Pancreaticoduodenectomy after Roux-en-Y Gastric Bypass: a novel reconstruction technique

Abstract

BackgroundThe obesity epidemic continues to increase around the world with its attendant complications of metabolic syndrome and increased risk of malignancies (1), including pancreatic malignancy (2,3). The Roux-en-Y gastric bypass (RYGB) effectively treats obesity and its associated morbidities including metabolic syndrome (4). RYGB creates a gastric pouch with alimentary limb, as well as a biliopancreatic (BP) limb that joins the alimentary limb to form a common channel. Thus, it has both restrictive and mal-absorptive components. Patients with a mass in the head of pancreas are recommended pancreaticoduodenectomy (PD) for suspected malignancy (5). As bariatric surgery is increasingly adopted in recent years (6), more reports of PD following RYGB are published. Post-surgical adhesions and altered anatomy following RYGB poses not only a diagnostic challenge by making endoscopy difficult, but also unique challenge of reconstruction following PD. There are many different techniques of reconstruction proposed. Here we describe a patient where the remnant BP limb was used for a venting anterior gastrojejunostomy. The pancreaticojejunostomy and hepaticojejunostomy was created with a new loop of jejunum and a new distal jejunojejunostomy was performed. MethodsA 59-year-old male presented with painless obstructive jaundice of one week's duration. He had a history of RYGB

Anatomical reconstruction after pancreaticoduodenectomy in a patient with previous Roux‐en‐Y gastric bypass for obesity: a novel complication for the future

“…This study was based on 96 patients under 55 different surgeons in 28 centres globally. 4,6,7 Multiple potential options for PD in patients with a previous RYGB have been described in overseas case reports, with the major surgical decisions being the degree of resection/preservation of both the gastric remnant and the biliopancreatic limb. 4 The gross advantages/disadvantages have been described by Mak et…”

“…Surgical decision making should be tailored to individual patients' anatomy and their associated pathology. 4,6…”

Obesity and Biliopancreatic Cancers: Exploring Current Evidence

“…Although the incidence cholangiocarcinoma post bariatric surgery appeared low, the three reported cases of cholangiocarcinoma were diagnosed at an advanced stage (Beghdadi, 2020). Cases by Tumour Type 3,[24][25][26][27][28]31 of the 24 cases. These were distributed as follow; Pain (4), Pain and Jaundice (3), Jaundice and Weight loss (1), Jaundice (1), and Incidental finding (4).…”

“…The review found 11 authors that reported pancreatic and cholangiocarcinoma with total 27 reported cases 3,19,[22][23][24][25][26][27][28][29][30][31] .…”

“…With regards to surgical management of the pancreatic cancer, majority of authors reported the option of gastrectomy of the remnant stomach and when not feasible gastrostomy was the option of choice. The remnant stomach was spared in six cases where pancreaticoduodenectomy with other with reconstruction was performed 3,24,[26][27][28]31 .…”