title: Pancreaticoduodenectomy with preservation of gastric tube blood flow after esophagectomy: Report of a case.
abstract: BACKGROUND
  During pancreaticoduodenectomy (PD), the gastroduodenal artery (GDA) is commonly divided. In this study, we described the clinical features of PD in which the GDA was preserved in order to avoid gastric tube ischemia in a patient who had previously undergone esophagectomy.
  
  
  METHODS
  A 70-year-old man had previously undergone esophagectomy. Esophagectomy and gastric tube reconstruction were performed 10 years earlier due to superior thoracic esophageal cancer. The patient was referred to our hospital for the treatment of obstructive jaundice and was diagnosed with middle bile duct cancer. We performed PD and preserved the GDA. The postoperative course was uneventful, and the gastric tube continued functioning well.
  
  
  CONCLUSIONS
  In a patient with a prior esophagectomy and gastric tube reconstruction, the blood flow to the gastric tube is supplied only by the GDA via the right gastroepiploic artery (RGEA). Therefore, we carefully chose a technique that would preserve the GDA and avoid gastric tube ischemia. Oncologically, this procedure may be debatable because the efficiency of lymph node dissection along the GDA and RGEA may be compromised. PD involving GDA preservation in common bile duct (CBD) cancer may be acceptable because the CBD is behind the pancreatic head, and the CBD lymph flows into the para-aorta lymph nodes behind the pancreas.
  
  
  CONCLUSIONS
  This procedure is suitable for patients who have previously undergone esophagectomy and this procedure prevents digestive function disorders. Using this method, preoperative angiographic assessment and meticulous surgical technique may lead to successful outcomes.
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Sho
authors.initials: S
authors.lastname: Okimoto
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan. Electronic address: tsukoba@hiroshima-u.ac.jp.
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Kobayashi
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Shintaro
authors.initials: S
authors.lastname: Kuroda
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Tahara
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Ohira
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Ide
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Ishiyama
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Hirotaka
authors.initials: H
authors.lastname: Tashiro
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 734-8551, 1-2-3, Kasumi, Hiroshima, Japan.
authors.forename: Hideki
authors.initials: H
authors.lastname: Ohdan
keywords: Bile duct cancer; Esophagectomy; Gastric tube; Gastroduodenal artery; Pancreaticoduodenectomy