Pancreatoduodenectomy with subtotal stomach-preserving and uncut Roux reconstruction

Pylorus-preserving pancreatoduodenectomy (PD) has become the therapy of choice for resectable tumors located in the head of the pancreas and periampullary region. In addition, a distal gastrectomy may still be required for tumors located in the dorsal part of the pancreatic head or when there is evidence of proximal duodenal invasion. This may lead to postoperative complications, including gastric dumping, marginal ulceration, and bile reflux gastritis. This study reports on the postoperative course following subtotal stomach-preserving PD with the uncut Roux reconstruction diverting biliary and pancreatic secretions from the gastric remnant.

A technique combining subtotal stomach-preserving PD with the uncut Roux reconstruction was applied in 10 patients. The postoperative clinical follow-up data are reviewed, and clinical criteria of biliary gastric reflux and gastritis were evaluated.

The postoperative course was uneventful in 4 patients and complicated in 6 patients. Delayed gastric emptying occurred in 3 patients. No deaths occurred in the postoperative period. One patient suffered from occasional nausea with abdominal discomfort for which endoscopy and cholescintigraphy were performed. Endoscopy confirmed complete occlusion of the afferent jejunal limb and showed marginal ulceration within the gastrojejunal anastomosis. Cholescintigraphy showed signs of enterogastric reflux. The check-up endoscopy following typical antisecretory therapy revealed complete ulcer healing. Four patients died of tumor recurrence 6, 7, 8, and 12 months following surgery.

This pilot study suggests that the uncut Roux reconstruction may represent a good alternative to gastrointestinal reconstruction following PD. Further studies including the determination of intragastric bile acid concentration and radionuclide isotope scanning in a larger number of patients are warranted.