Major pancreatic resection currently provides the only possibility of cure, or even increased survival, in patients with pancreatic and periampullary cancers. Consequently, there is an increased probability that patients with pancreatic or periampullary cancer who have previously undergone gastrectomy will undergo PD. However, PF has been the major concern in PD. Several studies have shown that pancreaticogastrostomy is associated with a very low rate of anastomotic leakage, suggesting that it is safer than PJ [10
]. However, pancreaticogastrostomy is theoretically unsuitable because the remnant stomach is small after gastrectomy, particularly in patients who have previously undergone distal or extensive gastrectomy. Thus, PJ is performed as pancreaticoenterostomy in patients who have previously undergone total gastrectomy.
To prevent PF, wrapping of skeletonized vessels and the anastomotic site of the pancreaticoenterostomy using the round ligament [5
], greater omentum [7
], or both [9
] has been evaluated. In general, Roux-en-Y reconstruction is performed after total gastrectomy, and the round ligament and the greater omentum are subsequently resected during total gastrectomy. Thus, wrapping the anastomotic site of pancreaticoenterostomy using the round ligament or the greater omentum is not possible.
It has been proposed that a soft, friable, and normal pancreas of normal size with a thin-walled main pancreatic duct increases the risk of PF. Nevertheless, surgical technique still plays a crucial role in preventing PF. Therefore, we routinely use a pancreatic stent tube to drain external pancreatic juice. Moreover, we use a jejunum substitute for the round ligament or the greater omentum to wrap the pancreatic anastomotic site.
After total gastrectomy, malnutrition and weight loss due to absence of gastric function are major issues. Further invasive surgeries such as PD may increase these nutritional deficiencies. Duodenum-preserving resection of the head of the pancreas was first introduced by Beger et al. [12
] for chronic pancreatitis. Since then, several modified procedures have been introduced, including pancreatic head resection with second-portion duodenectomy (PHRSD) [13
]. However, Ahn et al. [15
] found that preservation of the duodenal segment may play a significant role in the absorption of iron, calcium, fat and folic acid in PHRSD. The duodenum and the upper part of the jejunum are very important portions with regard to gut hormone secretion. Thus, preservation of the duodenal segment and the upper jejunum may be desirable for prevention of malnutrition. Fortunately, in our case, the Roux limb was longer and we were able to preserve the third portion of the duodenum using the Roux limb longitudinally in an effort to maintain gut hormone secretion. Moreover, this technique does not require jejunojejunostomy and reduces the anastomosis. As a result, the patient's nutritional state was fairly maintained.
To our knowledge, there have been no reports on a similar jejunal scarf-covering method to prevent PF following PD in patients who have undergone total gastrectomy. This constructive technique might be useful for preventing PF and maintaining postoperative nutrition in patients who have previously undergone total gastrectomy.