Pancreatic cancer with synchronous peritoneal and hepatic metastases: A case report.

Introduction and importance: There is evidence that patients with limited peritoneal carcinomatosis of pancreatic cancer or those with low burden of hepatic metastases are amenable to surgical resection. A case report of a patient with cancer of the pancreatic tail and synchronous peritoneal and hepatic metastases is presented. CASE PRESENTATION: A male patient, 66 years old, underwent cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) and radio-frequency ablation (RFA) for synchronous hepatic metastases simultaneously to distal pancreatectomy for adenocarcinoma of the pancreas. Adjuvant chemotherapy followed the R0 surgery. The patient remained disease free for 18 months, developed liver recurrence and died 28 months after the initial operation. DISCUSSION: CRS plus HIPEC with synchronous ablation or resection of hepatic metastases may be used for the treatment of pancreatic cancer with synchronous peritoneal and hepatic metastases in highly selected patients. CONCLUSION: Further studies are needed to confirm whether patients with synchronous peritoneal and hepatic metastases are offered survival benefit from complex surgical intervention (CRS plus HIPEC combined with hepatic resection or RFA).

Morbidity and mortality of patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: The purpose of this study was to record the incidence, and identify the prognostic variables of morbidity and mortality in patients with peritoneal malignancy undergoing cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: The files of patients with peritoneal malignancy who underwent CRS + HIPEC from 2015-2022 were retrieved. Morbidity and hospital mortality were recorded and correlated to a variety of clinical variables. RESULTS: A total of 44/192 (22.9%) patients were recorded with postoperative complications. Grade 3 and 4 complications were 12.5%. The possible prognostic variables of morbidity were the extent of peritoneal malignancy and the number of suture lines. The mortality rate was 2.5% (5 patients). The number of FFP units, and peritonectomy procedures were identified as possible prognostic variables of hospital mortality. CONCLUSIONS: The morbidity rate in patients undergoing CRS + HIPEC is acceptable compared to morbidity of previous publications or major gastrointestinal surgical operations. The possible prognostic variables of morbidity are the extent of peritoneal malignancy, and the number of suture lines. The mortality rate is low. The possible prognostic variables of mortality are the number of FFP units, and the number of peritonectomy procedures.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy in recurrent ovarian cancer: 18 years of experience.

AIM: To identify the clinical and pathological factors associated with relapse in women who had undergone secondary cytoreductive surgery due to locally advanced recurrent ovarian cancer. METHODS: Women with locally advanced recurrent ovarian cancer who had undergone cytoreduction between 2000 and 2018 were included in this study. Demographic, clinical and biochemical intraoperative findings were recorded for each woman. All factors were assessed in order to identify which correlated with the outcomes of interest (i.e. disease relapse, mortality and morbidity). RESULTS: In total, 181 women who had undergone secondary cytoreduction were analysed. The hospital mortality rate was 1.7 % (n = 3) and the morbidity rate was 32.1 % (n = 58). Recurrence was recorded in 101 (55.8 %) women. Infiltration of large bowel lymph nodes was a negative prognostic indicator of morbidity (p = 0.029). A prior surgical score of 1 (PSS-1) [odds ratio (OR) 0.465] and complete cytoreduction (OR 0.518) were found to be significant independent predictors for disease relapse. Median overall survival was greater for patients with PSS-1 (151.3 vs 59.4 vs 44.1 months; p = 0.049) and patients with complete cytoreduction (137.6 vs 36.2 vs 10.0 vs 27.4 months; p < 0.001). CONCLUSION: Complete cytoreduction and PSS-1 are associated with reduced disease relapse and increased overall survival. Infiltration of large bowel lymph nodes is associated with increased morbidity.

Low-Grade Pseudomyxoma Peritonei Behaving as a High-Grade Disease: A Case Series and Literature Review.

Patients with low-grade appendiceal mucinous carcinomas (LAMNs) treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have a favorable prognosis. However, a subgroup of patients presents a clinically aggressive course with disease progression despite receiving treatment. The purpose of this study is to report the experience of clinically aggressive LAMN patients treated by the same team, and to present a review of the literature. The cases of four patients with clinically aggressive LAMNs were reviewed. Clinical and histopathological characteristics were re-examined. Recurrences and the time of recurrence, as well as the survival time, were recorded. These patients were four men with clinically aggressive LAMNs treated with CRS plus HIPEC. One of them underwent CC-0 surgery, two underwent CC-1 surgery, and one underwent CC-3 surgery. All patients received systemic chemotherapy after surgery. Recurrence was recorded in three of the patients within 4-23 months after the initial treatment. Two of the patients underwent secondary CRS. Three patients died of disease recurrence within 13-23 months, and one is alive with a disease relapse at 49 months after his initial surgery. LAMNs were identified in both the initial specimens and the specimens obtained during reoperation. The prognosis of LAMN patients treated with CRS plus HIPEC is favorable. A small number of patients present a clinically aggressive course that is unresponsive to any treatment. Molecular and genetic studies are required to identify this group of LAMN patients who have an unfavorable prognosis.

Effect of N-acetyl-L-cysteine on inflammation after intraperitoneal mesh placement in a potentially contaminated environment: An experimental study in the rat.

BACKGROUND: The use of prosthetic meshes in abdominal wall reconstruction is a well-established approach; however, in certain cases where a bowel resection coexists its application is disputed. Any underlying inflammatory process may augment adhesion formation which is a major postoperative complication. In this animal study, our aim was to investigate the effect of N-acetyl-l-cysteine (NAC) on adhesion formation and the expression of inflammatory markers when a mesh was used in a clean or a potentially contaminated environment. METHODS: Sixty male Wistar rats were randomly and equally allocated in 3 groups: A, B and C. Animals in all groups underwent laparotomy, a prosthetic mesh was placed and chemoprophylaxis with ciprofloxacin was administered. In groups B and C an enterectomy was also performed. NAC was injected intraperitoneally in group C. Adhesion formation, IL-1a, IL-6, TNF-a and histological data including fibrosis, neutrophils' infiltration and neovascularization were assessed. Mesh samples were sent for cultivation. RESULTS: Adhesion formation was significantly less and inflammation markers were also lower in group C compared to group B (p<0.05). Histological findings were significant for greater fibrosis, neutrophils' infiltration and neovascularization in group B compared to both group A and C. Regarding mesh cultures, more specimens were tested positive in group B (p <0.05). Outcomes between group A and C did not differ. CONCLUSION: NAC effectively ameliorated adhesion formation and inflammation in a potentially septic environment where a prosthetic mesh was placed.

Ovarian cancer: 20-year experience with cytoreductive surgery and perioperative intraperitoneal chemotherapy.

PURPOSE: Complete cytoreduction has been established as the most significant factor of long-term survival in epithelial ovarian cancer. Perioperative intraperitoneal chemotherapy has been added in the treatment of ovarian cancer the last 20 years. The purpose of the study was to determine the outcome of women with ovarian cancer using the data of one surgical team. METHODS: Women with ovarian cancer treated from 2000 to 2019 by the same surgical team were enrolled in the study. The patients underwent cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Clinical and histopathological variables were correlated to hospital mortality, morbidity, survival and recurrences. RESULTS: The mean age of 350 women was 59.5+11.7 years. The hospital mortality and morbidity rate were 2.0% and 28.3%, respectively. Complete cytoreduction was possible in 60% of the cases. The overall 5- and 10-year survival rate was 47% and 39%, respectively. The prognostic variables of survival were the extent of peritoneal malignancy, the extent of previous surgery, the grade of differentiation, the use of adjuvant chemotherapy, the lymphadenectomy of the resected large bowel, and the postoperative morbidity. The recurrence rate was 45.7%. The extent of peritoneal carcinomatosis, the extent of previous surgery, and the grade of differentiation were the prognostic variables of recurrence. CONCLUSIONS: The limited extent of peritoneal carcinomatosis in women with well differentiated ovarian cancer that do not have history of previous surgery, who undergo standard pelvic peritonectomy procedure, and receive adjuvant chemotherapy are expected to be long-term survivors.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in the treatment of rare tumors with peritoneal metastases.

PURPOSE: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) is the standard treatment for tumors presented with peritoneal metastases (PM). Data in the literature about the treatment of rare tumors with PM are limited and of low-quality. The aim of the study was to assess the outcome and safety of CRS and HIPEC for these tumors. METHODS: Patients with rare tumors with PM that underwent CRS and HIPEC between 2005-2018, were retrospectively analyzed. Clinical and histopathological variables were correlated to survival. RESULTS: 43 patients, mean age 55.7 ± 12.9 years, underwent 48 cytoreductions. The most frequent histopathologic type was sarcomatosis (31.3%). The majority of the patients (70.8%) had limited extent of peritoneal disease. Complete or near-complete cytoreduction was achieved in 83.3% of the cases. Severe morbidity was recorded in 12.6%. The median disease-free survival and overall survival were 11 and 63 months, respectively. Although the completeness of cytoreduction was found to be significantly related to survival, the extent of peritoneal carcinomatosis was the single prognostic factor. CONCLUSIONS: CRS followed by HIPEC is an effective and safe method in the treatment of rare tumors with PM. Further large, well-designed prospective studies are needed to validate these results.

Twenty-years' experience with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for pseudomyxoma peritonei (PMP).

PURPOSE: Pseudomyxoma peritonei is treated with cytoreductive surgery (CRS) combined and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). The purpose of this study was to report the20-year experience of one surgical team inCRS and HIPEC for PMP of appendiceal origin. METHODS: Retrospective study of the files of patients with PMP of appendiceal origin that underwent CRS+HIPEC. Morbidity and hospital mortality were recorded. Clinical and histopathologic variables were correlated to survival and recurrence. RESULTS: The files of 41 patients with PMP of appendiceal origin that underwent CRS+HIPEC from 1999-2018 were retrieved. The mortality and the morbidity rates were 2.4% and 29.3%, respectively. The 5- and 8-year survival rate was 68.3%. The completeness of cytoreduction, and the extent of previous surgery were identified as the prognostic indicators of survival. The recurrence rate was 32.5% with the completeness of cytoreduction, the histologic type of the tumor being the prognostic indicator. CONCLUSIONS: CRS in combination with perioperative intraperitoneal chemotherapy is a safe and effective treatment in the management of PMP of appendiceal origin.

Ten-year experience with peritoneal mesothelioma.

PURPOSE: Peritoneal mesothelioma is a rare disease that remains confined to the peritoneal surfaces for long. Cytoreductive surgery (CRS) combined with hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is the most effective treatment and complete cytoreduction is the most significant prognostic indicator of long-term survival. This study attempted to present the results of CRS in combination with hyperthermic intraperitoneal chemotherapy in patients with peritoneal mesothelioma and identify the prognostic indicators of survival. METHODS: The files of patients with peritoneal mesothelioma were retrospectively reviewed. Morbidity, hospital mortality, recurrences, and the sites of recurrence were recorded. Survival and recurrence were correlated to performance status, age, extent of peritoneal dissemination, tumor grade, tumor volume, and completeness of cytoreduction. RESULTS: From 2005-2017, 29 patients underwent 33 cytoreductions for peritoneal mesothelioma. Hospital mortality and morbidity were 3% and 27.3% respectively. The median and 8-year survival were 66 and 62% months, respectively. The completeness of cytoreduction was the single prognostic indicator of survival, and the tumor grade the single prognostic indicator of recurrence. CONCLUSION: CRS combined with HIPEC is the therapeutic strategy that may provide long-term survival.

Cytoreductive Surgery in Combination with HIPEC in the Treatment of Peritoneal Sarcomatosis.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective treatment for peritoneal carcinomatosis, but it has been debated for peritoneal sarcomatosis. The purpose of the study is the presentation of perioperative and long-term results of CRS and hyperthermic intraoperative intraperitoneal chemotherapy in patients with peritoneal sarcomatosis. Retrospective study in a prospectively maintained database of 20 patients that underwent 29 CRS + HIPEC for peritoneal sarcomatosis. Clinical and histopathologic variables were correlated to survival. Complete cytoreduction was possible in 86.2% of the cases. The hospital mortality and morbidity rate were 0 and 20.7%, respectively. The median follow-up was 26 months, and recurrence was recorded in 20 cases (69%). The median and 5-year survival was 55 ± 13 (34-58) months and 43%, respectively. Prior surgical score (PSS) was the single variable related to survival (p = 0.018). The histologic subtype of the tumor was related to recurrence (p < 0.001). CRS and HIPEC in peritoneal sarcomatosis may offer a survival benefit in selected patients with low hospital mortality. The variety of histologic types of sarcomatosis has not made possible the identification of subgroups of patients that may be offered significant benefit by CRS and HIPEC. Further studies are required.

Klatskin tumors and "Klatskin-mimicking lesions": our 22-year experience

Background and study purpose: Hilar cholangiocarcinoma, also known as Altemeier-Klatskin tumor, is a rare malignancy that arises in the confluence of the hepatic ducts of the porta hepatis. The prognosis is rather poor. Several lesions mimic these tumors and lead to a misdiagnosis, resulting in radical hepatic resections. These lesions are known as Klatskin-mimicking lesions. We present our experience with the diagnosis and treatment of pathological lesions that can mimic a perihilar cholangiocarcinoma and establish an algorithm of treatment Methods: For the current retrospective study, a prospectively established bile-duct tumor database was analyzed by selecting patients with a preoperative diagnosis of perihilar cholangiocarcinoma. Results: In the last 22 years (from January 1, 1996, to December 31, 2017), 73 patients who were referred to our tertiary center with a primary diagnosis of a Klatskin tumor were treated. All patients underwent a thorough evaluation before deciding upon the treatment. However, only 58 cases had a confirmed preoperative diagnosis of hilar cholangiocarcinoma in the final histopathological examination. The final diagnosis in 15 patients differed from the primary cause for referral and the lesions were regarded as Klatskin-mimicking lesions. Conclusions: Clinicians should always highly suspect Klatskin-mimicking lesions when they evaluate a patient for a possible hilar cholangiocarcinoma in order to avoid a misdiagnosis and propose a proper treatment

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Klatskin tumors and "Klatskin-mimicking lesions": our 22-year experience.

Background and study purpose: Hilar cholangiocarcinoma, also known as Altemeier-Klatskin tumor, is a rare malignancy that arises in the confluence of the hepatic ducts of the porta hepatis. The prognosis is rather poor. Several lesions mimic these tumors and lead to a misdiagnosis, resulting in radical hepatic resections. These lesions are known as Klatskin-mimicking lesions. We present our experience with the diagnosis and treatment of pathological lesions that can mimic a perihilar cholangiocarcinoma and establish an algorithm of treatment Methods: For the current retrospective study, a prospectively established bile-duct tumor database was analyzed by selecting patients with a preoperative diagnosis of perihilar cholangiocarcinoma. Results: In the last 22 years (from January 1, 1996, to December 31, 2017), 73 patients who were referred to our tertiary center with a primary diagnosis of a Klatskin tumor were treated. All patients underwent a thorough evaluation before deciding upon the treatment. However, only 58 cases had a confirmed preoperative diagnosis of hilar cholangiocarcinoma in the final histopathological examination. The final diagnosis in 15 patients differed from the primary cause for referral and the lesions were regarded as Klatskin-mimicking lesions. Conclusions: Clinicians should always highly suspect Klatskin-mimicking lesions when they evaluate a patient for a possible hilar cholangiocarcinoma in order to avoid a misdiagnosis and propose a proper treatment.

Cytoreduction and HIPEC for peritoneal carcinomatosis of pancreatic cancer.

PURPOSE: Peritoneal carcinomatosis of pancreatic cancer is generally considered for palliative treatment. The purpose of this study was to report the outcome of cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in patients with pancreatic cancer and peritoneal carcinomatosis. METHODS: Patients with documented resectable peritoneal carcinomatosis of pancreatic cancer underwent cytoreductive surgery in combination with HIPEC from 2008-2016 by the same surgical team. RESULTS: Six patients underwent 8 cytoreductions. Complete or near-complete cytoreduction was possible in 7 cases, and palliative surgery in one case. Gemcitabine was used in 5 cases during HIPEC, and cisplatin+mitomycin-C in 2 others. All patients received adjuvant chemotherapy with gemcitabine. Four patients survived without evidence of recurrence for more than 12 months. CONCLUSIONS: Cytoreductive surgery with HIPEC may be considered a treatment option in highly selected patients with pancreatic cancer and peritoneal carcinomatosis.

A 20-year single center experience in the surgical treatment of colorectal liver metastasis.

PURPOSE: To present our experience in the treatment of patients with liver metastases from colorectal cancer. METHODS: The surgical and histopathological records of our department dating from 1st January 1997 to 31 December 2016 were examined, searching for patients who have undergone surgical treatment of colorectal liver metastasis. RESULTS: A total of 90 patients with colorectal liver metastases were treated in the last 20 years in our department. Their mean age was 65.28 years and 54 (60%) were male. The primary tumor was in the colon in 71 patients (78.9%) and in 19 (21.1%) patients in the rectum. Thirty-six (40%) patients presented with synchronous metastatic liver disease, from which 27 were subjected to simultaneous resection, 2 underwent a liver-first approach and 7 were subjected to resection of primary tumor first. Regarding the number of metastases 67 (74.4%) patients had single metastasis, 12 (13.3%) had 2 lesions, 4 (4.4%) had 3 lesions and 7 (7.8%) had 4-8 lesions. In-hospital and 30-day mortality was 3.85%. Median survival was 41 months. CONCLUSION: Surgical resection is the treatment of choice for the management of liver metastasis from colorectal cancer and can be safely performed. Follow up of patients with colorectal cancer is imperative as metachronous metastasis presents in a significant percentage of patients with negative locoregional lymph nodes of the primary tumor. The order of resection doesn't seem to alter outcome in synchronous metastasis. Recurrence is common and re-resection if feasible is the only chance of cure.

Cytoreductive surgery and hyperthermic intraperitenoal chemotherapy (HIPEC) for colorectal and appendiceal carcinomas with peritoneal carcinomatosis.

PURPOSE: Cytoreductive surgery combined with intraperitoneal chemotherapy has been established as the standard treatment for selected patients with peritoneal malignancy. The purpose of the study was the presentation of the 10- year experience with cytoreductive surgery and intraperitoneal chemotherapy in patients with peritoneal carcinomatosis of colorectal and appendiceal origin. METHODS: Clinical and histopathological variables were retrospectively reviewed in a prospectively maintained database. All patients underwent cytoreductive surgery with the purpose of complete or near-complete cytoreduction. The variables were correlated to survival, and recurrences. Morbidity and hospital mortality were recorded. RESULTS: From 2006-2016 100 patients underwent cytoreductive surgery for colorectal and appendiceal carcinomas with peritoneal carcinomatosis. The hospital mortality and morbidity were 2% and 43% respectively. Completeness of cytoreduction (CC) 0 surgery was possible in 51% of the patients. The median and 10-year survival were 13 months and 23% respectively. The completeness of cytoreduction, performance status and the lymph node status were identified as prognostic indicators of survival. The recurrence rate was 55%. The completeness of cytoreduction, the lymph node status, and the use of postoperative adjuvant systemic chemotherapy were identified as prognostic variables of recurrence. CONCLUSION: Nearly half of the patients with peritoneal carcinomatosis of colorectal and appendiceal origin may undergo complete cytoreduction and nearly half of them may enjoy long-term survival.

The effect of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) as an adjuvant in patients with resectable pancreatic cancer.

Background - aims: The long-term survival of pancreatic cancer is poor even after potentially curative resection. The incidence of local-regional failures is high. There is evidence that hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) is effective in controlling the local-regional failures. The purpose of the study is to identify the effect of HIPEC after surgical removal of pancreatic carcinoma. Patients - Methods: Prospective study including 33 patients with resectable pancreatic carcinomas. All patients underwent surgical resection (R0) and ΗIPEC as an adjuvant. Morbidity and hospital mortality were recorded. The patients were followed-up for 5 years. Survival was calculated. Recurrences and the sites of failure were recorded. RESULTS: The mean age of the patients was 67.8 ± 11.1 years (38-86). The hospital mortality was 6.1% (2 patients) and the morbidity 24.2% (8 patients). The overall 5-year survival was 24%. The mean and median survival was 33 and 13 months, respectively. The median follow-up time was 11 months. The recurrence rate was 60.6% (20 patients). Three patients were recorded with local-regional failures (9.1%) and the others with liver metastases. CONCLUSIONS: It appears that HIPEC as an adjuvant following potentially curative resection (R0) of pancreatic carcinoma may effectively control the local-regional disease. Prospective randomised studies are required.

A rare case of a transabdominal impalement after a fall from a ladder.

INTRODUCTION: Impalement injuries are caused by objects that penetrate and remain inside the human body. They are rare and often lead to complex surgical problems, demanding immediate measures and intensive care. PRESENTATION OF CASE: We report a case of a 39 year old male who presented in our emergency department with a history of fall from a 3m high ladder, landing on a wooden stick that penetrated the patient from his left lumbar region, leading to a trans-abdominal impalement injury. DISCUSSION: Nowadays impalement injuries although rare, demonstrate a challenging presentation for emergency providers. Their complexity often raises concerns about the proper surgical approach and postoperative management. In many cases, they may cause severe morbidity or even be lethal. CONCLUSION: The article describes a case of a transabdominal impalement injury and pinpoints the strategies followed regarding the prehospital care, as well as the intra- and postoperative management.

Cecal diverticulitis is a challenging diagnosis: a report of 3 cases.

BACKGROUND: Cecal diverticulitis is an uncommon cause of acute abdominal pain and presents clinically similar to acute appendicitis. There are many perspectives concerning the management of this condition, ranging from different types of surgical resections to conservative treatment with antibiotics. CASE REPORT: We present 3 cases of cecal diverticulitis. One of the patients was treated conservatively with intravenous antibiotics and the other 2 were treated with surgical resection. CONCLUSIONS: Conservative treatment with intravenous antibiotics can be used in uncomplicated cecal diverticulitis. Complicated cecal diverticulitis is managed surgically and the type of resection depends mainly on the extent of inflammation.

Is histological examination necessary when excising a pilonidal cyst?

BACKGROUND: Pilonidal disease is a common inflammatory condition mostly affecting young males. Malignant degeneration of a pilonidal cyst is rare, with incidence estimated at 0.1%. The most common type is squamous cell carcinoma and the treatment of choice remains en block resection of the lesion. CASE REPORT: We present the case of a patient with locally advanced squamous cell carcinoma arising in a pilonidal cyst, due to misdiagnosis of the disease during his first treatment. CONCLUSIONS: Detailed histological examination of all excised pilonidal cyst lesions is essential and any histological suspicion should prompt a wider excision.

Successful treatment of recurrent cholangitis by constructing a hepaticojejunostomy with long Roux-en-Y limb in a long-term surviving patient after a Whipple procedure for pancreatic adenocarcinoma.

PATIENT: Female, 74. FINAL DIAGNOSIS: Recurrent cholangitis. SYMPTOMS: -. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Gastroenterology and Hepatology. OBJECTIVE: Unusual clinical course. BACKGROUND: Cholangitis may result from biliary obstruction (e.g., biliary or anastomotic stenosis, or foreign bodies) or occur in the presence of normal biliary drainage. Although reflux of intestinal contents into the biliary tree after hepaticojejunostomy appears to be a rare complication, it is important to emphasize that there are few available surgical therapeutic techniques. CASE REPORT: A 74-year-old woman presented to our hospital after 17 years of episodes of cholangitis. The patient had undergone a pancreatoduodenectomy (Whipple procedure) 18 years earlier due to pancreatic adenocarcinoma. The reconstruction was achieved through the sequential placement of pancreatic, biliary, and retrocolic gastric anastomosis into the same jejunal loop. The postoperative course was uneventful and the patient received adjuvant chemotherapy. Approximately 6 months after the initial operation, the patient started having episodes of cholangitis. Over the next 17 years she experienced several febrile episodes presumed to be secondary to cholangitis. A computing tomography (CT) scan of the abdomen revealed intrahepatic bile ducts partially filled with orally administered contrast material (Gastrografin). Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the left intrahepatic bile ducts. A percutaneous transhepatic cholangiography showed that the bilioenteric anastomosis was normal, without stenosis. Based on these findings, a diagnosis of a short loop between the hepaticojejunostomy and the gastrojejunostomy permitting the reflux of intestinal juice into the biliary tree was made. During the re-operation, a new hepaticojejunal anastomosis in a 100-cm long Roux-en-Y loop was performed to prevent the reflux of the intestinal fluid into the biliary tree. The patient was discharged on postoperative day 10. One year after the second procedure, the patient enjoys good health and has been free of fever and abdominal pain and has not received any antibiotic therapy. CONCLUSIONS: Lengthening the efferent Roux-en-Y limb should be considered as a therapeutic option when treating a patient with recurrent episodes of cholangitis after hepaticojejunostomy.