PMC7566198_01
Contrast-enhanced computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) of the patient in case 1.. a. Contrast-enhanced CT images revealed dilatation of the intra- and extra hepatic bile duct due to a low-density 10-mm mass within the lower bile duct.. b. ERCP revealed dilatation of the common bile duct and stenosis of the lower bile duct; cytodiagnosis was class V.
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Abdominal contrast-enhanced computed tomography (CT) and endoscopic retrograde cholangiopancreatography revealed dilation of the intra- and extra-hepatic bile ducts, secondary to the presence of a low-density, 10-mm, mass within the lower bile duct (Fig. 1a, b).
Intraoperative findings for the patient in case 1.. a. Prior Billroth II reconstruction with adhesions at the gastrojejunal anastomosis.. b. The excision range is demarcated by the red line, with the previous gastrojejunal anastomosis preserved.
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Jejunal detachment was performed on the oral side of the gastrojejunal anastomosis site, preserving the previous gastrojejunal anastomosis site, and the pancreaticoduodenum was removed (Fig. 2a, b).
Intraoperative findings after reconstruction for the patient in case 1. In a and b, a new afferent loop was used for reconstruction.
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We proceeded with a modified Child (subtotal stomach-preserving pancreatoduodenectomy [SSPPD]-IIA-1) reconstruction, with creation of a new afferent loop, but with preservation of the previous gastrojejunostomy (Fig. 3a, b).
Pathological specimen from the patient in case 1.. a. Excised specimen.. b. The histological diagnosis of the pancreas head mass was metastatic adenocarcinoma (pap) of the stomach.
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Histological examination of the mass in the pancreatic head confirmed a diagnosis of metastatic gastric adenocarcinoma (Fig. 4a, b).
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Contrast-enhanced computed tomography (CT) and endoscopic ultrasonography (EUS) for the patient in case 2.. a. Contrast-enhanced CT images revealed dilation of the bile duct and of the common hepatic duct, with the contrast effect revealing a 26-mm cystic tumor in the head of the pancreas and mural nodules.. b. A cystic tumor with mural nodules was found in the pancreatic head.
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On endoscopic ultrasound, a cystic tumor with mural nodules was also observed in the pancreatic head (Fig. 5a, b).
Intraoperative findings for the patient in case 2.. a. Prior Billroth II reconstruction with adhesions at the gastrojejunal anastomosis.. b. The excision range is demarcated by the red line, and the gastrojejunal anastomosis was resected.
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The previous gastroduodenal anastomosis site was resected, and the pancreatoduodenum was removed (Fig. 6a, b).
Intraoperative findings after reconstruction for the patient in case 2. In a and b, a new afferent loop was used for reconstruction.
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A SSPPD-IIA-1 reconstruction was performed (Fig. 7a, b); the procedure was completed in 7 h and 38 m, with an intraoperative blood loss volume of 200 mL.
Pathological specimen from the patient in case 2.. a. Excised specimen.. b. The histological diagnosis of the pancreas head mass was an intraductal papillary mucinous carcinoma (IPMC).
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Histological examination confirmed a diagnosis of intraductal papillary muscinous carcinoma of the pancreatic head (Fig. 8a, b).
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Contrast-enhanced computed tomography (CT) of the patient in case 3. Contrast-enhanced CT images revealed dilation of the intrahepatic bile duct due to a low-density tumor mass in the pancreatic head.
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CEA, CA19-9, duke pancreatic monoclonal antigen type 2, and s-pancreas antigen-1 were elevated at 3.6 ng/mL, 48 U/L, 186 U/mL, and 21.9 U/mL, respectively. Contrast-enhanced CT revealed dilation of the intrahepatic bile duct secondary to a low-density tumor mass in the pancreatic head (Fig. 9).
Intraoperative findings for the patient in case 3.. a. A prior Roux-en-Y reconstruction with adhesions at the gastrojejunal anastomosis.. b. The excision range is demarcated by the red line, and the afferent loop, from the Treitz ligament to the jejunal anastomosis, was relatively long, and the gastrojejunal anastomosis was preserved.
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Treitz ligament to the jejunal anastomosis, was relatively long (Fig. 10a, b), and was used for reconstruction of the choledochojejunostomy and the pancreaticojejunostomy (Fig. 11).
Pathological specimen from the patient in case 3.. a. Excised specimen.. b. The histological diagnosis of the pancreas head mass was pancreatic carcinoma.
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The histological evaluation confirmed a diagnosis of the pancreatic head (Fig. 12a, b).