Unexpected duodenopancreatectomy in an “awake” gastrectomized patient: Case report and technical notes

INTRODUCTION AND IMPORTANCE: Early diagnosis, surgical techniques and adjuvant therapy in patients undergoing gastrectomy for cancer have prompted an increase in the number of long-term surviving patients. The detection of pancreatic head tumours in patients undergoing gastrectomy is challenging, even for expert surgeons. CASE PRESENTATION: A 78-year-old woman presented with a previous history of gastric cancer treated 2 years before D2 total gastrectomy and Roux-an-Y reconstruction. The patient reported uneven tissue located on the head of the pancreas 6 months after the operation. MRI showed dilation of the intrahepatic bile ducts and common bile duct stones. During the preoperative evaluation, neuraxial-type anaesthesia was proposed to the patient given her frailty. After choledochotomy, solid tissue involving the ampulla of Vater was found. Although not originally planned, a duodenopancreatectomy (DP) was performed under neuraxial anaesthesia. CLINICAL DISCUSSION: The approach to DP in patients with a history of gastrectomy and Roux-en-Y reconstruction requires a modified surgical approach, which is not standardized. Other cases of DP performed on patients under neuraxial anaesthesia are not described in the literature. Performing a modified reconstruction, we can reduce the number of intestinal anastomoses and the risk of anastomotic dehiscence. The choice of neuraxial anaesthesia has been demonstrated to be a suitable solution for the patient with rapid recovery. CONCLUSION: In our experience, DP is a safe and feasible procedure in gastrectomized patients. Mechanical hepaticojejunal (HJ) anastomosis is a possible alternative to traditional manual anastomosis. Neuraxial anaesthesia in selected patients can be considered a safe practice for rapid postoperative recovery compared to general anaesthesia.