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Balloon dilation of jejunal afferent loop functional stenosis following left hepatectomy and hepaticojejunostomy long time after pylorus-preserving pancreaticoduodenectomy: a case report.

Yoon YI, Hwang S, Ko GY, Lee JJ, Kang CM, Seo JH, Kwon YJ, Cheon SJ - Korean J Hepatobiliary Pancreat Surg (2015)

Bottom Line: The patient recovered uneventfully, but clamping of the percutaneous transhepatic biliary drainage (PTBD) tube resulted in cholangitis.Biliary imaging studies revealed that biliary passage into the afferent jejunal limb was significantly impaired.This very unusual condition was regarded as disuse atrophy of the jejunal loop, which was successfully managed by balloon dilation and intraluminal keeping of a large-bore PTBD tube for 1 month.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

ABSTRACT
We present a rare case of functional stenosis of the jejunal loop following left hepatectomy and hepaticojejunostomy long after pylorus-preserving pancreaticoduodenectomy (PPPD), which was successfully managed by balloon dilation. A 70-year-old Korean man had undergone PPPD 6 years before due to 1.8 cm-sized distal bile duct cancer. Sudden onset of obstructive jaundice led to diagnosis of recurrent bile duct cancer mimicking perihilar cholangiocarcinoma of type IIIb. After left portal vein embolization, the patient underwent resection of the left liver and caudate lobe and remnant extrahepatic bile duct. The pre-existing jejunal loop and choledochojejunostomy site were used again for new hepaticojejunostomy. The patient recovered uneventfully, but clamping of the percutaneous transhepatic biliary drainage (PTBD) tube resulted in cholangitis. Biliary imaging studies revealed that biliary passage into the afferent jejunal limb was significantly impaired. We performed balloon dilation of the afferent jejunal loop by using a 20 mm-wide balloon. Follow-up hepatobiliary scintigraphy showed gradual improvement in biliary excretion and the PTBD tube was removed at 1 month after balloon dilation. This very unusual condition was regarded as disuse atrophy of the jejunal loop, which was successfully managed by balloon dilation and intraluminal keeping of a large-bore PTBD tube for 1 month.

No MeSH data available.


Related in: MedlinePlus

Sequences of CT scan follow-up. (A) Left liver and caudate lobe occupied 45% of the total liver volume; (B) Follow-up CT scan 10 days after PVE showed a noticeable atrophy of the left liver; (C) Follow-up CT scan 5 days after left liver resection showed deeply seated location of the hepaticojejunostomy and intraluminal location of a tube (arrow); and (D) Postoperative 2 month CT scan showed uneventful recovery from the redo surgery.
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Figure 2: Sequences of CT scan follow-up. (A) Left liver and caudate lobe occupied 45% of the total liver volume; (B) Follow-up CT scan 10 days after PVE showed a noticeable atrophy of the left liver; (C) Follow-up CT scan 5 days after left liver resection showed deeply seated location of the hepaticojejunostomy and intraluminal location of a tube (arrow); and (D) Postoperative 2 month CT scan showed uneventful recovery from the redo surgery.

Mentions: Since the left liver appeared to be 45% of the total liver volume (Fig. 2A) and he underwent PPPD, we performed left portal vein embolization (PVE) to facilitate left liver resection as well as to ensure patient safety. Follow-up computed tomography (CT) 10 days after PVE showed a noticeable atrophy of the left liver (40% of the total liver volume: Fig. 2B), thus we performed resection of the left liver and caudate lobe and remnant extrahepatic bile duct at 13 days after left PVE (Fig. 3). There were heavy adhesions around the left liver and caudate lobe, thus very meticulous time-consuming dissection was necessary. The pre-existing choledochojejunostomy from PPPD was transected and a frozen-section biopsy revealed that there was no tumor invasion at this area. Thus we decided to use the jejunal loop for biliary reconstruction instead of making a new Roux-en-Y jejunal loop limb. This finding might implicate de novo malignancy or skipped bile duct cancer recurrence because the pre-existing choledochojejunostomy was spared from tumor invasion. Removal of the liver and residual extrahepatic bile duct resulted in two separate bile duct openings at the remnant right liver, which were unified by customized unification sutures with 5-0 and 6-0 Prolenes. The opening at the jejunal loop, which was correspondent to the prior choledochojejunostomy, was used for biliary reconstruction. To match the jejunal limb length, the retrocolic tunnel portion was extensively mobilized. The patient had a PTBD catheter at the time of surgery, thus this catheter was replaced with a 3 mm-sized silatic tube and its tip with multiple side-holes were placed within the jejunal loop across the newly formed hepaticojejunostomy (Fig. 2C).


Balloon dilation of jejunal afferent loop functional stenosis following left hepatectomy and hepaticojejunostomy long time after pylorus-preserving pancreaticoduodenectomy: a case report.

Yoon YI, Hwang S, Ko GY, Lee JJ, Kang CM, Seo JH, Kwon YJ, Cheon SJ - Korean J Hepatobiliary Pancreat Surg (2015)

Sequences of CT scan follow-up. (A) Left liver and caudate lobe occupied 45% of the total liver volume; (B) Follow-up CT scan 10 days after PVE showed a noticeable atrophy of the left liver; (C) Follow-up CT scan 5 days after left liver resection showed deeply seated location of the hepaticojejunostomy and intraluminal location of a tube (arrow); and (D) Postoperative 2 month CT scan showed uneventful recovery from the redo surgery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4494079&req=5

Figure 2: Sequences of CT scan follow-up. (A) Left liver and caudate lobe occupied 45% of the total liver volume; (B) Follow-up CT scan 10 days after PVE showed a noticeable atrophy of the left liver; (C) Follow-up CT scan 5 days after left liver resection showed deeply seated location of the hepaticojejunostomy and intraluminal location of a tube (arrow); and (D) Postoperative 2 month CT scan showed uneventful recovery from the redo surgery.
Mentions: Since the left liver appeared to be 45% of the total liver volume (Fig. 2A) and he underwent PPPD, we performed left portal vein embolization (PVE) to facilitate left liver resection as well as to ensure patient safety. Follow-up computed tomography (CT) 10 days after PVE showed a noticeable atrophy of the left liver (40% of the total liver volume: Fig. 2B), thus we performed resection of the left liver and caudate lobe and remnant extrahepatic bile duct at 13 days after left PVE (Fig. 3). There were heavy adhesions around the left liver and caudate lobe, thus very meticulous time-consuming dissection was necessary. The pre-existing choledochojejunostomy from PPPD was transected and a frozen-section biopsy revealed that there was no tumor invasion at this area. Thus we decided to use the jejunal loop for biliary reconstruction instead of making a new Roux-en-Y jejunal loop limb. This finding might implicate de novo malignancy or skipped bile duct cancer recurrence because the pre-existing choledochojejunostomy was spared from tumor invasion. Removal of the liver and residual extrahepatic bile duct resulted in two separate bile duct openings at the remnant right liver, which were unified by customized unification sutures with 5-0 and 6-0 Prolenes. The opening at the jejunal loop, which was correspondent to the prior choledochojejunostomy, was used for biliary reconstruction. To match the jejunal limb length, the retrocolic tunnel portion was extensively mobilized. The patient had a PTBD catheter at the time of surgery, thus this catheter was replaced with a 3 mm-sized silatic tube and its tip with multiple side-holes were placed within the jejunal loop across the newly formed hepaticojejunostomy (Fig. 2C).

Bottom Line: The patient recovered uneventfully, but clamping of the percutaneous transhepatic biliary drainage (PTBD) tube resulted in cholangitis.Biliary imaging studies revealed that biliary passage into the afferent jejunal limb was significantly impaired.This very unusual condition was regarded as disuse atrophy of the jejunal loop, which was successfully managed by balloon dilation and intraluminal keeping of a large-bore PTBD tube for 1 month.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

ABSTRACT
We present a rare case of functional stenosis of the jejunal loop following left hepatectomy and hepaticojejunostomy long after pylorus-preserving pancreaticoduodenectomy (PPPD), which was successfully managed by balloon dilation. A 70-year-old Korean man had undergone PPPD 6 years before due to 1.8 cm-sized distal bile duct cancer. Sudden onset of obstructive jaundice led to diagnosis of recurrent bile duct cancer mimicking perihilar cholangiocarcinoma of type IIIb. After left portal vein embolization, the patient underwent resection of the left liver and caudate lobe and remnant extrahepatic bile duct. The pre-existing jejunal loop and choledochojejunostomy site were used again for new hepaticojejunostomy. The patient recovered uneventfully, but clamping of the percutaneous transhepatic biliary drainage (PTBD) tube resulted in cholangitis. Biliary imaging studies revealed that biliary passage into the afferent jejunal limb was significantly impaired. We performed balloon dilation of the afferent jejunal loop by using a 20 mm-wide balloon. Follow-up hepatobiliary scintigraphy showed gradual improvement in biliary excretion and the PTBD tube was removed at 1 month after balloon dilation. This very unusual condition was regarded as disuse atrophy of the jejunal loop, which was successfully managed by balloon dilation and intraluminal keeping of a large-bore PTBD tube for 1 month.

No MeSH data available.


Related in: MedlinePlus