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Accumulated oncologic experience, a profound understanding of tumor biology, development of potent adjuvant chemotherapy, and early detection of malignant lesions resulted in improved survival outcomes in certain types of cancers arising from the gastrointestinal tract, and gastric cancer is thought to be one of those showing the most outstanding favorable surgical outcomes. This long-term survival can possibly bring about two potential clinical problems that surgeons need to consider: one being the issue of quality of life and the other being the possible occurrence of a second primary cancer.When considering the fact that even pancreatoduodenectomy (PD) alone for periampullary cancer is a very complex surgical procedure requiring meticulous dissection around major vascular structures and delicate anastomosis, previous radical subtotal gastrectomy (RSTG) or radical total gastrectomy with various types of gastrointestinal reconstruction make usual PD more complicated and difficult. We present three consecutive cases of PD for periampullary cancer after previous RSTG for lower third gastric cancer and discuss surgical strategies and pitfalls in this type of PD. All the patients underwent RSTG for gastric cancer. Types of anastomosis, entities, and operative characteristics of PD are summarized in Table 1.
The first case is a 72-year-old woman. A pancreatic mass was discovered on a computed tomography (CT) scan during a routine follow-up appointment after an RSTG with Billroth Type I anastomosis for early gastric cancer 6 months prior. She underwent PD with the Child method anastomosis1 and was discharged on the 11th postoperative day after an uneventful recovery. The final diagnosis was established as a 1.9-cm acinar cell carcinoma confined to the pancreas without lymph node metastasis (pT1N0M0) (Fig. 1A).
The second case is a 64-year-old man. He had undergone RSTG with Billroth Type II anastomosis for gastric cancer 20 years prior. CTand positron emission tomography CT scans revealed a 2.6-cm pancreatic head cancer abutting the superior mesenteric vein (SMV) and serum CA 19-9 304.0 U/mL (reference range, 0 to 37.0 U/mL). He...