Pylorus-Preserving Pancreatoduodenectomy for Ampullary Carcinoma after Esophagectomy with Retrosternal Ileocolonic...

Pancreatoduodenectomy after esophagectomy with an ileocolonic interposition is technically challenging because perfusion of both the remnant stomach and the interposed ileocolonic conduit must be preserved. Although pancreatic head resection after proximal gastrectomy or gastric conduit reconstruction has been reported, pylorus-preserving pancreatoduodenectomy (PPPD) after an ileocolonic interposition has not been previously reported. We report a case of PPPD after an ileocolonic interposition in which both the right gastroepiploic vessels and the middle colic arterial arcade were preserved, and intraoperative indocyanine green (ICG) fluorescence imaging was used to confirm adequate perfusion.

A 78-year-old man presented at our hospital with fatigue. Contrast-enhanced CT revealed a localized ampullary tumor with upstream dilatation of the common bile duct and main pancreatic duct, without distant metastases or significant lymphadenopathy. Eight years earlier, he had undergone thoracoabdominal esophagectomy with 3-field lymph node dissection and retrosternal ileocolonic interposition for esophageal squamous cell carcinoma in our hospital. In that setting, perfusion of the remnant stomach depended on the right gastroepiploic vascular territory, whereas the interposed ileocolonic conduit was supplied by the middle colic arterial arcade. Therefore, PPPD was planned with preservation of both vascular territories. Careful dissection enabled preservation of the gastroduodenal artery, right gastroepiploic vessels, and the mesentery carrying the middle colic vessels. Intraoperative ICG fluorescence imaging confirmed adequate perfusion of both the remnant stomach and the ileocolonic conduit. The postoperative course was uneventful, and the patient was discharged on POD 14. Histopathological examination revealed an ampullary adenocarcinoma (pT2N0M0, stage IB). The patient remained alive without recurrence 18 months after surgery.

This case demonstrates that PPPD after esophagectomy with an ileocolonic interposition is feasible in select patients. Preservation of both the right gastroepiploic vessels and the middle colic arterial arcade is essential to maintain perfusion of the remnant stomach and the ileocolonic conduit. Intraoperative ICG fluorescence imaging is useful for the real-time confirmation of perfusion in both vascular territories.