Transduodenal Ampullography: Extending Surgical Safety Near Pancreaticobiliary Junction
Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India
Abstract
Aim and background
The pancreaticobiliary junction (PBJ) is a complex anatomical location where the pancreatic duct and distal common bile duct (CBD) join. Surgical procedures near the PBJ are challenging, and inadvertent injury to either of these ducts can increase postoperative morbidity. Choledochal cyst (CDC) excision involves securing the distal bile duct near the PBJ. The surgical morbidity in these patients can be precipitated by improper closure of the distal biliary stump, causing pancreatic leak or intra-abdominal collections. In this report, we describe a novel technique – transduodenal ampullography (TAG), in securing the distal biliary stump during CDC excision, which can be used in special situations near the PBJ.
Case description
A female in her mid-thirty with type I CDC was planned for CDC excision. While trying to excise the intrapancreatic portion of the CDC, the distal stump was accidentally transected and retracted into the pancreatic parenchyma. In order to avoid pancreatic leak, the distal stump was secured using TAG. Through a duodenotomy, the major papillary prominence was identified, and the ampulla was cannulated. The retracted distal stump was identified after injecting dye into the cannula in the ampulla. The identified distal stump was secured using interrupted sutures with a pancreatic stent in situ. Roux-en-Y bilioenteric anastomosis was done with the proximal stump, and bowel continuity was maintained with a jejunojejunostomy. The patient's postoperative course was uneventful. In this report, we describe the technique in detail, its advantages, and its limitations.
Conclusion
Transduodenal ampullography is a safe, simple and feasible technique, which can be used to secure the intrapancreatic distal bile duct in special situations.
Clinical significance
Surgical procedures near the PBJ are challenging and are associated with inherent morbidity due to their anatomical location.
Transduodenal ampullography is a safe and feasible technique which can be used in special surgical situations near the PBJ.
How to cite this article
Dasari M, Gurana KR, Sharma VK, et al. Transduodenal Ampullography: Extending Surgical Safety Near Pancreaticobiliary Junction. Euroasian J Hepato-Gastroenterol 2025;15(2):213–217.
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Keywords: Choledochal cyst, Common bile duct, Pancreatic duct, Pancreatic fistula
Article notes
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Received 2025 Sep 20; Accepted 2025 Oct 30; Issue date 2025 Jul-Dec.
Introduction
The pancreaticobiliary junction (PBJ) is a complex anatomical location where the pancreatic duct and distal common bile duct (CBD) join. Surgical procedures near the PBJ are challenging; inadvertent injury to either of these ducts can increase postoperative morbidity. Choledochal cyst (CDC) excision involves securing the distal bile duct near the PBJ. The CDC is a CBD abnormality, requiring surgical intervention. Complete excision of the extrahepatic cyst is the treatment recommended, leaving a proximal stump at the hilum which requires bilioenteric anastomosis for biliary continuity and a distal stump towards the pancreatic head region which needs closure.1–4 The outcome of surgical excision of the CDC is satisfactory in most of the cases. Management of the distal stump is of utmost importance in decreasing the postoperative morbidity. An improperly secured distal stump can cause postoperative pancreatic leak/fistula, intra-abdominal collections, and hemorrhage.2,5,6 In this report, we share a novel technique to secure the distal stump during CDC excision.
Case Description
A female in her mid-thirty was referred to our center with recurrent episodes of pain in the right upper abdomen. On evaluation, a type I CDC (Fig. 1) was diagnosed on magnetic resonance cholangiopancreatography (MRCP). After proper informed consent, she was planned for laparoscopic CDC excision. During the procedure, dense fibrous vascularized adhesions were encountered around the CDC in the hepatoduodenal ligament. The bleeding from these vascularized adhesions made it difficult to delineate the anatomy during laparoscopic approach, and the procedure was converted to an open approach. The abdominal cavity was entered through a right subcostal incision. Cholecystectomy was performed after establishing the critical view of safety. The anatomy in the hepatoduodenal ligament was delineated, and the CDC was separated after securing all the adhesions using a harmonic scalpel and bipolar forceps. Proximal dissection of the bile duct was carried out around 1 cm above the insertion of the cystic duct towards the hilum. While delineating the distal intrapancreatic portion of the CDC, the distal stump of the CBD was mistaken for an adhesion and was transected accidentally using a harmonic scalpel, causing retraction of the distal stump into the pancreatic parenchyma. After thorough review of the MRCP, the distal transected CBD was identified to be nonstenotic. In order to avoid postoperative pancreatic leak and related complications, it was decided to identify and secure the distal CBD using transduodenal ampullography (TAG), which was illustrated in Figure 2.
Transduodenal Ampullography (TAG)
The duodenum was kocherized adequately so that the head of the pancreas was free to handle. An adequate longitudinal duodenotomy was done on the second part of the duodenum (Fig. 3). The major papillary prominence was identified and probed to identify the distal transected CBD. These multiple attempts were unsuccessful as the probe inadvertently slipped into the pancreatic duct due to the short length of the intrapancreatic distal CBD. An 8F infant feeding tube (IFT) was cannulated into the ampulla (Fig. 4), and a diluted methylene blue dye was injected through the IFT. Efflux of the stained fluid from the posterosuperior surface of the pancreatic head helped in locating the site of the retracted distal stump of the intrapancreatic CBD (Fig. 5). After securing a probe into the pancreatic duct, the site of efflux of stained fluid on the pancreatic head was secured using polydioxanone 5-0 sutures in an interrupted fashion, making sure the probe in the pancreatic duct was not taken into the sutures (Fig. 6). The pancreatic probe was removed, and again an IFT (the tip of the IFT was cut to help in passing a guidewire later) was secured into the ampulla. A leak test was done by injecting saline and air through the IFT in the ampulla to check for the appropriateness of the closure of the distal stump of the CBD (Fig. 7). After a negative leak test, an endoscopically removable plastic stent was secured in the pancreatic duct after exchanging the IFT in the ampulla with a guidewire (Figs 8 and 9). Duodenotomy was closed with interrupted polydioxanone 3-0 sutures. Proximal transection of the CDC was done 2 cm distal to the primary biliary confluence (identified by opening the CDC). The duodenojejunal (DJ) flexure was identified, and the jejunum was transected 30 cm distal to the DJ flexure using a stapling device to create a Roux limb of 60 cm length. Roux-en-Y end-to-side choledochojejunostomy was done with interrupted polydioxanone 3-0 sutures (Fig. 10). Bowel continuity was maintained with a side-to-side jejunojejunostomy 60 cm distal to the bilioenteric anastomosis. The abdomen wound was closed after securing an abdominal drain in the Morrison pouch. Postoperatively, she suffered superficial surgical site infection which was managed appropriately. Her drain output was minimal with an elevated drain fluid amylase level on third postoperative day (POD) and was removed on fifth POD. She was discharged on sixth POD. After 3 weeks postoperatively, endoscopic removal of the pancreatic stent was done.
Discussion
Although the surgical output of CDC excision is satisfactory, some postoperative complications like bile leak, retained intraductal stones, and pancreatic leaks can occur, sometimes requiring interventions.4–11 Incomplete excision of the distal stump of the CDC may predispose to cystolithiasis, recurrent cholangitis, pancreatitis, and malignancy.6,10 It is therefore recommended to dissect and excise the distal stump of the CDC till its junction with the pancreatic duct.6 While trying to excise the distal stump completely, there can be injury to the pancreatic parenchyma and pancreatic duct, causing postoperative problems like hemorrhage, pancreatic parenchymal and ductal injury leading to stricture.2,12 An improperly secured distal stump of the CBD can cause pancreatic leak/fistula, intra-abdominal collection, and postoperative hemorrhage.2,5,11 Conversely, inappropriate deeper suturing of the distal stump can cause occlusion or narrowing of the pancreatic duct, leading to recurrent pancreatitis and chronic pancreatitis. Therefore, the management of the distal stump is important in decreasing postoperative morbidity and can be challenging.5,12,13
Postoperative pancreatic problems following CDC excision were well studied. These problems can contribute to a spectrum of postoperative morbidity, from a simple biochemical pancreatic fistula to persistent pancreatic fistula requiring intervention. Pancreatic leak can manifest as intra-abdominal collections requiring percutaneous drainage. Persistent, longstanding postoperative pancreatic fistula may require endoscopic pancreatic duct stenting. A properly secured distal stump during CDC excision can decrease these problems. In this report, a simple technique in managing the distal CBD stump through TAG was elaborated.
Multiple techniques like cholangiography, cholangioscopy, and intraoperative ultrasound were described to delineate the extent of the distal CBD stump during CDC excision.6,14,15 Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) can also be used to secure the distal CBD. However, ERCP in a laparotomy setting can be challenging. The continuous insufflation during endoscopy causes distension of the stomach and duodenum, making access to the retroperitoneum difficult. ERCP also requires special equipment and expertise. Transduodenal ampullography is a safe technique, feasible to perform, and does not require any sophisticated devices. By using this technique, with the probe in the pancreatic duct, the distal CBD stump can be closed properly, avoiding pancreatic duct occlusion or stricture.
This technique – transduodenal ampullography can also be used in multiple other surgical procedures near the PBJ. Remnant intrapancreatic CDC are associated with recurrent cholangitis, pancreatitis, and malignancy.6 The surgical excision of the remnant CDC can be challenging due to dense adhesions, and TAG can ease these surgical challenges. Methylene blue used during TAG can demarcate the PBJ, thereby can be used in pancreas-preserving complete excision of intrapancreatic CBD for benign biliary diseases. Transduodenal ampullography can be used in the enucleation of benign pancreatic head tumors as staining both the CBD and pancreatic duct with methylene blue can delineate these structures better. This technique can also be employed as a leak test after securing pancreatic duct stumps during distal pancreatectomy. With expertise, this technique can be feasible even in a minimally invasive approach.
Though we did not experience any clinically significant complications in our patient, this technique had some limitations. This technique required an extra duodenotomy with a subsequent suture line which was a potential source for leak and duodenal stenosis. There was an increased risk of postoperative pancreatitis due to manipulation in the pancreatic duct, which can be decreased by leaving a stent in the pancreatic duct. During follow up, this technique required an additional intervention in the form of endoscopy to remove the pancreatic stent.
Conclusion
Transduodenal ampullography is a feasible, easy to perform and safe technique in securing the distal CBD in special situations. This technique can be employed in a wide spectrum of surgical procedures performed in the vicinity of the PBJ, to prevent postoperative complications.
Clinical Significance
- Surgical procedures near the PBJ are challenging and are associated with inherent morbidity due to their anatomical location.
- Transduodenal ampullography is a safe and feasible technique which can be used in special surgical situations near the PBJ.
Orcid
Mukteshwar Dasari https://orcid.org/0000-0002-8957-9340
Krishna R Gurana https://orcid.org/0000-0001-7567-338X
Vijay K Sharma https://orcid.org/0000-0001-9156-7878
Sri VS Kannan https://orcid.org/0009-0001-3539-2601
Deeban Ganesan https://orcid.org/0009-0006-8317-8390
Abhijit Chandra https://orcid.org/0000-0002-3940-7428
Footnotes
Footnote Group
References
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