Disconnection of the ampulla of Vater

A patient with ampullary disconnection during gastrectomy is presented, emphasizing the chronicity and retractile scarring which exposes the bile and pancreatic ducts to simultaneous injury. As wider appreciation of this potentially lethal lesion is gained, greater use of predissection cholangiography or probe identification of the papilla should occur. Steps to detect the lesion and primary repair by duodenal advancement or, in unrecognized instances, the Hepp operation using a Roux-en-Y limb after a suitable waiting period are recommended.