# Pancreatoduodenectomy for Pancreatic Cancer after Prior Modified Puestow Procedure: A Case Report

## TL;DR

A patient with a history of chronic pancreatitis and prior surgery successfully underwent cancer treatment with careful planning.

## Contribution

This case demonstrates the safe execution of pancreatoduodenectomy after a modified Puestow procedure.

## Key findings

- The patient had no recurrence of cancer 36 months post-surgery.
- Utilizing existing surgical anatomy minimized additional bowel resection during the procedure.
- Neoadjuvant chemotherapy and pseudocyst management were effective preoperative strategies.

## Abstract

Chronic pancreatitis is a known risk factor for pancreatic cancer and may develop over the course of long-term disease management. When a pancreatectomy is required following pancreatic duct decompression surgery, careful consideration of the surgical approach is necessary due to altered anatomy. This study reports a case of pancreatoduodenectomy for intraductal papillary mucinous carcinoma after the modified Puestow procedure.

A 52-year-old man with chronic alcoholic pancreatitis underwent the modified Puestow procedure for pancreatic duct decompression following an unsuccessful endoscopic stone removal. Ten years later, the patient presented with obstructive jaundice. Imaging revealed a pancreatic head tumor with biliary dilatation and an adjacent pancreatic pseudocyst, confirming the diagnosis of pancreatic cancer. After neoadjuvant chemotherapy with gemcitabine plus S-1 and endoscopic management of the infected pseudocyst, pancreatoduodenectomy was performed. A pancreaticojejunostomy was performed utilizing the jejunal limb fashioned during the modified Puestow procedure thereby minimizing the need for additional bowel resection. Pathological examination revealed invasive intraductal papillary mucinous carcinoma. The postoperative course was uneventful, and no recurrence was observed at 36 months.

Pancreatoduodenectomy for intraductal papillary mucinous carcinoma after the modified Puestow procedure can be safely performed with meticulous preoperative planning.