Matsumura Masaru, Kobayashi Masahiro, Okubo Satoshi, Haruta Shusuke, Koyama Rikako, Uruga Hironori, Shindoh Junichi, Imamura Tsunao, Takazawa Yutaka, Hashimoto Masaji
Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan.
Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.
Surg Case Rep. 2023 Jun 25;9(1):117. doi: 10.1186/s40792-023-01700-0.
Pancreatic head resection following proximal gastrectomy jeopardizes the blood flow of the remnant stomach owing to right gastroepiploic conduit sacrifice, thereby necessitating total gastrectomy. However, owing to its high invasiveness, concomitant remnant total gastrectomy with pancreatectomy should be avoided as much as possible. Herein, we describe our experience of total pancreatectomy with right gastroepiploic conduit preservation in a patient with a history of proximal gastrectomy and reconstruction by jejunum interposition.
A 78-year-old woman with a history of gastric cancer was followed up at our institute for multiple intraductal papillary mucinous neoplasm, and main pancreatic duct stricture in the pancreatic head was newly detected. The cystic lesion was extended to the pancreatic body. Proximal gastrectomy and reconstruction by jejunal interposition were previously performed, and the mesenteric stalk of the interposed jejunum was approached through the retrocolic route. We planned total pancreatectomy with right gastroepiploic conduit preservation. Following adhesiolysis, the interposed jejunum and its mesentery lying in front of the pancreas were isolated. The arterial arcade from the common hepatic artery to the right gastroepiploic artery was detached from the pancreas. Furthermore, the right gastroepiploic vein was isolated from the pancreas. The pancreatic body and tail were pulled up in front of the remnant stomach, and the splenic artery and vein were resected. The pancreatic body and tail were pulled out to the right side, and the pancreatic head was divided from the pancreatic nerve plexus to the portal vein. The jejunal limb for entero-biliary anastomosis was passed through the hole behind the superior mesenteric artery and vein, and gastrointestinal anastomosis using the antecolic route and Braun anastomosis were performed.
To avoid remnant total gastrectomy, right gastroepiploic conduit preservation is an optional procedure for pancreatic head resection in patients who have undergone proximal gastrectomy with reconstruction by jejunal interposition.
近端胃切除术后行胰头切除术会因牺牲胃网膜右血管而危及残胃的血流，从而需要行全胃切除术。然而，由于其侵袭性高，应尽可能避免同时进行残胃全切除术和胰腺切除术。在此，我们描述了1例有近端胃切除术病史并经空肠间置重建的患者保留胃网膜右血管行全胰切除术的经验。
1例78岁有胃癌病史的女性患者在我院因多发导管内乳头状黏液性肿瘤接受随访，新发现胰头主胰管狭窄。囊性病变延伸至胰体。此前已行近端胃切除术及空肠间置重建，经结肠后途径接近间置空肠的肠系膜蒂。我们计划保留胃网膜右血管行全胰切除术。松解粘连后，分离位于胰腺前方的间置空肠及其系膜。将从肝总动脉至胃网膜右动脉的动脉弓从胰腺上分离。此外，将胃网膜右静脉从胰腺上分离。将胰体和胰尾向上拉至残胃前方，切除脾动静脉。将胰体和胰尾拉向右侧，将胰头从胰神经丛至门静脉处离断。将用于胆肠吻合的空肠袢经肠系膜上动静脉后方的孔引出，采用结肠前途径进行胃肠吻合及布朗吻合。
为避免残胃全切除术，对于已行近端胃切除术并经空肠间置重建的患者，保留胃网膜右血管是胰头切除术的一种可选术式。
