Abstract
Background
Portal Annular Pancreas (PAP) is a relatively uncommon entity with 4% reported incidence. Pancreaticoduodenectomy is challenging in cases with PAP and is associated with higher postoperative pancreatic fistula rate and overall morbidity. PAP is classified according to the pattern and location of fusion around the portal vein as—supra-splenic, infra-splenic & mixed fusion type. Also, the ductal anatomy can vary as pancreatic duct present only in the ante-portal portion or only in the retro-portal portion or ducts in both ante and retro-portal portion. At present, ideal surgical strategy is not defined as per the PAP types.
Methods
The case demonstrated in the video presented with a localized, large duodenal mass with type IIA PAP (supra-splenic fusion with both ante and retro-portal ducts) detected on the preoperative triphasic CT scan. To achieve a single pancreatic cut surface with a single pancreatic duct for anastomosis, an extended pancreatic resection was performed using meso-pancreas triangle approach.
Results
Patient had a smooth intraoperative course & the postoperative recovery was also uneventful. Pathology reported pT3 duodenal cancer with negative margins and uninvolved lymph nodes.
Conclusion
A preoperative knowledge of PAP and its various types is extremely important in order to tailor intraoperative management, specially of the retro-portal portion. In patients with retro-portal duct or both ante and retro-portal ducts (as the case presented in the video), an extended resection is recommended to mitigate postoperative pancreatic fistula.
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The Problem
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1.
Preoperative recognition of portal annular pancreas and the corresponding modulation of pancreatic resection are essential to mitigate the risks associated with improperly managed retro-portal pancreas.
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2.
The incidence of clinically relevant fistula is 71 % when the standard line of transection is used after pancreaticoduodenectomy. However, this incidence decreases to 16 % when an extended resection is performed to obtain a single pancreatic stump.
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3.
This report describes a mesopancreas-triangle approach for a patient with a main duct intrapapillary mucinous neoplasm of the pancreatic head and type 2A portal annular pancreas.
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4.
The pancreatic transection and division of the annular part should be the final steps of the surgery to decrease blood loss during the procedure, optimize lymphadenectomy, and achieve an appropriate transection line.
Introduction
Preoperative recognition of the portal annular pancreas and modulation of the pancreatic resection is essential to mitigate risk associated with improperly managed a retro-portal pancreas. The incidence of clinically relevant fistula after pancreaticoduodenectomy decreased to 16 % from 71 % when extended resection was used to obtain a single pancreatic stump.1,2,3,4,5 Although the risk is real and the extended resection may have a significant impact on the final operative outcome, the appropriate surgical strategy in this scenario is yet to be described.
Case Details
This report describes the mesopancreas-triangle approach for a patient with main duct intrapapillary mucinous neoplasm of the pancreatic head and type 2A portal annular pancreas (Fig. 1, Video 1).
Intrapapillary mucinous neoplasm (IPMN) of the pancreatic head with a type 2A portal annular pancreas
Surgical Technique
After extended kocherization, periportal lymphadenectomy is performed along the common hepatic artery, continuing toward the celiac trunk, and the peripancreatic head plexus is disconnected. Subsequently, the infra-pancreatic superior mesenteric vein (SMV) is identified, followed by identification of the superior mesenteric artery (SMA) at the level of the proximal dorsal jejunal vein. Dissection along the SMA is then completed using an uncinate first approach until its origin from the aorta. This specific approach ensures disconnection of the pancreatic head from the mesopancreas-triangle area before the annular region is addressed (Video 1).
The pancreatic transection is directed toward the left, targeting the splenic vein. Finally, the specimen containing the supra-splenic annular pancreas is suspended on the portal vein, which is dissected meticulously as the final step of the operation (Video 2).
Conclusion
This stepwise approach allows enhanced control during dissection, reduced complications, and optimized lymphadenectomy.
References
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John R, Simon B, Eapen A, et al. Portal Annular pancreas: an underrecognized variant, prevalence, and clinical relevance. Trop Gastroenterol. 2020;40:132–6.
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Pandrowala S, Parray A, Chaudhari V, et al. Portal annular pancreas (PAP): an underestimated devil in pancreatic surgery: systematic review of literature and case report. J Gastrointest Surg. 2021;25:1332–9.
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Parray, A.M., Nadkarni, S., Chaudhari, V. et al. Pancreaticoduodenectomy in the Portal Annular Pancreas–Mesopancreas Triangle Approach (with Video). Ann Surg Oncol 30, 5758–5760 (2023). https://doi.org/10.1245/s10434-023-13782-z
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DOI: https://doi.org/10.1245/s10434-023-13782-z