Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature

Abstract

Background: Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.

Case summary: A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.

Conclusion: Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.

Keywords: Ampullary tumor; Case report; Endoscopic papillectomy; Operating microscope; Pancreaticoduodenectomy; Transduodenal local excision.

Figure 1

Preoperative examination of the ampullary tumor. A and B: Contrast-enhanced computed tomography and magnetic resonance imaging showing an enhanced lesion (arrow) located in the descending part of the duodenum; C: Magnetic resonance cholangiography revealing a mild dilation of the common bile duct, and no cut-off sign or stricture of either the bile duct or pancreatic duct; D: Endoscopic view of the ampullary adenoma.

Figure 2

Steps of the surgical procedure under the operating microscope. A: Exposure of the duodenal papillary adenoma; B: Kelly forceps placed under the tumor to raise the ampulla of Vater; C: Identifying the pancreaticobiliary duct (arrow) by insertion of a silicone catheter. One orifice was created in this case; D: Dissecting the ampullary adenoma carefully to ensure an adequate margin; E: Suturing the pancreaticobiliary duct to the surrounding duodenal mucosa with 6/0 prolene sutures; F: Closure after the duodenotomy.