a whipple s resection is associated with a high morbidity and a significant mortality rate ( 10 ) . the decision to undertake such an operation should , therefore , only materialise after careful consideration of the pre - operative laboratory and radiology data ( 4 ) . the ability to accurately determine , microscopically , if a pancreatic or peri - ampullary lesion is benign or malignant , pre - operatively , is hindered by the relative inaccessibility of the head of the pancreas and its associated structures to biopsy ( 8) . the literature reports that around 7% of the histology obtained post - whipple s resection are benign ( 5 ) . here we present two cases initially deemed at the hepato - pancreatico - biliary ( hpb ) multi - disciplinary team ( mdt ) meeting to require a whipple s resection , which upon post - operative histological analyses were confirmed sc was a 46 yr old gentleman who was referred from his district hospital with a six month history of upper abdominal pain and weight loss . his past medical history included a prolapsed lumbar disc and he was not on any regular medications . a computer tomography ( ct ) scan of his abdomen and pelvis revealed no significant abnormalities except for changes suspicious of duodenal diverticular disease . prior to his consultation he had endoscopies of both his upper and lower gastro - intestinal tracts which were reported as revealing no abnormalities . an endoscopic retrograde cholangio - pancreatogram ( ercp ) was precluded due to the difficulty of the duodenal diverticulum obscuring the ampulla of vater . a subsequent endoscopic ultrasound scan ( eus ) revealed an 8 mm soft tissue lesion in the distal common bile duct ( cbd ) causing dilatation of the pancreatic duct ( figure 1 ) . the hpb mdt meeting felt that although the lesion could be benign , a malignant process could not be excluded thus a whipple s procedure was advised . eus demonstrating a lesion in the distal cbd his admission full blood count , biochemical profile , liver function tests and clotting were all within normal limits . laparotomy revealed no evidence of bilary dilatation and no obvious malignant mass identified although some thickening of the ampulla was seen . sc spent 2 days in the intensive care unit ( icu ) for routine monitoring . on post - operative day 6 he subsequently made a full recovery and was discharged home 3 weeks after his operation . the histology of the operative specimen revealed cholesterol polyps in the distal cbd associated with a juxta - papillary duodenal diverticulum ( figure 2 ) . histology at x20 magnification demonstrating cholesterol polyps at the convergence of the distal cbd and main pancreatic duct . pw was a 53 yr old gentleman who was referred from by his general practioner for recurrent episodes of self - limiting epigastric pain over the course of 3 months which were clinically associated with jaundice . his medical history included a road traffic accident at the age of 7 when he lost his right kidney . he was an ex - smoker of 10 pack years and drank one bottle of wine per week . he had a strong family history of ischaemic heart disease and his father died of bowel cancer . an ultrasound prior to this clinic appointment revealed a dilated common bile duct ( cbd ) of up to 10 mm , a distended thin walled gallbladder , no calculi and a normal pancreatic body . the ct of his abdomen and pelvis confirmed a dilated cbd and some areas of focal calcification on the head of the pancreas ( figure 3 ) . the eus demonstrated a thickened distal cbd with a 1.5 cm hypoechoic lesion in the pancreatic head ( figure 4 ) . the hpb mdt meeting suspected a malignant lesion and felt that a whipple s procedure would offer the best chance of cure . ct abdomen demonstrating calcification at the head of the pancreas eus demonstrating lesion at the pancreatic head with thickening of distal cbd at laparotomy , the head of the pancreas was felt to be thickened and was adherent to the pylorus of the stomach through fibrotic tissue . his recovery was complicated by sepsis secondary to collection in the gall bladder bed which was drained under radiological guidance . the histology of the resected specimen was reported as showing intramural benign gland hyperplasia within the distal cbd and ampulla ( figure 5 ) . histology at x100 magnification demonstrating glandular lobules of duct - like structures within fibrous stroma of the ampulla sc was a 46 yr old gentleman who was referred from his district hospital with a six month history of upper abdominal pain and weight loss . his past medical history included a prolapsed lumbar disc and he was not on any regular medications . a computer tomography ( ct ) scan of his abdomen and pelvis revealed no significant abnormalities except for changes suspicious of duodenal diverticular disease . prior to his consultation he had endoscopies of both his upper and lower gastro - intestinal tracts which were reported as revealing no abnormalities . an endoscopic retrograde cholangio - pancreatogram ( ercp ) was precluded due to the difficulty of the duodenal diverticulum obscuring the ampulla of vater . a subsequent endoscopic ultrasound scan ( eus ) revealed an 8 mm soft tissue lesion in the distal common bile duct ( cbd ) causing dilatation of the pancreatic duct ( figure 1 ) . the hpb mdt meeting felt that although the lesion could be benign , a malignant process could not be excluded thus a whipple s procedure was advised . eus demonstrating a lesion in the distal cbd his admission full blood count , biochemical profile , liver function tests and clotting were all within normal limits . laparotomy revealed no evidence of bilary dilatation and no obvious malignant mass identified although some thickening of the ampulla was seen . sc spent 2 days in the intensive care unit ( icu ) for routine monitoring . on post - operative day 6 he subsequently made a full recovery and was discharged home 3 weeks after his operation . the histology of the operative specimen revealed cholesterol polyps in the distal cbd associated with a juxta - papillary duodenal diverticulum ( figure 2 ) . histology at x20 magnification demonstrating cholesterol polyps at the convergence of the distal cbd and main pancreatic duct . pw was a 53 yr old gentleman who was referred from by his general practioner for recurrent episodes of self - limiting epigastric pain over the course of 3 months which were clinically associated with jaundice . his medical history included a road traffic accident at the age of 7 when he lost his right kidney . he was an ex - smoker of 10 pack years and drank one bottle of wine per week . he had a strong family history of ischaemic heart disease and his father died of bowel cancer . an ultrasound prior to this clinic appointment revealed a dilated common bile duct ( cbd ) of up to 10 mm , a distended thin walled gallbladder , no calculi and a normal pancreatic body . the ct of his abdomen and pelvis confirmed a dilated cbd and some areas of focal calcification on the head of the pancreas ( figure 3 ) . the eus demonstrated a thickened distal cbd with a 1.5 cm hypoechoic lesion in the pancreatic head ( figure 4 ) . the hpb mdt meeting suspected a malignant lesion and felt that a whipple s procedure would offer the best chance of cure . ct abdomen demonstrating calcification at the head of the pancreas eus demonstrating lesion at the pancreatic head with thickening of distal cbd at laparotomy , the head of the pancreas was felt to be thickened and was adherent to the pylorus of the stomach through fibrotic tissue . his recovery was complicated by sepsis secondary to collection in the gall bladder bed which was drained under radiological guidance . the histology of the resected specimen was reported as showing intramural benign gland hyperplasia within the distal cbd and ampulla ( figure 5 ) . histology at x100 magnification demonstrating glandular lobules of duct - like structures within fibrous stroma of the ampulla cholesterol polyps in the bilary system are most commonly found within the gallbladder ( 6 ) . they are characterised by mucosal villous hyperplasia with cholesterol - laden epithelial macrophages and are generally asymptomatic ( 7 ) . in contrast , cholesterol polyps within the cbd are much rarer and can present with obstructive jaundice ( 9 ) . ectopic glandular tissue at the ampulla of vater has been previously documented , more commonly of pancreatic origin ( 3 ) suggested management includes ercp with a sphicterotomy at the time of biopsy ; upon histological confirmation of the diagnosis , limited excision of the ectopic tissue or wide local excision can be undertaken ( 2 ) . both cases illustrate the importance of pre - operative diagnosis as both pathologies can be managed by limited resection rather than a formal whipple s procedure . neither of these patients underwent an ercp which may have been able to biopsy the lesions in the ampulla and distal cbd . although an ercp is a relatively invasive diagnostic procedure with not insignificant risks of pancreatitis , cholangitis and bleeding , it could avoid the need for a higher - risk whipple s procedure in rare ampullary or peri - ampullary lesions .
benign pathologies demonstrated after a whipple s resection ( pancreatoduodenectomy ) for pancreatic and peri - ampullary lesions are relatively uncommon . here 
 we report two cases where a whipple s procedure was undertaken for suspected pancreaticobiliary cancer and where the final histology revealed , in each case , a rare benign lesion . 
 the first case confirmed a cholesterol polyp in the distal common bile duct whilst the second case revealed ampullary intramural ectopic gland hyperplasia . 
 although pre - operative imaging helps in differentiating some benign lesions from malignant lesions , rare benign pathology may still mimic malignant conditions leading to a whipple s resection .