Pancreaticoduodenectomy after distal gastrectomy: A case series

INTRODUCTIONPancreatoduodenectomy (PD) after gastrectomy requires more attention during surgery than ordinary PD due to anatomical variation with different types of gastrointestinal anastomoses, the complication of anatomical dissection, and the extent of adhesions present. Herein, we describe the PD strategies we used in three patients who strategy for three patients who had previously undergone distal gastrectomy for gastric cancer treatment. DISCUSSIONGenerally, reconstruction following PD in patients who have undergone a prior Billroth I reconstruction is simple, as there is no previous afferent loop. By comparison, reconstruction after a Billroth II or R-Y reconstruction requires special consideration of the point of circulation and length of the remnant intestine used for pancreaticojejunostomy, choledochojejunostomy or gastrojejunostomy. CONCLUSIONThere is no consensus regarding the best method for performing PD and reconstruction in patients with a prior history of gastrectomy. The appropriateness of using the existing afferent loop for reconstruction depends on whether the jejunum is of sufficient length for bile duct and pancreatic anastomosis. Regardless of the approach used, it is necessary to avoid excessive tension during reconstruction. Based on our experience and previous studies published in the English literature, we propose that reconstruction needs to be considered on a case-by-case basis.