Wharton’s jelly mesenchymal stem cells: Future regenerative medicine for clinical applications in mitigation of radiation injury

Wharton’s jelly mesenchymal stem cells(WJ-MSCs)are gaining significant attention in regenerative medicine for their potential to treat degenerative diseases and mitigate radiation injuries.WJ-MSCs are more naïve and have a better safety profile,making them suitable for both autologous and allogeneic transplantations.This review highlights the regenerative potential of WJ-MSCs and their clinical applications in mitigating various types of radiation injuries.In this review,we will also describe why WJ-MSCs will become one of the most probable stem cells for future regenerative medicine along with a balanced view on their strengths and weaknesses.Finally,the most updated literature related to both preclinical and clinical usage of WJ-MSCs for their potential application in the regeneration of tissues and organs will also be compiled.

Potential plausible role of Wharton’s jelly mesenchymal stem cells for diabetic bone regeneration

This letter addresses the review titled“Wharton’s jelly mesenchymal stem cells:Future regenerative medicine for clinical applications in mitigation of radiation injury”.The review highlights the regenerative potential of Wharton’s jelly mesenchymal stem cells(WJ-MSCs)and describes why WJ-MSCs will become one of the most probable stem cells for future regenerative medicine.The potential plausible role of WJ-MSCs for diabetic bone regeneration should be noticeable,which will provide a new strategy for improving bone regeneration under diabetic conditions.

人脐带Wharton’s jelly源间充质干细胞培养中碱性成纤维细胞生长因子的作用

背景：培养脐带源间充质干细胞过程中,细胞形态常易变得宽大不规则,传代不易贴壁,死亡率高,找到一个维持细胞稳定的方法是有必要的。目的：拟采用组织块培养法从人脐带Wharton’s jelly中分离培养间充质干细胞,观察碱性成纤维细胞生长因子对其生物学特性的影响。方法：采用组织块法分离培养和扩增脐带组织间充质干细胞,对照组用DMEM/F12培养基＋体积分数为10%胎牛血清培养,实验组用DMEM/F12培养基＋体积分数为10%胎牛血清＋20μg/L碱性成纤维细胞生长因子培养。观察组织块游出细胞的时间和细胞形态,每隔3d或4d更换培养液,待细胞达到80%~90%融合时,用0.25%胰酶消化后,按1：2或1：3的比例传代。结果与结论：倒置显微镜下观察对照组中从8~10d开始有细胞从组织块四周游出贴壁,实验组中从6~8d开始有细胞从组织块四周游出贴壁,1周后可见多数呈长梭形或扁平形的成纤维样细胞,围绕组织块成旋涡状,前3代细胞形态及传代间隔时间两组基本相同;3代以后实验组细胞较对照组易于贴壁,传代死亡率低,生长曲线提示增殖能力强。流式细胞术分析两组细胞周期显示第3,6代70%以上的细胞处于G0/G1期,且第3,6代细胞均阳性表达CD29,CD44,弱表达HLA-ABC,不表达CD34、CD45和HLA-DR。结果提示采用组织块培养法可从人脐带Wharton’s jelly中分离出具有间充质干细胞特性的细胞,且碱性成纤维细胞生长因子能使细胞从组织块游出时间提前和有助于促使细胞贴壁,一定程度上维持细胞形态稳定性,提高增殖能力,并且不改变细胞的表面标志物表达。

“生物药”——Wharton's jelly源间充质干细胞

干细胞治疗代表生物冶疗进入到了一个崭新的时代。间充质干细胞是存在于胚胎或成体组织中来源于中胚层具有多向分化潜能的干细胞。由于成体间充质干细胞的质量与数量自身缺陷,使之应用受到了很大限制。Wharton's jelly组织,是起始于胚胎发育第13天的胚外中胚层组织。使用基因微阵列分析及功能分析,首次发现Wharton's jelly源间充质干细胞(Wharton's jelly derived mesenchymal stem cells,WJMSCs)高表达胚胎早期干性基因及心肌细胞分化早期特异转录因子,可分化心肌细胞等多种细胞。进而,应用临床级WJMSCs经冠状动脉移植治疗ST抬高型急性心肌梗死患者的随机双盲临床试验,首次证明WJMSCs可明显改善心肌活力及心脏功能。因此,WJMSCs具有极其重要益处;无伦理涉及,有强的分化潜能,无致瘤性;加之,WJMSCs可作为产品,在任何时候病情需要时立即应用。为此,WJMSCs作为真正意义上的干细胞族,将最有希望成为具有应用前景的于细胞生物药。

脐带Wharton’s jelly源间充质干细胞——细胞治疗理想选择

脐带Wharton’s jelly源间充质干细胞(WJ-MSCs)是原始的间充质干细胞,具有较强的自我更新及多向分化潜能,无致肿瘤性,同时具有较低的免疫原性,在临床前期多种疾病的防治中具有较好的作用。由于其取材方便,应用无伦理争议,是细胞治疗修复组织损伤的理想选择。文章就WJ-MSCs的性质及应用等做一综述。

人脐带Wharton’s Jelly来源间充质干细胞与人牙周膜干细胞成骨分化能力的对比研究

目的:比较人脐带Wharton’s Jelly来源间充质干细胞(human umbilical cord Wharton’s Jelly-derived mesechymal stem cells,h UCWJMSCs)与人牙周膜干细胞(periodontal mesenchymal stem cells,h PDLSCs)成骨分化能力。方法:体外培养h UCWJMSCs和h PDLSCs。MTT法检测细胞增殖情况;成骨诱导后测定细胞的ALP活性,茜素红染色检测细胞矿化能力,Real-time PCR分析OPN和Runx2基因的表达。结果:hUCWJMSCs增殖能力高于hPDLSCs;经矿化诱导后hPDLSCsALP表达、矿化结节形成高于hUCWJMSCs(P<0.05);Runx2在hPDLSCs中表达高于hUCWJMSCs(P<0.05);而hUCWJMSCs中OPN表达高于hPDLSCs(P<0.05)。结论:h UCWJMSCs、hPDLSCs均具有成骨分化能力,hPDLSCs成骨分化能力较强。

Comparison of human amniotic fluid-derived and umbilical cord Wharton＇s Jelly-derived mesenchymal stromal cells： Characterization and myocardial differentiation capacity

Objective To compare the characterization and myocardial differentiation capacity of arnniotic fluid-derived mesenchymal stromal cells （AF MSCs） and umbilical cord Wharton＇s Jelly-derived mesenchymal stromal cells （WJ MSCs）. Methods The human AF MSCs were cultured from amniotic fluid samples obtained by amniocentesis. The umbilical cord WJ MSCs were obtained from Wharton＇s Jelly of umbilical cords of infants delivered full-term by normal labor. The morphology, growth curves, and analyses by flow cytometry of cell surface markers were compared between the two types of cells. Myocardial genes （GATA-4, c-TnT, a-actin, and Cx43） were detected by real-time PCR and the corresponding protein expressions were detected by Western blot analysis after myocardial induced in AF MSCs and WJ MSCs. Results Our findings revealed AF MSCs and WJ MSCs shared similar morphological characteristics of the fibroblastoid shape. The AF MSCs were easily obtained than the WJ MSCs and had a shorter time to reach adherence of 2.7 ± 1.6 days to WJ MSCs of 6.5 ± 1.8 days. The growth curves by MTT cytotoxic assay showed the AF MSCs had a similar proliferative capacity at passage 5 and passage 10. However, the proliferative capacities ofWJ MSCs were decreased at 5 passage relative to 10 passage. Both AF stem cells and WJ stem cells had the characteristics of mesenchymal stromal cells with some characteristics of embryonic stem cells. They express CD29 and CD105, but not CD34. They were positive for Class I major histocompatibility （MHC I） antigens （HLA-ABC）, and were negative, or mildly positive, for MHC Class II （HLA-DR） antigen. Oct-4 was positive in all the two cells types. Both AF MSCs and WJ MSCs could differentiate along myocardium. The differentiation capacities were detected by the expression of GATA-4, c-TnT, a-actin, Cx43 after myocardial induction. Conclusions Both AF MSCs and WJ MSCs have the potential clinical application for myogenesis in cardiac regenerative therapy.

Human umbilical cord Wharton's jelly-derived oligodendrocyte precursor-like cells for axon and myelin sheath regeneration

Human umbilical mesenchymal stem cells from Wharton＇s jelly of the umbilical cord were induced to differentiate into oligodendrocyte precursor-like cells in vitro. Oligodendrocyte precursor cells were transplanted into contused rat spinal cords. Immunofluorescence double staining indicated that transplanted cells survived in injured spinal cord, and differentiated into mature and immature oligodendrocyte precursor cells. Biotinylated dextran amine tracing results showed that cell transplantation promoted a higher density of the corticospinal tract in the central and caudal parts of the injured spinal cord. Luxol fast blue and toluidine blue staining showed that the volume of residual myelin was significantly increased at 1 and 2 mm rostral and caudal to the lesion epicenter after cell transplantation. Furthermore, immunofluorescence staining verified that the newly regenerated myelin sheath was derived from the central nervous system. Basso, Beattie and Bresnahan testing showed an evident behavioral recovery. These results suggest that human umbilical mesenchymal stem cell-derived oligodendrocyte precursor cells promote the regeneration of spinal axons and myelin sheaths.

Neural differentiation of human Wharton＇s jelly-derived mesenchymal stem cells improves the recovery of neurological function after transplantation in ischemic stroke rats

Human Wharton＇s jelly-derived mesenchymal stem cells（h WJ-MSCs）have excellent proliferative ability,differentiation ability,low immunogenicity,and can be easily obtained.However,there are few studies on their application in the treatment of ischemic stroke,therefore their therapeutic effect requires further verification.In this study,h WJ-MSCs were transplanted into an ischemic stroke rat model via the tail vein 48 hours after transient middle cerebral artery occlusion.After 4 weeks,neurological functions of the rats implanted with h WJ-MSCs were significantly recovered.Furthermore,many h WJ-MSCs homed to the ischemic frontal cortex whereby they differentiated into neuron-like cells at this region.These results confirm that h WJ-MSCs transplanted into the ischemic stroke rat can differentiate into neuron-like cells to improve rat neurological function and behavior.

人脐带Wharton's Jelly来源间充质干细胞和人牙周膜干细胞复合PHBHHx、PHBV支架成骨分化能力的体外研究

目的:探讨人脐带Wharton's Jelly来源间充质干细胞(h UCWJMSCs)和人牙周膜干细胞(h PDLSCs)复合聚(3-羟基丁酸酯-3-羟基己酸酯)(PHBHHx)、聚羟基丁酸-羟基戊酸酯(PHBV)支架成骨分化的能力。方法:将2种干细胞分别接种在2种支架中,MTT法及粘附率分析2种干细胞和PHBHHx、PHBV的生物相容性;成骨诱导后ALP活性检测、茜素红染色和扫描电镜观察研究两种干细胞在两种支架上的成骨分化情况。结果:2种干细胞与PHBV具有更好的黏附效果及增殖效率(P <0. 05),且h UCWJMSCs组优于h PDLSCs组; h UCWJMSCs和h PDLSCs与PHBV组ALP活性检测、茜素红染色阳性表达明显高于与PHBHHx组; h UCWJMSCs与2种支架组的表达高于h PDLSCs组。扫描电镜显示2种干细胞与PHBV组可见大量矿化基质形成。结论:h UCWJMSCs与PHBV生物相容性和成骨能力优于h PDLSCs组。

Wharton's jelly mesenchymal stem cells differentiate into retinal progenitor cells

Human Wharton＇s jelly mesenchymal stem cells were isolated from fetal umbilical cord. Cells were cultured in serumfree neural stem cellconditioned medium or neural stem cellconditioned medium supplemented with Dkk1, a Wnt/13 catenin pathway antagonist, and LeftyA, a Nodal signaling pathway antagonist to induce differentiation into retinal progenitor cells. Inverted microscopy showed that after induction, the spindleshaped or fibroblastlike Wharton＇s jelly mesenchymal stem cells changed into bulbous cells with numerous processes. Immunofluorescent cytochemical stain ing and reversetranscription PCR showed positive expression of retinal progenitor cell markers, Pax6 and Rx, as well as weakly downregulated nestin expression. These results demonstrate that Wharton＇s jelly mesenchymal stem cells are capable of differentiating into retinal progenitor cells in vitro.

Application of Delayed Surgical Managements in Patients with Stensen＇s Duct Injury

The study aimed to retrospectively evaluate surgical treatment outcomes after delayed parotid gland and duct injuries. Nine patients subjected to parotid gland and duct injuries with l- to 3-month treatment delay were retrospectively evaluated with special reference of etiology, past medical history, and injury location. Conservative treatment, microsurgical anastomosis, and diversion of salivary flow or ligation were chosen for delayed parotid gland and duct injuries concerning to their site of injury, time of repair and procedures. Assistant treatment as pressure dressing was adopted thereafter. All patients experienced an uneventful recovery at the time of finalizing the study. Two patients received Stensen＇s duct ligation, 5 received microsurgical anastomosis and 2 accepted salivary flow diversion for 5 patients with sialoceles and 4 patients with fistulas, and no re-occurrence was found. Facial paralysis occurred after surgery in 4 patients, and 3 of them recovered after the nerve nutrition treatment. Our study suggested that appropriate surgical treatment is efficient for the re-establishment of the tissue function and facial aesthetic for delayed injury of the parotid and its duct.

Vanishing bile duct syndrome in Hodgkin's lymphoma: A case report and literature review

Vanishing bile duct syndrome (VBDS) has been described in different pathologic conditions including infection, ischemia, adverse drug reactions, autoimmune diseases, allograft rejection, and humoral factors associated with malignancy. It is an acquired condition characterized by progressive destruction and loss of the intra-hepatic bile ducts leading to cholestasis. Prognosis is variable and partially dependent upon the etiology of bile duct injury. Irreversible bile duct loss leads to significant ductopenia, biliary cirrhosis, liver failure, and death. If biliary epithelial regeneration occurs, clinical recovery may occur over a period of months to years. VBDS has been described in a number of cases of patients with Hodgkin&#x02019;s lymphoma (HL) where it is thought to be a paraneoplastic phenomenon. This case describes a 25-year-old man found on liver biopsy to have VBDS. Given poor response to medical treatment, the patient underwent transplant evaluation at that time and was found to have classical stage IIB HL. Early recognition of this underlying cause or association of VBDS, including laboratory screening, and physical exam for lymphadenopathy are paramount to identifying potential underlying VBDS-associated malignancy. Here we review the literature of HL-associated VBDS and report a case of diagnosed HL with biopsy proven VBDS.

Human Wharton’s jelly mesenchymal stem cells inhibit cytokine storm in acute respiratory distress syndrome in a rat model

Objective:To evaluate the potential effect of human Wharton’s jelly mesenchymal stem cells(hWJMSCs)on acute respiratory distress syndrome in lipopolysaccharide(LPS)-induced rats.Methods:The hWJMSCs(5×10^(4)/mL,5×10^(5)/mL,5×10^(6)/mL)were administered to rats on day 1 and day 8 after being induced by LPS(5 mg/kg body weight).TNF-αlevels in the lung and IL-18 and IL-1βlevels in the serum were measured using ELISA.In addition,caspase-1 expression in lung tissues was quantified using qRT-PCR,and NF-κB and IL-6 expressions were assessed using immunohistochemistry.Results:The hWJMSCs decreased TNF-αlevels in the lung and plasma IL-18 and IL-1βlevels.Moreover,the hWJMSCs downregulated the expressions of caspase-1,IL-6,and NF-κB in lung tissues.Conclusions:The hWJMSCs can decrease inflammatory markers of acute respiratory distress syndrome in a rat model and may be further investigated for the treatment of acute respiratory distress syndrome.

Comparison between the therapeutic effects of differentiated and undifferentiated Wharton’s jelly mesenchymal stem cells in rats with streptozotocin-induced diabetes

BACKGROUND Despite the availability of current therapies,including oral antidiabetic drugs and insulin,for controlling the symptoms caused by high blood glucose,it is difficult to cure diabetes mellitus,especially type 1 diabetes mellitus.AIM Cell therapies using mesenchymal stem cells(MSCs)may be a promising option.However,the therapeutic mechanisms by which MSCs exert their effects,such as whether they can differentiate into insulin-producing cells (IPCs) beforetransplantation, are uncertain.METHODSIn this study, we used three types of differentiation media over 10 d to generateIPCs from human Wharton’s jelly MSCs (hWJ-MSCs). We further transplantedthe undifferentiated hWJ-MSCs and differentiated IPCs derived from them intothe portal vein of rats with streptozotocin-induced diabetes, and recorded thephysiological and pathological changes.RESULTSUsing fluorescent staining and C-peptide enzyme-linked immunoassay, we wereable to successfully induce the differentiation of hWJ-MSCs into IPCs.Transplantation of both IPCs derived from hWJ-MSCs and undifferentiated hWJMSCshad the therapeutic effect of ameliorating blood glucose levels andimproving intraperitoneal glucose tolerance tests. The transplanted IPCs homedto the pancreas and functionally survived for at least 8 wk after transplantation,whereas the undifferentiated hWJ-MSCs were able to improve the insulitis andameliorate the serum inflammatory cytokine in streptozotocin-induced diabeticrats.CONCLUSIONDifferentiated IPCs can significantly improve blood glucose levels in diabetic ratsdue to the continuous secretion of insulin by transplanted cells that survive in theislets of diabetic rats. Transplantation of undifferentiated hWJ-MSCs cansignificantly improve insulitis and re-balance the inflammatory condition indiabetic rats with only a slight improvement in blood glucose levels.

Modalities of testing Helicobacter pylori in patients with nonmalignant bile duct diseases

AIM:This paper describes the procedure of detection of Helicobacter pylori(H.pylori)in bile specimens in patients suffering from benign diseases of biliary ducts(lithiasis with/without nonspecific cholangitis). METHODS:The group of 72 patients entering the study consisted of 32 male and 40 female(45 % and 55 %, respectively).Bile was obtained during ERCP in 68 patients, and during cholecystectomy in 4 patients.A fast urease test (FUT)to determine the existence of H.pylori in gastric mucosa was carried out for all the patients during the endoscopic examination.The existence of genetic material of H.pylori was determined by detection of ure A gene by the method of nested PCR.The results of this reaction were shown by electrophoresis on 10 g·L^(-1)agarose gel in a band of 256 bp. RESULTS:The majority of the patients included in our study had biliary lithiasis without signs of cholangitis(48 patients, 67 %),whereas other patients were complicated by cholangitis(17 patients,24 %).Seven patients(9 %)had normal ERCP,forming thus the control group.In the group of patients with lithiasis 26 patients(24.2 %)had positive PCR of H.pylori in bile and among the patients with associated cholangitis positive PCR was detected in 9 patients(52.9 %).Among the seven patients with normal ERCP only one(14 %)had positive PCR of H.pylori.A high percentage of H.pylori infection of gastric mucosa was observed(57 patients,79 %).It was also observed that its slightly higher positivity was in the patients with distinct bile pathology:81% FLIT positive patients in the group with choledocholithiasis alone and 76 % in the group with choledocholithiasis associated with cholangitis.Seventy-one percent of the patients with regular findings had positive FUT.CONCLUSION: The prevalence of H. pylori infection both in bile and in gastric mucosa in patients with benign diseases of biliary ducts does not show a statistically significant difference in relation to the prevalence of the same with the patients with normal ERCP. The existence of H. pylori infection possibly does not play a role in pathogenesis of benign biliary diseases.

Numerical Investigation of Electrohydrodynamic (EHD) Flow Control in an S-Shaped Duct

An electrohydrodynamic （EHD） method, which is based on glow discharge plasma, is presented for flow control in an S-shaped duct. The research subject is an expanding channel with a constant width and a rectangular cross section. An equivalent divergence angle and basic function are introduced to build the three-dimensional model. Subsequently, the plasma physical models are simplified as the effects of electrical body force and work （done by the force） on the fluid near the wall. With the aid of FLUENT software, the source terms of momentum and energy are added to the Navier-Stokes equation. Finally, the original performance of three models （A, B and C） is studied, in which model A demonstrates better performance. Then EHD control based on model A is discussed. The results show that the EHD method is an effective way of reducing flow loss and improving uniformity at the duct exit. The innovation in this study is the assessment of the EHD control effect on the flow in an S-shaped duct. Both the parametric modeling of the S-shaped duct and the simplified models of plasma provide valuable information for future research on aircraft inlet ducts.

Soluble factors secreted by human Wharton’s jelly mesenchymal stromal/stem cells exhibit therapeutic radioprotection: A mechanistic study with integrating network biology

BACKGROUND Human Wharton’s jelly-derived mesenchymal stromal/stem cells(hWJ-MSCs)have gained considerable attention in their applications in cell-based therapy due to several advantages offered by them.Recently,we reported that hWJ-MSCs and their conditioned medium have significant therapeutic radioprotective potential.This finding raised an obvious question to identify unique features of hWJ-MSCs over other sources of stem cells for a better understanding of its radioprotective mechanism.AIM To understand the radioprotective mechanism of soluble factors secreted by hWJMSCs and identification of their unique genes.METHODS Propidium iodide staining,endogenous spleen colony-forming assay,and survival study were carried out for radioprotection studies.Homeostasis-driven proliferation assay was performed for in vivo lymphocyte proliferation.Analysis of RNAseq data was performed to find the unique genes of WJ-MSCs by comparing them with bone marrow mesenchymal stem cells,embryonic stem cells,and human fibroblasts.Gene enrichment analysis and protein-protein interaction network were used for pathway analysis.RESULTS Co-culture of irradiated murine splenic lymphocytes with WJ-MSCs offered significant radioprotection to lymphocytes.WJ-MSC transplantation increased the homeostasis-driven proliferation of the lymphocytes.Neutralization of WJ-MSC conditioned medium with granulocyte-colony stimulating factor antibody abolished therapeutic radioprotection.Transcriptome analysis showed that WJ-MSCs share several common genes with bone marrow MSCs and embryonic stem cells and express high levels of unique genes such as interleukin(IL)1-α,IL1-β,IL-6,CXCL3,CXCL5,CXCL8,CXCL2,CCL2,FLT-1,and IL-33.It was also observed that WJ-MSCs preferentially modulate several cellular pathways and processes that handle the repair and regeneration of damaged tissues compared to stem cells from other sources.Cytokine-based network analysis showed that most of the radiosensitive tissues have a more complex network for the elevated cytokines.CONCLUSION Systemic infusion of WJ-MSC conditioned media will have significant potential for treating accidental radiation exposed victims。

Allogeneic mesenchymal stem cells may be a viable treatment modality in cerebral palsy

BACKGROUND Cerebral palsy(CP)describes a group of disorders affecting movement,balance,and posture.Disturbances in motor functions constitute the main body of CP symptoms.These symptoms surface in early childhood and patients are affected for the rest of their lives.Currently,treatment involves various pharmacotherapies for different types of CP,including antiepileptics for epilepsy and Botox A for focal spasticity.However,none of these methods can provide full symptom relief.This has prompted researchers to look for new treatment modalities,one of which is mesenchymal stem cell therapy(MSCT).Despite being a promising tool and offering a wide array of possibilities,mesenchymal stem cells(MSCs)still need to be investigated for their efficacy and safety.AIM To analyze the efficacy and safety of MSCT in CP patients.METHODS Our sample consists of four CP patients who cannot stand or walk without external support.All of these cases received allogeneic MSCT six times as 1×106/kg intrathecally,intravenously,and intramuscularly using umbilical cord-derived MSCs(UC-MSC).We monitored and assessed the patients pre-and post-treatment using the Wee Functional Independence Measure(WeeFIM),Gross Motor Function Classification System(GMFCS),and Manual Ability Classification Scale(MACS)instruments.We utilized the Modified Ashworth Scale(MAS)to measure spasticity.RESULTS We found significant improvements in MAS scores after the intervention on both sides.Two months:Rightχ^(2)=4000,P=0.046,leftχ^(2)=4000,P=0.046;four months:Rightχ^(2)=4000,P=0.046,leftχ^(2)=4000,P=0.046;12 months:Rightχ^(2)=4000,P=0.046,leftχ^(2)=4000,P=0.046.However,there was no significant difference in motor functions based on WeeFIM results(P>0.05).GMFCS and MACS scores differed significantly at 12 months after the intervention(P=0.046,P=0.046).Finally,there was no significant change in cognitive functions(P>0.05).CONCLUSION In light of our findings,we believe that UC-MSC therapy has a positive effect on spasticity,and it partially improves motor functions.

Simultaneous Courvoisier's and double duct signs

Presence of Courvoisier's or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system.The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown.We report a case of obstructive jaundice secondary to an ampullary cancer demonstrating the Courvoisier's sign on clinical examination and a double duct sign on imaging.The patient underwent a pancreaticoduodenectomy which confirmed an ampullary adenocarcinoma.