Comparison of clinical outcomes according to the history of previous gastrectomy in patients undergoing pancreatoduodenectomy: a propensity score matching analysis

Various types of reconstruction after pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: a single-enter experience

Purpose

The incidence of patients requiring pancreaticoduodenectomy (PD) following any type of gastrectomy is increasing as the population of elderly patients is increasing, especially in endemic areas of gastric cancer such as Korea. All types of gastrectomy can be categorized as subtotal gastrectomy with Billroth I (BI), Billroth II (BII), and total gastrectomy with Roux-en-Y anastomosis. In this paper, we reviewed our experiences of PD for patients who previously underwent gastrectomy.

Methods

We reviewed the medical records of the patients who underwent PD following any type of gastrectomy among 505 consecutive patients who underwent PD in a single institution between 2011 and 2020 retrospectively.

Results

There were 13 patients who had undergone gastrectomy including 7 patients of BI, 1 patient of BII, and 5 patients of total gastrectomy. For all 7 patients of BI, the reconstruction was not different from conventional PD. For the 1 patient of BII, previous gastrojejunal anastomosis was preserved and reconstruction was performed in Roux-en-Y method. For the 5 patients with total gastrectomy, 2 different types of reconstruction were performed. In one patient, we removed the remaining jejunum with the specimen, and reconstruction was performed. For the other 4 patients, the remaining jejunum, distal to the Treitz ligament, was preserved and was utilized for anastomosis. Surgeries for all patients were uneventful.

Conclusion

PD following any type of gastrectomy can be safe. Especially, if the length of remained jejunum is long enough, its utilization for the reconstruction can be an appropriate option.

Unexpected duodenopancreatectomy in an "awake" gastrectomized patient: Case report and technical notes

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A patient with a previous history of gastric cancer was admitted to our unit with fever and jaundice.

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Preoperative evaluation showed the presence of calculi of the common bile duct (CBD). During the preoperative anaesthetic evaluation, neuraxial-type anaesthesia was proposed given the patient’s frailty.

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Exploration of the CBD revealed neoplastic tissue involving the ampulla of Vater. A duodenopancreatectomy was performed under neuraxial anaesthesia.

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A modified reconstruction was performed, and a mechanical stapler for hepaticojejunal (HJ) anastomosis was used.

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The outpatient follow-up showed physical recovery of the patient with a resumption of appetite and weight gain, and HJ anastomosis showed no stricture during the MRI performed 5 months after the operation.

Introduction and importance

Early diagnosis, surgical techniques and adjuvant therapy in patients undergoing gastrectomy for cancer have prompted an increase in the number of long-term surviving patients. The detection of pancreatic head tumours in patients undergoing gastrectomy is challenging, even for expert surgeons.

Case presentation

A 78-year-old woman presented with a previous history of gastric cancer treated 2 years before D2 total gastrectomy and Roux-an-Y reconstruction. The patient reported uneven tissue located on the head of the pancreas 6 months after the operation. MRI showed dilation of the intrahepatic bile ducts and common bile duct stones. During the preoperative evaluation, neuraxial-type anaesthesia was proposed to the patient given her frailty. After choledochotomy, solid tissue involving the ampulla of Vater was found. Although not originally planned, a duodenopancreatectomy (DP) was performed under neuraxial anaesthesia.

Clinical discussion

The approach to DP in patients with a history of gastrectomy and Roux-en-Y reconstruction requires a modified surgical approach, which is not standardized. Other cases of DP performed on patients under neuraxial anaesthesia are not described in the literature. Performing a modified reconstruction, we can reduce the number of intestinal anastomoses and the risk of anastomotic dehiscence. The choice of neuraxial anaesthesia has been demonstrated to be a suitable solution for the patient with rapid recovery.

Conclusion

In our experience, DP is a safe and feasible procedure in gastrectomized patients.

Mechanical hepaticojejunal (HJ) anastomosis is a possible alternative to traditional manual anastomosis. Neuraxial anaesthesia in selected patients can be considered a safe practice for rapid postoperative recovery compared to general anaesthesia.