Pancreatoduodenectomy for ampullary cancer with cavernous transformation of the portal vein: a case report

Introduction: Cavernous transformation of the portal vein (CTPV) is a rare vascular condition associated with long-standing portal vein (PV) obstruction. Pancreaticoduodenectomy in patients with CTPV is technically challenging because fragile collateral vessels may cause massive intraoperative bleeding and compromise portal venous flow. Presentation of case: A 72-year-old woman presented with jaundice and was diagnosed with ampullary carcinoma (cT2N0M0, cStage IB). Preoperative imaging, including three-dimensional reconstruction, revealed a markedly tortuous PV with extensive collateral vessels within the hepatoduodenal ligament. No liver cirrhosis or PV thrombosis was identified; however, comprehensive thrombophilia testing was not performed, and the etiology of CTPV remained undetermined. Because of the high risk of bleeding, hepatoduodenal ligament lymph node dissection was omitted, and subtotal stomach-preserving pancreaticoduodenectomy was performed without vascular reconstruction. Histopathological examination revealed pT2N0M0, pStage IB ampullary carcinoma with lymphovascular invasion, but no metastases were found in the 15 examined lymph nodes. The patient received S-1 adjuvant chemotherapy for 6 months and remained recurrence-free for 25 months. Discussion: This case highlights the importance of individualized surgical planning in patients with ampullary carcinoma and CTPV. Careful assessment of the distribution of abnormal portal venous collaterals is important for determining the feasibility and extent of surgery. Detailed preoperative vascular assessment and intraoperative monitoring of portal venous flow may help balance oncological radicality with surgical safety. Conclusion: Pancreaticoduodenectomy may be feasible in selected patients with ampullary carcinoma and CTPV when vascular anatomy is carefully assessed, and the operative strategy is individualized to minimize vascular injury and the risk of massive bleeding.