Two Cases of Pylorus-Preserving Pancreatoduodenectomy with Remnant Stomach Preservation in Patients Who Have Undergone Proximal Gastrectomy.

Introduction: Pancreaticoduodenectomy after proximal gastrectomy (PG) presents technical challenges owing to the need to preserve blood flow in the remnant stomach. Considering the oncological factors and preservation of the remnant stomach blood supply, it is crucial to preserve or reconstruct the right gastric artery (RGA) and/or right gastroepiploic artery (RGEA). In cases where the RGEA is preserved, technical considerations for reconstruction arise owing to the poor motility of the remnant stomach.

Case presentation: A 79-year-old man was diagnosed with pancreatic head cancer and underwent pylorus-preserving pancreatoduodenectomy (PPPD) three years after PG for gastric cancer. The second patient, a 64-year-old man with a history of PG for esophagogastric junction cancer two years prior, was diagnosed with distal cholangiocarcinoma and underwent PPPD. In both cases, preserving the RGEA while ensuring adequate oncological resection margins was considered feasible. We were able to safely preserve the RGA, RGEA, and remnant stomach. The jejunum was mobilized from the right mesocolon, and all anastomoses (pancreatojejunostomy, choledochojejunostomy, and duodenojejunostomy [D-J]) were performed on the proximal side of the transverse mesocolon to minimize the tension on the D-J anastomosis.

Conclusion: Pancreatoduodenectomy after PG requires careful consideration of curability and surgical invasiveness. It is crucial to devise reconstruction techniques that minimize tension on the D-J anastomosis.