Technical Considerations for Pancreaticoduodenectomy with Preservation of the Right Gastroepiploic Vessels after Proximal Gastrectomy: A Case Report.

INTRODUCTION: Pancreaticoduodenectomy (PD) in patients with a history of proximal gastrectomy poses a significant challenge because the remnant stomach depends largely on the right gastric artery and right gastroepiploic artery (RGEA) for its blood supply. As these vessels are routinely resected during standard PD, their preservation requires alternative surgical strategies and meticulous techniques. CASE PRESENTATION: An 81-year-old man who underwent postoperative follow-up at our institution was found to have an incidental pancreatic head tumor on CT. He had previously undergone robot-assisted proximal gastrectomy for esophagogastric junction cancer. After neoadjuvant chemotherapy with gemcitabine plus S-1, PD with preservation of the RGEA and right gastroepiploic vein (RGEV) was planned. Gastric transection, which is usually conducted at an early stage, was intentionally delayed until immediately before the dissection of the gastroduodenal artery (GDA) to minimize tension on the preserved vessels. Indocyanine green fluorescence imaging confirmed adequate perfusion of the remnant stomach. Reconstruction was performed using the modified Child method. A pancreatojejunostomy was created ventral to the preserved RGEV, allowing the vein to course dorsal to the anastomosis and separate the preserved GDA-RGEA axis from the anastomosis, thereby minimizing the risk of vascular compromise in the event of a postoperative pancreatic fistula. The postoperative course was complicated by a pancreatic fistula and cholangitis, both of which were managed conservatively, and oral intake was well tolerated. Eight months after surgery, the patient remains well and is receiving adjuvant chemotherapy, with no significant postoperative weight loss and no evidence of recurrence. CONCLUSIONS: PD with preservation of the RGEA/RGEV is a feasible and effective option for patients with a history of proximal gastrectomy. Careful patient selection and technical modifications may enable safe oncological resection while preserving the remnant gastric perfusion and postoperative function.