Shah MM, Martin BM, Stetler JL, Patel AD, Davis SS, Sarmiento JM, Lin E. Reconstruction Options for Pancreaticoduodenectomy in Patients with Prior Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A. 2017 Nov;27(11):1185-1191.

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“In summary, of the 13 patients that have been described in the literature who underwent PD after RYGB, 7 (54%) of these patients underwent reconstruction, similar to our preferred approach (Fig. 2), which involved remnant gastrectomy with the BP limb forming the BP anastomoses. Overall, 8 (61.5%) of the 13 patients had remnant gastrectomy. Five patients did not have a remnant gastrectomy. There are 10 patients in the literature where the surgeon attempted resecting the gastric remnant, and 8 (80%) of these patients had successful remnant gastrectomy. However, based on the published literature, this is clearly a small sampling of what might have actually been performed. We have had three such patients where we performed PD in patients with prior RYGB (similar to Fig. 2a). In all patients, we had adequate BP limb length for the anastomoses. The patients had early recovery of bowel function and were discharged from the hospital on or before postoperative day 5 without any significant complications.

FIG. 4.  Reconstruction options with reversal of gastric bypass. (a) PD includes resection of the BP limb. The Roux-limb is disconnected at the gastrojejunostomy (red line) and used for the PJ, HJ, and to drain the gastric remnant. The gastric pouch is anastomosed to the gastric remnant resulting in reversal of the bypass. (b) PD includes division of the jejunum at the red line, and this BP limb is used to form the PJ and the HJ. The Roux-limb is disconnected at the gastrojejunostomy (blue line) and used to drain the gastric remnant. The gastric pouch is anastomosed to the gastric remnant. © 2017 Emory University. Used with permission.

This article, with its accompanying review of the existing literature, offers individualized reconstruction options for RYGB patients undergoing PD. The availability of bariatric surgeons who are familiar with the anatomy, and their experience with revisional and reoperative bariatric surgery can also be resources for decision-making.”

Trudeau MT, et al. Pancreatic Head Resection after Roux-en-Y Gastric Bypass Study Group. Pancreatic Head Resection Following Roux-en-Y Gastric Bypass: Operative Considerations and Outcomes. J Gastrointest Surg. 2020 Jan;24(1):76-87.

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Results: Ninety-six patients with a previous RYGB undergoing pancreatic head resection were assembled. Pathologic indications between the RYGB and normal anatomy cohorts did not differ. Propensity score matching of RYGB vs. patients with unaltered anatomy demonstrated no differences in major postoperative outcomes. In total 20 distinct reconstructions were employed (of 37 potential options); the three most frequent reconstructions accounted for 52.1%, and none demonstrated superior outcomes. There were no differences in outcomes observed between original biliopancreatic limb use (66.7%) and those where a secondary Roux limb was created for biliopancreatic reconstruction. Remnant stomachs were removed in 54.7% of cases, with no outcome differences between resected and retained stomachs. Venting gastrostomy tubes were used in 36.2% of retained stomachs without obvious outcome benefits. Jejunostomy tubes were used infrequently (11.7%).

Conclusions: Pancreatic head resection after RYGB is an infrequently encountered, unique and challenging scenario for any given surgeon. These patients do not appear to suffer higher morbidity than those with unaltered anatomy. Various technical reconstructive options do not appear to confer distinct benefits.

More PubMed results on pancreatoduodenectomy after Roux-en-Y.