Gastric cancer is the second most common tumor in China and ranks first in the mortality rate of all kinds of malignant tumors. Gastric cancer is easily metastasized through lymph nodes and bloodstream, and stage III/IV gastric cancer accounts for more than 60% of the total gastric cancer patients in China, so recurrence after surgery is more common, especially for some more advanced gastric cancers with higher malignancy. The surgical difficulty, surgical risk and surgical complications are far more than the first surgery, so the surgical approach, surgical strategy and surgical skills are very important. Here I will share a case of a highly malignant low age gastric cancer patient with recurrence of tumor who underwent secondary surgery for radical treatment. Patient Tong XX, female, 23 years old, was diagnosed as “gastric cancer” in February 2011 when she went to a local hospital for examination in mid-2010 after she felt persistent vague pain in the upper abdomen without any obvious cause, which was aggravated by satiety and was not accompanied by malignant vomiting and vomiting of blood and black stool. “On February 10, 2011, the patient underwent laparoscopic assisted radical distal gastrectomy (Bi-I type gastrointestinal anastomosis) at a local hospital, and the postoperative pathological diagnosis was: ulcerated infiltrative hypofractionated adenocarcinoma on the side of the gastric sinus. Since the patient not only belonged to the hypofractionated adenocarcinoma with very high malignancy, but also was in the low age group with high metabolism, she was very prone to tumor recurrence after surgery. Therefore, the patient received FOLFOX chemotherapy after surgery, however, during the follow-up in October 2014, tumor markers such as CEA and CA125 were found to have increased to different degrees. A CT examination was performed immediately, suggesting “postoperative changes of gastric cancer, a mass at the edge of the remnant stomach with indistinct boundaries with the surface of the pancreas, splenomegaly; several small lymph nodes in the abdominal cavity and retroperitoneum; a small amount of pelvic fluid”, highly suspecting recurrence of gastric cancer. Further gastroscopy suggested: “Bi-I style postoperative stomach; chronic atrophic gastritis with H. pylori infection; nature of residual gastric augmentation to be investigated” and biopsy pathology: “anastomotic hypofractionated adenocarcinoma”. These tests confirmed the recurrence of a highly malignant “hypofractionated adenocarcinoma”. There were many anatomical difficulties in the second surgery of recurrent gastric cancer: first, the patient was very young, only 23 years old, and the younger the patient, the more malignant the tumor is. Since the first radical surgery had cleared a wide range of lymph nodes, resulting in extensive adhesions to the large abdominal vessels and related areas such as the biliary tract, a second surgery that cleared the lymph nodes again would require careful debridement to reveal and thoroughly clear the hepatic artery, portal vein, abdominal trunk, left gastric artery and related lymph nodes around the biliary system. It is even necessary to expose and clear the lymph nodes around the abdominal trunk and splenic artery, which puts high demands on the surgical operation and may even lead to bleeding and serious damage to important organs. Secondly, the patient underwent a BiI-type anastomosis of the remnant stomach and duodenum in the first surgery, so total gastrectomy must be performed in the second surgery for the purpose of radical treatment, however, the duodenal stump after resection and reanastomosis is extremely difficult to dissect and difficult to separate, and if the duodenal stump is short from the duodenal papilla where the bile and pancreatic ducts open, or if the duodenal stump is short from the head of the pancreas, based on anatomical Again, preoperative CT indicates that the recurrent tumor is poorly demarcated from the head of the pancreas and may have invaded the pancreas or the duodenal bulb. If the tumor also encircles the common bile duct and hepatoduodenal ligament and compresses the gallbladder, it may have serious related effects on the biliary system and the patient’s general condition, so total gastrectomy + pancreaticoduodenectomy is still necessary for the purpose of radical treatment. Pancreaticoduodenectomy is the most complex surgery in general surgery except liver transplantation, and superimposed on the necessary total gastrectomy, the surgery is more traumatic and has more postoperative complications, but based on anatomical and radical purposes, for this patient, it may be necessary to be forced to perform this high-risk, difficult and complex surgery. After careful and repeated discussion of the surgical plan by team members and repeated communication with the family to inform them of the associated risks, the family understood and agreed. On November 21, 2014, the surgical exploration was performed by the hospital’s General Hospital. During the operation, after careful exploration, the abdominal cavity was severely adherent, and if the original frontal approach was continued, it was bound to cause serious bleeding and side injuries. Therefore, Dr. Qiu chose the lateral approach, which requires more surgical skills: the second segment of the duodenum was opened with a Kocher incision in the lateral wall, and the electric knife gradually released the duodenum and lifted it up and pushed it to the upper left, thus gradually and completely exposing the pancreas. At this time, the exploration revealed that the tumor had already encircled the hepatoduodenal ligament and common bile duct, and the tissue in the hepatic portal had to be forcibly and rigidly dissected and separated. Under the concept of precision surgery, the hepatic artery, portal vein, intrinsic hepatic artery, up to the splenic artery vasculature were carefully separated with a fine vascular sheath dissection technique, and the associated paravalvular lymph nodes were completely and thoroughly cleared. At the same time, due to the unclear demarcation between the tumor and the head of the pancreas, there were dense adhesions. The pancreatic gland has special anatomical location and physiological functions, and once it is damaged, it will cause serious consequences and difficult to repair, then it is necessary to perform a mega surgery like pancreaticoduodenectomy, which will cause serious blow to the patient’s general condition. In order to avoid removing the pancreas as much as possible and at the same time to get the purpose of radical cure, the surgeon, with a very delicate operation, stripped the tumor from the pancreas completely and kept the pancreatic peritoneum intact. The operation took only 3 hours and the bleeding was less than 100ml. After the operation, considering that it was the second time for the patient to undergo a major gastrointestinal surgery, the surgeon was able to perform a complete resection of the recurrent stomach and the recurrent tumor and reconstruct the digestive tract. After the operation, considering that the patient had undergone the second major gastrointestinal surgery and was in poor general condition before the operation, we formulated an individualized nutrition recovery plan for the patient together with the nutrition department and other related departments under the concept of rapid recovery surgery. The postoperative paraffin pathology showed “residual gastrectomy specimen”: hypofractionated adenocarcinoma with partial indolent cell carcinoma (2 places, augmented type), infiltration to extra-plasma fibrofatty tissue, invasion of nerves, local adhesion of small amount of liver tissue on the plasma surface of the tumor; no cancer involvement at the upper and lower cut ends; 12 perigastric lymph nodes with no cancer metastasis. Chronic inflammation of the mucosa of “part of the small intestine”. Secondary surgery is a difficult task in surgical practice, and it is even more difficult to perform secondary surgery due to recurrence of malignant tumor. In this case, due to the high malignancy of the tumor and the invasion of several important abdominal organs and vessels, the patient was in poor general condition before surgery. With accurate preoperative evaluation, precise surgical planning, and delicate intraoperative surgical operations such as sphincter dissection of large vessels, solid skills in the use of electric knife and fine dissection of complex adhesions, and excellent postoperative care, we were able to achieve a satisfactory outcome for this young patient.