A 50-year-old, right-handed woman was admitted to the Department of Hepatobiliary Surgery of the hospital because of main complaints of pruritus and vague abdominal pain.
Two years before this admission, the patient was seen by an ophthalmologist and was diagnosed with chronic dacryocystitis. After receiving lacrimal duct intubation therapy, she felt well and left the hospital. One year after this treatment, with a main complaint of vaginal bleeding, the patient was diagnosed with dysfunctional uterine bleeding. Interestingly, the results of computed tomography (CT) of the chest and abdomen revealed that this patient had SIT. Without contraindications, she underwent endometrial ablation therapy and left the hospital a few days later.
Approximately 1 month before admission, the patient visited a dermatologist with the main complaint of pruritus and received a local glucocorticoid treatment for the skin, but the symptoms remained. Approximately 10 days before admission, she complained of vague abdominal pain and terrible pruritus with jaundice.
There was no history of hepatitis, no known allergies to medications, and no family history of SIT or exposure to toxins. On examination, the patient was well groomed, pleasant and cooperative. There was jaundice of the sclera and tenderness in the upper abdomen. The heartbeats were heard best on the right side of the body.
For the assistant examinations, the carbohydrate antigen 19-9 (CA 19-9) level was 126.4 units per milliliter (reference range, 0-27). Her blood total bilirubin was 230.1 mumol per liter (mumol/L) (reference range, 5.1-28.0). Magnetic resonance imaging (MRI) of the abdomen revealed the following: (1) SIT (Figures 1A,B); (2) distended gallbladder; (3) vine-tree-like dilatation of the intrahepatic and extrahepatic bile ducts (Figure 1C); (4) conspicuously cramped lower end of the common bile duct (CBD) and a thickened wall of the lower end of the CBD (Figure 1D); and (5) slight dilatation of the pancreatic duct. Therefore, cholangiocarcinoma was suspected in this simple SIT patient.
After admission to the hospital, the total bilirubin level was 376.5 mumol/L, and percutaneous transhepatic cholangial drainage (PTCD) was performed. The total bilirubin level decreased to 184.9 mumol/L. After the 20-day full preoperative preparation, the patient underwent LPD therapy (Figure 2).
The left-right transposition of viscera is greatly inconvenient for surgeons performing LPD, although the order of operative steps was similar. Therefore, in the first hour of the operation, the surgeon stood on the left side of the patient and spent substantial time observing the total left-right transposition of viscera, revising the surgical plan and practicing the possible operation of some surgical instruments. During LPD, the surgeon paid more attention to exploring the complex vascular variants one after another. The colon was located in front of the small bowel, and anastomosing the small intestine with the pancreas and bile duct were behind the colon. The cholangiojejunostomy and pancreaticojejunostomy were not performed until the surgeon had adapted to the patient's unique structure of left-right viscera transposition. The whole operation was successful and safe. The total bilirubin level was reduced to 98.1 mumol/L on the second day after the operation. The patient left the hospital and was lost to follow-up.
Finally, the results of histologic examination showed that the tumor was a moderately ulcerated and highly differentiated adenocarcinoma of the duodenal papilla (Figure 3), and tumor cells had invaded the CBD but failed to involve the pancreas tissues and lymph nodes.