilum, which was far from the pancreatic head tumor. After confirming that there was no distant metastasis by a thorough whole-body search, we performed a pancreaticoduodenectomy following neoadjuvant chemotherapy. During the operation, we carefully manipulated the area of the CTPV and omitted lymph node dissection in the hepatoduodenal ligament to prevent massive venous bleeding and intestinal congestion. Pancreaticoduodenectomy was performed without any intraoperative complications and the postoperative course was uneventful. Complete tumor resection was histologically confirmed.

Conclusion

Although pancreaticoduodenectomy for patients with CTPV involves many surgical difficulties, we successfully performed it by determining specific treatment strategies tailored to the patient and following careful and delicate surgical procedures.

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

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.

Minute ampullary carcinoid tumor with lymph node metastases: a case report and review of literature

Background

Carcinoid tumors are usually considered to have a low degree of malignancy and show slow progression. One of the factors indicating the malignancy of these tumors is their size, and small ampullary carcinoid tumors have been sometimes treated by endoscopic resection.

Case presentation

We report a case of a 63-year-old woman with a minute ampullary carcinoid tumor that was 7 mm in diameter, but was associated with 2 peripancreatic lymph node metastases. Mild elevation of liver enzymes was found at her regular medical check-up. Computed tomography (CT) revealed a markedly dilated common bile duct (CBD) and two enlarged peripancreatic lymph nodes. Endoscopy showed that the ampulla was slightly enlarged by a submucosal tumor. The biopsy specimen revealed tumor cells that showed monotonous proliferation suggestive of a carcinoid tumor. She underwent a pylorus-preserving whipple resection with lymph node dissection. The resected lesion was a small submucosal tumor (7 mm in diameter) at the ampulla, with metastasis to 2 peripancreatic lymph nodes, and it was diagnosed as a malignant carcinoid tumor.

Conclusion

Recently there have been some reports of endoscopic ampullectomy for small carcinoid tumors. However, this case suggests that attention should be paid to the possibility of lymph node metastases as well as that of regional infiltration of the tumor even for minute ampullary carcinoid tumors to provide the best chance for cure.

Radical surgical resection for carcinoid tumors of the ampulla

Ampullary carcinoid tumors are extremely rare. The present study describes the clinicopathological features and outcomes for 10 ampullary carcinoid patients who underwent radical resection from 1998 to 2005. During this study period, 294 patients underwent pancreatoduodenectomy for ampullary neoplasms in our institution. The mean patient age was 58.0 +/- 13.4 years, and seven were male. Initial clinical manifestations were jaundice in four patients, nonspecific gastrointestinal symptoms in five, and completely asymptomatic in one. Standard pancreatoduodenectomy was performed in three patients, and pylorus-preserving pancreatoduodenectomy in seven, and there were no major complications. The mean tumor size and volume were 2.1 +/- 1.3 cm and 4.1 +/- 6.9 ml, respectively. Synaptophysin staining was positive in ten patients and chromogranin staining positive in eight. R0 resection was achieved in all ten patients. Overall and disease-free survival rates were 90 and 80% at 1 year, and 64 and 56% at 3 years, respectively. The liver was the most common site of initial metastasis after curative resection. Univariate analyses revealed that a maximal tumor diameter > or =2 cm and tumor extension beyond the ampulla were risk factors for tumor recurrence. In conclusion, while the majority of ampullary carcinoids are indolent, this tumor is associated with a relatively poor prognosis. We believe that radical resection, with the aim of complete tumor removal and cure, is the treatment of choice.