Benign duodenal villous adenoma obstructing the ampulla of Vater: a surgical dilemma

The discovery of an elevated serum alkaline phosphatase level during routine blood screening in a 53-year-old man led to tests that showed a large benign villous adenoma obstructing the ampulla of Vater in the second part of the duodenum. Although the preferred treatment of such a lesion is local excision, the tumor was extensive and necessitated a pancreatoduodenectomy. Histologically benign duodenal villous adenomas that also obstruct the common bile duct are uncommon and may be missed during surgical exploration; therefore, whenever there are no stones to account for symptoms or signs of extrahepatic obstruction, the surgeon should carefully palpate the ampullary region of the duodenum.