Electronic Clinical Challenges and Images in GI

Question: A 59-year-old man was referred for evaluation of a mass found during laparoscopic cholecystectomy performed 11 days prior. The patient initially sought medical evaluation for a palpable mass in his right upper quadrant in addition to a 25-lb weight loss. Ultrasonography revealed a dilated gallbladder with wall thickening and a 2.0 1.8 1.4-cm mass on the superolateral aspect. At the time of laparoscopic choecystectomy, a mass adherent to the radial hepatic margin was identified and seemed to invade the perimuscular connective tissue. athology was interpreted as invasive, moderately differentiated adenocarcinoma. The patient was referred to our institution. Preoperative testing revealed a CA19 –9 level of 277 U/mL (normal, 55 U/mL). He ubsequently underwent locoregional lymphadenectomy and partial right hepatectomy (segments IVb and V) for complete oncologic esection. On postoperative day 5, increasing bilious output from his Jackson-Pratt (JP) drain was noted, raising suspicion for bile eak. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a bile leak from the cystic duct remnant (Figure A) nd other notable findings (Figure B). The cystic duct remnant leak was initially treated with endoscopic sphincterotomy and lacement of two 10-F, 9-cm plastic stents into the extrahepatic bile duct. Over the subsequent days, increasing output from the JP rain was noted. The high-volume drainage was noted to have an amylase concentration 17,000 U/L. The previously bilious ffluent now appeared colorless and repeat ERCP was performed. What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.