Supplementary Material for: Pancreatoduodenectomy for cholangiocarcinoma during second trimester of pregnancy: case report and review of literature

Introduction
Cholangiocarcinoma during pregnancy is an extremely rare entity with poor prognosis. Limited data are available regarding the diagnosis, progression, and pregnancy-related outcomes.
Case presentation
We present a case of mid to distal cholangiocarcinoma diagnosed by endosonographically guided biopsy during pregnancy at 15 weeks of gestation. Pregnancy termination was considered but based on multidisciplinary team and shared decision making, surgery was performed during pregnancy. The patient underwent pancreatoduodenectomy with radical resection at 17 weeks of gestation. The postoperative period was complicated by a grade B postoperative pancreatic fistula treated by antibiotics only. At 39 weeks of gestation, a caesarean section was performed and a healthy boy was delivered.
Conclusion
Decision making on to perform a pancreatoduodenectomy in pregnant patients is challenging. This case report is the first to report on successful pancreatoduodenectomy during pregnancy for extrahepatic cholangiocarcinoma. Moreover, this case highlights the second trimester as favorable period for surgical intervention and the importance of close follow-up and diagnostic assessment of pregnant patients with unexplained and persistent abnormal liver function tests.