Jejunal Loop-Preserving and Mesentery-Sparing Reconstruction after Pancreaticoduodenectomy in a Patient with Prior Total Gastrectomy.

introductionPancreaticoduodenectomy (PD) after a total gastrectomy is technically challenging because the proximal jejunum has already been utilized for an esophagojejunostomy. Consequently, reconstruction after PD requires the use of a more distal jejunal segment, and the optimal reconstruction strategy remains controversial. We report a case of a jejunal loop-preserving and mesentery-sparing reconstruction after PD in a patient with a prior total gastrectomy. CASE PRESENTATION: A 70-year-old man with a history of Roux-en-Y total gastrectomy for gastric cancer presented with obstructive jaundice. Imaging studies demonstrated a periampullary tumor with suspected regional lymph node metastasis, and ampullary carcinoma was diagnosed. A PD was performed through an upper midline laparotomy. Following the resection of the pancreatic head and proximal jejunum, reconstruction was achieved using the pre-existing Roux limb without additional mesenteric division. Pancreaticojejunostomy and hepaticojejunostomy were performed using a distal jejunal segment, followed by a side-to-side jejunojejunostomy that preserved jejunal continuity and mesenteric integrity. The operative time was 459 minutes, and blood loss was 603 mL. The postoperative course was uneventful, and the patient was discharged on POD 21. Histopathological examination confirmed adenocarcinoma of the ampulla of Vater (pT3bN1M0, Stage IIIA) with negative surgical margins.

conclusionsThis jejunal loop-preserving and mesentery-sparing reconstruction avoided additional jejunal transection and mesenteric dissection while maintaining the continuity of the jejunal loop. The technique may represent a simple and anatomically reasonable alternative to conventional double Roux-en-Y reconstruction in selected patients undergoing PD after a total gastrectomy.