A novel reconstructive strategy for pancreaticoduodenectomy following Roux-en-Y distal gastrectomy

The rate of pancreaticoduodenectomy (PD) performed for both benign and malignant periampullary diseases has increased. In addition, Roux-en-Y reconstruction after distal gastrectomy for cancer or ulcer is still widely used. Therefore, a surgeon may be confronted with a partially- gastrectomized patient who needs a PD. This is a very challenging circumstance for surgeons because of adhesions, bloodstream, anatomical changes and length of the remnant intestine. In our experience, we performed two pancreaticoduodenectomies after distal gastrectomy in patients with periampullary tumors. We preserve gastrojejunal anastomosis and perform an end-to-side pancreaticojejunostomy (PJ) on the afferent limb of gastrojejunal anastomosis and a termino-lateral hepaticojejunal anastomosis on an independent transmesocolic Roux-en-Y limb. In literature, few cases of PD after distal gastrectomy are reported and most of them consider only PD after Billroth II reconstruction. Many authors have demonstrated pancreaticogastrostomy (PG) is superior to PJ in terms of lower risk of pancreatic and biliary fistula, but it is not possible to anastomose pancreas stump with gastric wall in patients who have been undergone distal gastrectomy. For this reason, we retrospectively review our experience about PD following distal gastrectomy and suggest a novel standardized technique which allow surgeons to benefit from same advantages of a typical PG also in this group of patients.