Disinsertion of Duodenal Papilla

DISINSERTION OF DUODENAL PAPILLA DURING DUODENAL SURGERY – 20 YEARS AFTER SURGICAL REPAIR (Abstract): The authors present the case of a 68 years old patient admitted for chronic calculous cholecistitis and symptomatic choledocolithiasis with obstructive jaundice and moderate biochemical cholestasis. The patient had a Reichel-Polya gastric resection for ulcer 20 years ago with disinsertion of duodenal papilla repaired with jejunal loop patch in “Roux en Y”. Intraoperatively we noticed chronic sclerous acalculous cholecistitis, equivalence of cholecistocholedocal fistula, choledocolithiasis. Exploration of the duodenal papilla identified a relative oddian stenosis. The first and second parts of duodenum were absent and replaced by a jejunal loop in “Roux en Y” patching the papilla on the side, with a free blind end and anastomosed laterally to the gastric stump. The second, subvaterian part of duodenum have been closed and left blind. The treatment of the common bile duct lithiasis consisted in cholecistectomy with primary closure of the large communication between the gallbladder and common bile duct, coledocolithotomy, common bile duct (CBD) lavage. To ensure an adequate biliary flow we decided for a side-to-side anastomosis between the CBD and the blind part of the jejunal Roux-en-Y loop. The blind end of the second subvaterian part of the duodenum was anastomosed in an end-to-end fashion also to the blind end of the jejunal Roux-en-Yloop to ensure some biliary flow through remaining part of the duodenum. The postoperative course was simple. At 2 years of follow-up the patient is free of symptoms.