PMC3764962_01
The post-PD and postradiation therapy surgical field. S = Gastric remnant; P = pancreas; AL = obstructed afferent loop; HA = hepatic artery; T = transverse colon.
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F1
Once adhesions from the previous surgery were taken down and the free peritoneal cavity was entered, the liver, hepatoduodenal ligament, stomach, efferent loop, jejunojejunostomy and afferent loop were recognized (fig. 1).
a Peripherally, the afferent loop was transected distal to the affected segment (AAL). The distal remnant of the normal afferent loop (NAL) was pulled toward the pancreas through the transverse mesocolon (TM) and had a sufficient redundancy to provide construction of the anastomoses without tension. T = Transverse colon. b Proximally, the afferent loop was fully mobilized through a field of dense adhesions and scar tissue. The HJ and PJ were taken down and the affected afferent loop (AAL) was removed. The surgical bed of the primary operation was exposed. P = Pancreas; HA = hepatic artery; PV = portal vein; T = transverse colon.
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F2
Peripherally, the afferent loop was transected distal to the involved segment (fig. 2a). Proximally, mobilization of the afferent loop exposed the surgical bed of the previous PD; no macroscopic evidence of local recurrence in the pancreatic bed, the liver or the peritoneal surface was observed (fig. 2b).
The PJ was taken down and examined. The remnant pancreas (P) was resected until a dilated and normal pancreatic duct (PD) was exposed. A new duct-to-mucosa PJ was then performed and the reconstruction of the afferent loop was completed after revision of the HJ. CA = Celiac axis; PV = portal vein.
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F3
A short segment (1.5 cm) of the remnant pancreas was resected until the dilated pancreatic duct was revealed and a revised duct-to-mucosa PJ was performed using an anastomotic stent (fig. 3).