Pancreaticoduodenectomy for Pancreatic Adenocarcinoma Mimicking Common Bile Duct Lithiasis: A Report of Two Cases on Management Challenges in a Limited-Resource Setting

The differential diagnosis between adenocarcinoma of the pancreatic head and distal common bile duct lithiasis represents a classic clinical trap. In limited-resource settings, the scarcity of advanced imaging modalities frequently exposes clinicians to preoperative diagnostic and triage errors. Methods: We report two original clinical observations of patients operated on at the Bouaké Teaching Hospital (C？te d’Ivoire) for suspected distal common bile duct lithiasis, whose surgical strategy was intraoperatively redirected toward a major oncological resection. Results: A 42-year-old man and a 35-year-old woman, both with an ECOG performance status of 1, presented with obstructive jaundice. Abdominal ultrasound and CT scan revealed a large, multilithiasic gallbladder with dilatation of the intra- and extrahepatic bile ducts. No stones were visualized in the common bile duct, and no pancreatic mass was detected. The initial diagnosis of distal common bile duct lithiasis was refuted intraoperatively upon discovering an indurated tumor of the pancreatic head. A pancreaticoduodenectomy (Whipple procedure) was successfully performed in both patients after intraoperative confirmation of resectability and prior extensive informed consent. Postoperative courses were complicated by a biochemical leak, according to the International Study Group of Pancreatic Surgery (ISGPS) definition [1], in Case 2, which resolved with conservative management. Histopathological examination confirmed pancreatic adenocarcinoma in both cases (pT2N0M0, R0 for Case 1; pT2N0M0, R0 for Case 2). At the 6-month follow-up, both patients are alive and recurrence-free. Conclusion: In the presence of persistent obstructive jaundice without a formally identified lithiasic cause on standard imaging, magnetic resonance cholangiopancreatography (MRCP) is essential to resolve diagnostic uncertainty. Despite an unexpected intraoperative discovery and a limited technical platform, pancreaticoduodenectomy remains feasible in selected cases and offers the only curative option for these often young African patients.