Korean J Hepatobiliary Pancreat Surg.  2015 May;19(2):66-70. 10.14701/kjhbps.2015.19.2.66.

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

• KMID: 2243051
• DOI: http://doi.org/10.14701/kjhbps.2015.19.2.66

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.

Keyword

Balloon dilation; Functional stenosis; Disuse atrophy; Hepaticojejunostomy; Redo surgery

MeSH Terms

Aged
Bile Duct Neoplasms
Bile Ducts, Extrahepatic
Cholangiocarcinoma
Cholangitis
Choledochostomy
Constriction
Constriction, Pathologic*
Diagnosis
Drainage
Extremities
Follow-Up Studies
Hepatectomy*
Humans
Jaundice, Obstructive
Liver
Muscular Disorders, Atrophic
Pancreaticoduodenectomy*
Portal Vein
Radionuclide Imaging

Figure

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  Fig. 1 The preoperative assessment process. (A) The postoperative status following pylorus-preserving pancreaticoduodenectomy (PPPD) was visible on the computed tomography (CT) scan; (B) Recurrent bile duct cancer mimicked perihilar cholangiocarcinoma of type IIIb on magnetic resonance cholangiography; and (C) and (D) Cholangioscopic biopsy was attempted for tissue confirmation.

• 

  Fig. 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.

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  Fig. 3 Gross photograph of the resected liver specimen. A wide area of the hepatic hilum was involved with extension beyond the bile duct, thus the whole paracaval portion had to be removed.

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  Fig. 4 Sequences of hepatobiliary scintigraphy follow-ups taken at postoperative 2 weeks (A), 1 week after balloon dilation (B) and 4 weeks after balloon dilation (C).

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  Fig. 5 Sequences of tube cholangiography. (A) and (B) Direct cholangiogram through the PTBD tube showed uneventful filling of the intrahepatic duct and hepaticojejunostomy, but outflow passage at 5 minutes was impaired; and (C) and (D) Balloon dilation of the afferent jejunal loop was performed by using a 20 mm- wide balloon and a large-bore catheter was placed deep into the afferent jejunal loop.

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