Non-operative management of the benign gastric ulceration is indicated in nearly all cases with the exception of hemorrhage, perforation, obstruction, and refractory disease. Gastric ulcer location determines the preferred treatment modality with the classification system proposed by Johnson [1].

The authors reserve the use of a Billroth II (B II) gastroenterostomy for those patients in whom Billroth I (B I) is not feasible, most often because of an inability of the duodenum and greater curvature to approximate without tension. This usually involves carrying out a wide-mouthed gastroenterostomy with extension of the afferent limb along the closed portion of the stomach nearest to the lesser curve [1].

Carcinoma of the pancreatic head is one of the most common gastrointestinal malignancies and, because of its aggressive nature, one of the hardest to cure. The classic presentation of cancer of the pancreatic head is unremitting jaundice usually accompanied by dark urine, light stool, and pruritus. Significant weight loss is common even when the pancreatic cancer is resectable [2].

In the presence of the malignancy, the resection is indicated in the absence of proven metastases and if the tumor is of such size that the major blood vessels are not implicated beyond the ability of the surgeon to accomplish a safe vascular resection and repair [3].

The double Roux-en-Y reconstruction is considered as an alternative way reconstruction after the pancreaticoduodenectomy. When the pancreaticoduodenectomy is performed the double Roux-en-Y digestive tract reconstruction can be addressed to decrease the liquid flow and pressure in the duodenal lumen and reduce not only the distance between the pancreaticojejunostomy and choledochojejunostomy but also the risks of tracting, twisting and angularity of the jejunal loop associated with common reconstruction methods [4].

A 68-year-old male was transferred from the Department of gastroenterology and hepatology where the diagnostic evaluation was done. He presented with abdominal pain localized in the right upper abdominal part, loss of weight and jaundice. The patient had undergone B II gastric resection due to benign gastric ulceration 23 years prior to the admission.

The laboratory tests showed high levels of total blood bilirubin 184.3 µmol/L (normal 3–19 µmol/l), as well as high levels of the inflammation parameters. White blood cells number was 14.5x10⁹/L (normal 3.40–9.70x10⁹/L), while the C-reactive protein value was 129.5 µg/L (normal 0.0–3.3 µg/L).

Esophagogastroduodenoscopy (EGD) showed no abnormalities in the stomach part that had been left or in afferent and efferent jejunal loops. On the gastrojejunal anastomosis there was a polyp, 3 mm in diameter, where the biopsy was taken. The result of the biopsy showed an inflammatory origin.

Abdominal CT scanning revealed a dilated choledochal duct incorporated in a solid, low differentiated neoplastic mass of pancreatic head, 2 cm in diameter. Tumor had infiltrated a duodenum. However, the great blood vessels were not affected.

Surgical technique
Considering the earlier laparotomy, we performed medial superior et inferior relaparotomy to open the abdominal cavity. Exploration of the abdominal cavity revealed enlarged, distended gallbladder and multiple adhesions between the small bowel loops. On the pancreatic head there was a mass, 2 cm in diameter, expanding and infiltrating through the duodenal wall. We carried out the classical cholecystectomy and adhesiolysis. While preparing the pancreas and the duodenum for resection, we identified the celiac trunk, as well as the common bile duct and the portal vein. We successfully performed pancreaticoduodenectomy and transected an afferent jejunal loop. The efferent loop of gastrojejunal anastomosis created during the B II resection was also transected. We used a distal limb from the transected efferent loop to create the choledochojejunal and the pancreaticojejunal anastomoses (Figure 1). A proximal limb, transected about 60 cm away from gastrojejunal anastomosis was used to form jejunojejunal end-to-side reconstruction. The jejunojejunal anastomosis was addressed manually, in one layer (Figure 2).

On the first postoperative day the patient had undergone one more laparotomy due to intra-abdominal bleeding. Laboratory tests revealed low red blood cells number 2.06x10¹²/L ( normal 4.34–5.72 x 10¹²/L), low blood hemoglobin 60 g/L ( normal 138–175 g/L ), and low hematocrit 0.172 L/L (normal 0.415–0.530 L/L). During the exploration of abdominal cavity we revealed the source of bleeding on the small bowel mesentery which was addressed with hemostatic stitches.

The early postoperative course went without complications such as bile leakage, pancreatic leakage, and digestive tract obstruction. The patient had undergone regular check-ups including EGD and tumor marker levels, without any signs of recurrence of the tumor.

Both B II and Roux-en-Y are acceptable techniques for reconstruction after subtotal gastrectomy. It has been described that patients with Roux-en-Y reconstruction had fewer problems related to the bile reflux; however, higher incidence of stasis in the Roux limb tends to result in longer hospital stay. Roux-en-Y reconstruction is also connected with a triad of postoperative symptoms including abdominal pain, vomiting and nausea called Roux-en-Y loop syndrome. On the other hand, B II reconstruction is a simpler operation with only one anastomosis, but has increased reflux associated problems such as esophagitis and gastritis, risk of afferent loop and dumping syndrome [5].

In Figure 3 and Figure 4, black arrows showing the jujunal loop is transected choledochojejunal, pancreaticojejunal and jejunojejunal anastomosis, respectively.

In a study, about single versus double Roux-en-Y reconstruction, where 319 patients were included, it was concluded that the double Roux-en-Y reconstruction of the alimentary tract is not beneficial in terms of surgical outcome, and postoperative morbidity and mortality [6]. Also the report about double Roux-en-Y reconstruction performed after gastrectomy due to gastric and hilar bile duct carcinoma, showed an uneventful postoperative course and longer hospitalization [7].

In this case, we performed a double Roux-en-Y reconstruction after pancreaticoduodenectomy. By performing the reconstruction using this technique we managed to successfully address pancreaticojejunal, choledochojejunal and jejunojejunal anastomosis on a patient who had undergone gastrojejunostomy after B II resection.

Double Roux-en-Y reconstruction is not often performed due to complications such as Roux-en-Y loop syndrome. We showed that double Roux-en-Y reconstructions after pancreaticoduodenectomy can be successful way for reconstruction in case that gastric resection was performed prior.

1. Abdel-Misih RZ, Larson JD, Abdel-Misih SR. The Management of Benign Gastric Ulcer. In: Cameron JL, Cameron AM eds. Current Surgical Therapy. Philadelphia: Elsevier-Saunders; 2014. p. 74–5.    
2. Strasberg SM, Linehan DC. Tumors of the pancreas, biliary tract and liver. In: Ashley SW ed. ACS Surgery: Principles and practice. 6ed. Philadelphia: BC Decker Inc; 2009. p. 1–21.    
3. Zollinger RM, Ellison EC. Pancreaticoduodenectomy, Whipple procedure. In: Zollinger`s Atlas of Surgical Operations. 9ed. New York: McGraw-Hill Inc; 2011. p. 276–93.    
4. Jia CK, Lu XF, Yang QZ, Weng J, Chen YK, Fu Y. Pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction for benign pancreatic diseases. World J Gastroenterol 2014 Sep 28;20(36):13200–4.   [CrossRef]   [Pubmed]    
5. Woodward A, Sillin LF, Wojtowycz AR, Bortoff A. Gastric stasis of solids after Roux gastrectomy: is the jejunal transection important? J Surg Res 1993 Sep;55(3):317–22.   [CrossRef]   [Pubmed]    
6. Uzunoglu FG, Reeh M, Wollstein R, et al. Single versus double Roux-en-Y reconstruction techniques in pancreaticoduodenectomy: a comparative single-center study. World J Surg 2014 Dec;38(12):3228–34.   [CrossRef]   [Pubmed]    
7. Hasegawa K, Kubota K, Midorikawa Y, et al. Extended right hepatectomy and total gastrectomy with double Roux-en-Y reconstruction for hilar bile duct and gastric carcinomas. Hepatogastroenterology 2003 Mar-Apr;50(50):374–6.   [Pubmed]