Pancreaticoduodenectomy for Ampullary Carcinoma after Clinical Resolution of Necrotizing Pancreatitis with Giant Walled-Off Necrosis: A Case Report.

introductionAmpullary carcinoma is typically treated with pancreaticoduodenectomy (PD). Nevertheless, performing curative resection remains remarkably challenging when the clinical course is complicated by necrotizing pancreatitis and extensive walled-off necrosis (WON). Although resection is occasionally performed after mild pancreatitis, few reports describe curative surgery following severe necrosis requiring necrosectomy. We report a rare case managed with necrosectomy for extensive WON, followed by PD after regression of the necrotic area. CASE PRESENTATION: A 77-year-old man presented with obstructive jaundice and underwent endoscopic retrograde cholangiopancreatography with biliary metal stent placement and biopsy, leading to a diagnosis of ampullary adenocarcinoma without distant metastasis. Shortly after the procedure, he developed acute necrotizing pancreatitis, which progressed to extensive WON surrounding the pancreatic head and body. Despite conservative treatment, the patient deteriorated due to peritonitis caused by ascending colon perforation adjacent to the necrotic area. Emergency laparotomy revealed widespread peripancreatic necrosis and colonic perforation; right hemicolectomy with ileostomy, open necrosectomy, and multiple drain placements were performed. Over the subsequent 4 months, infection control, rehabilitation, and nutritional support led to gradual regression of the necrosis, marked improvement of inflammatory markers, and no evidence of tumor progression on serial CT. Approximately 6 months after the onset of pancreatitis, a subtotal stomach-preserving PD with lymph node dissection and ileostomy closure was performed. The operation was technically demanding due to dense adhesions and fibrosis, particularly around the superior mesenteric vein. The operative time was 744 min, with an estimated blood loss of 8110 mL. Postoperative complications included a clinically relevant postoperative pancreatic fistula, bile leakage from the hepaticojejunostomy, and stenosis of the portal vein; all were managed conservatively. The patient was discharged on POD 86 and remained alive and recurrence-free 6 months later.

conclusionsPD may be feasible in highly selected patients after clinical resolution of necrotizing pancreatitis complicated by extensive WON and colonic perforation. However, surgeons should be aware that the procedure remains highly invasive and technically demanding, even when radiologic and laboratory findings suggest resolution, and should be considered only after thorough multidisciplinary evaluation and careful counselling.