Successful pancreatoduodenectomy for carcinoma of the ampulla of vater after esophagectomy with remnant gastrectomy.

A 59-year-old man was admitted to our hospital because his serum hepatobiliary enzymes were elevated on the medical check-up in September 2003. In his past history, he had undergone distal gastrectomy for a gastric adenoma 17 years before. Furthermore, he had undergone subtotal esophagectomy with remnant gastrectomy, the right colon and ileum were used for the reconstruction, and a cervical esophago-ileostomy and an abdominal colo-duodenostomy were made in the fashion of an interposition. Duodenoscopy was performed and showed the protruded lesion of the ampulla of Vater, biopsied specimens from this tumor revealed adenocarcinomas. Accordingly, we performed pancreaticoduodenectomy with regional lymph nodes dissection. The problem in this case was that the rt middle colic artery (MCA), and the middle colic vein (MCV) tend to be injured because these vessels are situated near the caudal region of the pancreas. We were able to identify the superior mesenteric vein (SMV) safely due to approaching this vein from the flank and mobilizing the duodenum, dissecting behind the mesenteric trunk from right to left. Double cancer of the ampulla of Vater and the esophagus are extremely rare, with only 4 cases reported. And we recommended the use of the dorsal approach to the SMV to avoid injuring the MCV such as in this case.