J Gastrointest Surg (2011) 15:367–370 DOI 10.1007/s11605-010-1245-4
CASE REPORT
Pylorus-Preserving Pancreaticoduodenectomy after Transhiatal Esophagectomy Sparing the Right Gastroepiploic Vessels and Gastric Tube Georgios P. Fragulidis & Panagiotis G. Athanasopoulos & Aikaterini Melemeni & Konstantinos D. Chondrogiannis & Konstantinos Nastos & Vassileios Koutoulidis & Andreas Polydorou
Received: 6 March 2010 / Accepted: 25 May 2010 / Published online: 9 June 2010 # 2010 The Society for Surgery of the Alimentary Tract
Abstract Introduction Pancreaticoduodenectomy after transhiatal esophagectomy is a technically demanding procedure in sense of preserving the blood supply to the gastric tube. Case Report We report a case of pylorus-preserving pancreaticoduodenectomy for pancreatic head cancer, 13 years after a transhiatal esophagectomy, sparing the gastric tube and the right gastroepiploic artery and vein. Discussion This type of operation is less time-consuming and less invasive, since no further reconstruction of the alimentary tract or the vascular system is applied. Keywords Pylorus-preserving pancreaticoduodenectomy . Esophagectomy . Gastric tube . Gastroduodenal artery . Right gastroepiploic artery
Introduction Pancreaticoduodenectomy (PD) is the procedure of choice in pancreatic head cancer. However, in patients who G. P. Fragulidis (*) : P. G. Athanasopoulos : K. Nastos : A. Polydorou Second Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis Sophias Ave., 11528 Athens, Greece e-mail:
[email protected] A. Melemeni : K. D. Chondrogiannis First Department of Anaesthesia, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis Sophias Ave., 11528 Athens, Greece V. Koutoulidis Department of Radiology, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis Sophias Ave., 11528 Athens, Greece
underwent transhiatal esophagectomy with the stomach being anastomosed to the cervical esophagus, choosing the best technique for the PD presents a great challenge.1 The surgeon is usually confronted with two options: to preserve the blood supply to the stomach via the right gastric and gastroduodenal artery (GDA) or to sacrifice blood vessels and substitute the devascularized stomach with the colon. We herein present a case of pylorus-preserving pancreaticoduodenectomy (PPPD) for pancreatic head cancer, sparing the gastric tube and its unique vessels, the right gastroepiploic artery (RGEA), 13 years after transhiatal esophagectomy for esophageal cancer.
Case Report A 50-year-old Caucasian male was referred to our clinic with a 1-month medical history of painless obstructive jaundice, dark urine, and clay-colored stools (total bilirubin (Bilt) 17 mg/dl). The patient had undergone transhiatal esophagectomy for esophageal cancer 13 years ago. An abdominal contrast-enhanced computed tomography (CT) scan showed an ill-defined, almost iso-attenuating 2.5-cm mass in the pancreatic head with marked dilatation of the intra- and extrahepatic bile ducts (Fig. 1). The presence of the gastric tube in the posterior mediastinum
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J Gastrointest Surg (2011) 15:367–370
Fig. 2 Preoperative digital angiography of the celiac axis, demonstrating the cephalad course of the right gastroepiploic artery (RGEA, arrows). The distal half of the artery is located above the diaphragm into the thorax. Fig. 1 Contrast-enhanced computed tomography scan of the abdomen. An ill-defined hypodensity is seen in the pancreatic head at the level of superior mesenteric artery origin (white arrow). Gallbladder dilatation is also noted (black arrow).
was also noted on CT images of the thorax. A plastic endoprosthesis was placed in the common bile duct (CBD), via endoscopic retrograde cholangiopancreatography, to restore the bile flow. Endoscopic ultrasonography-guided fine-needle aspiration biopsy and cytology revealed cells with high-grade dysplasia of the ductal epithelium indicative of ductal adenocarcinoma. An angiographic study of the Haller's tripod and superior mesenteric artery depicted the RGEA as the only vessel perfusing the gastric tube (Fig. 2). During patient's preoperative management, laboratory evaluation showed aspartate aminotransferase 23 IU/L (normal,
