Laparoscopic Intraoperative Bariatric Surgery Finding of Heterotopic Pancreatic Tissue

Abstract

Heterotopic pancreas is defined as pancreatic tissue found outside the usual anatomic or vascular continuity of the pancreas. Mostly discovered incidentally during autopsies in up to 14% of patients and only 0.2% of upper abdominal laparotomies, it remains a diagnostic challenge when discovered during bariatric surgery. Although, heterotopic pancreatic tissue is usually asymptomatic and benign, it behaves as normal pancreatic tissue and therefore pancreatitis, cysts, pseudocysts, and malignant transformation may be seen which can complicate the post-surgical period. In addition, complications of mass effect including gastric-outlet, bile-duct obstruction, bleeding from ulcerated mass, and intussusception have also been reported. We report two cases of incidental lesions found during laparoscopic bariatric surgery in the proximal jejunum that were removed intraoperatively and pathologic analysis revealed benign heterotopic pancreatic tissue. The first case was a 39-year-old female who presented for elective Roux-en-Y gastric bypass. During the laparoscopic intra-abdominal small bowel inspection, the surgeon noticed an approximately 12cm polypoid tumor located distal to the ligament of Treitz. An intraoperative endoscopy did not reveal any mucosal abnormalities up until the ligament of Treitz. Resection of the tumor was done and sent to Pathology for frozen section. The pathologist confirmed pancreatic cells with some ectopic glands, however malignancy was not ruled out. The gastric bypass procedure was aborted and resection of the small bowel lesion was done. Final pathologic diagnosis was consistent with benign heterotopic pancreas. The second case was a 47-year-old female who presented for elective Roux-en-Y gastric bypass. During the laparoscopic intra-abdominal small bowel inspection, the surgeon noticed a small bowel tumor approximately 35cm distal to the ligament of Treitz. The tumor was firm on laparoscopic instrument manipulation with a small fungating appearing lesion anteriorly, which was resected. Final pathologic diagnosis was consistent with submucosal heterotopic pancreas. Diagnosis of heterotopic pancreas, benign or malignant, is difficult solely based on laproscopic appearance, however it is imperative to consider in the differential diagnosis. More importantly, in bariatric patients undergoing anatomy-altering surgery (i.e. Roux-en-Y gastric bypass), such lesions while still amenable should be resected to avoid potential complications.Figure 1Figure 2