Pancreaticoduodenectomy after Roux-en-Y gastric bypass and novel endoscopic ultrasound-directed transgastric ERCP procedure

Performing a pancreaticoduodenectomy (PD) in patients having undergone a Roux-en-Y gastric bypass (RNYGB) poses a significant surgical challenge. We present a patient with a history of RNYGB and endoscopic ultrasound-directed transgastric ERCP (EDGE) procedure who underwent a successful PD. This 77-year-old female with history of open RNYBG presented with resectable pancreatic adenocarcinoma. A preoperative EDGE procedure was required for biliary decompression. A PD was performed by removing the entire biliopancreatic limb for oncologic resection. The reconstructive technique here involved utilizing the old common channel for the hepaticojejunostomy, pancreaticojejunostomy, and remnant gastrojejunostomy. The case also included Axios stent placement during a preoperative EDGE procedure. This case describes the first reported successful PD in a patient with prior RNYGB and EDGE procedure. Although the optimal technique for this clinical scenario remains unestablished, this unique case contributes to the literature by demonstrating an effective approach for practicing surgeons.