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. The 5-year survival rate after diagnosis with pancreatic cancer remains ⬍5% [4,5]. The evaluation of the patient with biliary or pancreatic pathologic findings and previous Roux-en-Y gastric bypass anatomy can be difficult. Endoscopic access to the gastric remnant and biliary tree is difficult and might require laparoscopic access of the gastric remnant for endoscopy and endoscopic retrograde cholangiopancreaticography . The anatomic alterations can complicate future surgery of the gastrointestinal tract for surgeons unfamiliar with the RYGB surgical anatomy. Perhaps because of the patient’s RYGB anatomy (with minimal manipulation of the gastric pouch and Roux limb), the patient had a relatively rapid return of normal bowel function. Unlike a Whipple procedure performed on an unaltered gastrointestinal tract anatomy, no disruption of the food-conducting portion of the stomach occurred. The surgical options at pancreaticoduodenectomy in a patient with RYGB include the possibility of resecting the bypassed portion of stomach along with the specimen. The gastric remnant was left in situ in the present case because of the ease of specimen resection and construction of the anastomosis to the “old” hepatobiliary limb. We believed it was worthwhile to preserve the gastric remnant in the event that nutritional access by gastrostomy tube would be possible if needed in the future. The possible disadvantages of leaving the remnant in place include the additional anastomosis and the possible risk of anastomotic leak, as well as the slight risk of marginal ulceration. The patient’s Roux limb obstructive symptoms just before her death could possibly have occurred even with an antecolic Roux limb because of the extensive omental disease.
Conclusion With the increasing number of bariatric procedures being performed, many additional cases of pancreatic cancer in
this patient population will inevitably occur in the years ahead. The ability to obtain surgical resection amidst the anatomic alterations that LRYGB presents is therefore essential. Pancreaticoduodenectomy, an already complex procedure, can be further complicated by the anatomic distortion of a previous LRYGB. We have described 1 approach in which this endpoint can be achieved satisfactorily, although the patient ultimately died of metastatic pancreatic cancer. Disclosures P. Caushaj received an educational grant from Covidien (USSC); and P. Papasavas is a consultant to W.L. Gore & Associates. The remaining authors claim no commercial associations that might be a conflict of interest in relation to this article. References  Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospective studied cohort of U.S. adults. N Engl J Med 2003;328:1625–38.  American Cancer Society. Cancer facts and figures. Available from: http://www.cancer.org/docroot/home/index.asp. Accessed August 5, 2007.  Steer ML, Exocrine pancreas. In: Townsend CM, Beauchamp RD, Evers BM, Mattox, editors. Sabiston textbook of surgery. 17th ed. Philadelphia: Elsevier; 2004, p. 1643–78.  Wray CJ, Ahmad SA, Matthews JB, Lowy AM. Surgery for pancreatic cancer: recent controversies and current practice. Gastroenterology 2005;128:6:1626 – 41.  Conlon KC, Klimstra DS, Brennan MF. Long-term survival after curative resection for pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-year survivors. Ann Surg 1996;223:273–9.  Ceppa FA, Gagné DJ, Papasavas PK, Caushaj PF. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:21– 4.
Pancreatic cancer after previous bariatric surgery As a consequence of the widespread acceptance of bariatric surgery as the best available effective therapy for patients with severe obesity, there are now literally millions of patients worldwide who have undergone one form or another of major surgical alteration of their upper digestive tract for weight control. As time passes for this enormous cohort of anatomically altered postbariatric patients, it is inevitable that some of them will develop other unrelated intra-abdominal conditions that also require surgical attenThe opinions expressed herein are the private views of the author and do not construe an official position of the United States Army Medical Department.
tion. In many of these situations, such as a sigmoidectomy for diverticular disease, the alterations of the previous bariatric surgery will pose little, if any, problem. In others, however, a previous bariatric procedure could lead to significant technical implications for workup, surgical exposure, and reconstruction options for future surgical situations, particularly in the upper abdomen. In this article, Rutkoski and associates report an instance where they encountered such a challenge in a patient who developed a cancer of the pancreatic head about 5 years after undergoing successful Roux-en-Y gastric bypass. In this case, the bariatric anatomy had implications for the evaluation of the patient’s clinical picture of jaundice and
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pancreatitis and also required creative planning to allow biliary and pancreatic reconstruction in a manner that would not compromise the existing Roux-en-Y or gastric pouch. The surgeons chose to leave the now-isolated bypassed gastric remnant in situ as a possible future nutrition portal. Another alternative would be to remove the entire bypassed stomach to simplify the final anatomy and avoid an additional anastomosis. Both alternatives seem reasonable, and a matter of surgeon preference. In years to come, cases will arise in which the existence of bariatric surgical anatomy will require modification of a “usual” surgical plan. In addition to the pancreatic cancer case presented, conditions such as esophageal cancer and upper abdominal blunt or penetrating trauma come to mind. All such potential cases remind us of the importance of reviewing the details of previous bariatric op reports so that we have the clearest possible picture of the existing anatomy before venturing forth in a surgically altered field. It is important to know which procedure the patient has undergone and its technical details. In our mobile society, providing patients a courtesy copy of their operative report for
them to have available for future reference is a simple method to help achieve this goal. Obviously, cases will inevitably arise in which the previous operative data are not readily available. In these instances, surgeons are well-advised to take the time intraoperatively to carefully check the anatomic arrangement and integrity of the existing bariatric arrangement during any secondary procedure in the vicinity. Rutkoski and colleagues are to be congratulated for their initiative in helping to call attention to what will be an increasingly encountered situation as the number of bariatric surgical patients continues to steadily increase. Disclosures The author claims no commercial associations that might be a conflict of interest in relation to this article. Preston L. Carter, M.D., F.A.C.S. Madigan Army Medical Center Tacoma, Washington