Management of portal annular pancreas during laparoscopic pancreaticoduodenectomy

Abstract

Portal annular pancreas (PAP) is a pancreatic congenital anomaly consisting of pancreatic parenchyma encircling the portal vein and/or the superior mesenteric vein. It has been reported that the risk of developing a post-operative pancreatic fistula is higher following pancreaticoduodenectomy in patients with PAP, probably because of the possibility of leaving undrained a portion of pancreatic parenchyma during the reconstructive phase. Few manuscripts have reported a surgical technique of pancreaticoduodenectomy in case of PAP, herein we report the first case of a patient with PAP undergoing laparoscopic pancreaticoduodenectomy.

Keywords: Circumportal pancreas; laparoscopic pancreaticoduodenectomy; pancreas anomaly; portal annular pancreas.

Figure 1

(a) Pre-operative computed tomography-scan axial image showing portal annular pancreas, with pancreatic tissue anterior (asterisk) and posterior (star) to the portal vein. (b) Laparoscopic view of the main pancreatic stump (asterisk) and pancreatic parenchyma (star) posterior to the portal vein, before (b) and after (c) the beginning of transection

Figure 2

Schematic representation of parenchymal and pancreatic duct distribution with respect to the portal vein and superior mesenteric artery (a); two pancreatic stumps can be identified after transection of pancreatic parenchyma, anterior, and posterior to the portal vein (b); following pancreatic mobilisation at the left of portal vein and superior mesenteric artery, additional 2 cm of pancreatic parenchyma are resected to obtain a single pancreatic stump (c), which is further mobilized (for about 4 cm) for the pancreatogastrostomy (d)