Portal Annular Pancreas Research Articles

Portal Annular Pancreas - A Rare Congenital Anomaly Not To Be Missed During Pancreatic Resections

Portal Annular Pancreas - A Rare Congenital Anomaly Not To Be Missed During Pancreatic Resections

ASO Author Reflections: The Role of Robotic Surgery in Patients with Portal Annular Pancreas.

ASO Author Reflections: The Role of Robotic Surgery in Patients with Portal Annular Pancreas.

Pancreaticoduodenectomy in the Portal Annular Pancreas-Mesopancreas Triangle Approach (with Video).

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. 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. Patient had a smooth intraoperative course & the postoperative recovery was also uneventful. Pathology reported pT3 duodenal cancer with negative margins and uninvolved lymph nodes. 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.

Serous cystic neoplasm with portal annular pancreas

門脈輪状膵（portal annular pancreas：PAP）は，膵鉤状突起が門脈あるいは上腸間膜静脈を全周性に取り囲んで膵体部の背側に癒合する膵の形態異常である．通常は無症状で臨床的意義に乏しいため見逃されることが多いが，膵切除の際には術後の膵液瘻のリスクとなるため注意が必要である．PAPを伴う膵SCNに対し腹腔鏡下膵体尾部切除術を施行した一例を経験したので報告する．

Can the transection plane be optimized inpancreatic resections?

According to current protocol, the separation of pancreatic head and body is performed at the level of superior mesenteric vein (SMV). Previous data indicate that the resection plane should be modified in portal annular pancreas. We presumed that the optimal line of pancreatic resections could also be different in other cases. Our aim is to simulate pancreatic resections in different planes and find the optimal resection line with the minimum number of cut vessels. 25 abdominal vascular corrosion casts were prepared, the aorta and the portal vein were cannulated. CT scans were taken on the casts, and specific planes were reconstructed simulating different resection lines. The total amount of cross sections of vessels were calculated in the different planes. In our series, the optimal plane is the SMV in 11/25, 2 cm left in 10/25, 1 cm left in 4/25, 1 cm right in 1/25 and 2 cm right in none of our cases. The group of left sided extension contain more than half of the cases. With left sided resections, the cut surface of the vessels may be lowered to even 29% compared to the SMV plane. Our study revealed that pancreatic resections should be extended to the left side of the SMV in more than half of our cases. Therefore, the resection plane should be determined by preoperative imaging methods. Using DICOM viewer with multiplanar reconstruction, the resection planes can be simulated in clinical practice, which would reduce the risk of postoperative bleeding.

Surgical management of portal annular pancreas

Background: Portal annular pancreas is a rare congenital abnormality in the fusion of the dorsal and ventral pancreatic buds during gestation. In these cases, the uncinate process lies posterior to the portal vein and fuses with the body of the pancreas. This creates a circumferential encasement of the portal vein and three variations of the pancreatic duct anatomy have been described to be associated with this anatomic variation. In this video, we discuss the surgical management a healthy female with no past medical, surgical, alcohol, or endoscopic history who presented with recurrent pancreatitis and a diagnosis of a high-risk IPMN.

CIRCUMPORTAL PANCREAS: CASE REPORT OF A RARE PANCREATIC ANAMOLY.

Circumportal pancreas/ Portal annular pancreas is a rare congenital pancreatic anomaly resulting from fusion of the pancreatic parenchyma around the conuence of portal and superior mesenteric veins. It is usually asymptomatic, but if undetected, it could have serious consequences during pancreatic surgery. We describe a variant of this anomaly encountered at our institute during routine examination of an abdominal contrast enhanced computed tomography and ultrasonography.

Portal annular pancreas - A rare congenital anomaly not to be missed during pancreatic resections

Portal annular pancreas - A rare congenital anomaly not to be missed during pancreatic resections

A patient with a neuroendocrine tumor of the pancreatic uncinate process with portal annular pancreas

A patient with a neuroendocrine tumor of the pancreatic uncinate process with portal annular pancreas

Portal annular pancreas: An unsual pancreatic pseudotumor with clinical significance

Portal annular pancreas (PAP) is a rare congenital anomaly due to abnormal fusion of ventral pancreatic bud left to the developing portal vein. Its incidence is 1.1%–3.4% in the literature. PAP is commonly involving the uncinate process; complete encircling is relatively rare. Proposed hypothesis for the congenital PAP is (1) hypertrophied ventral pancreatic bud fuses with the body of the pancreas left to the portal vein and (2) malformation of the portal vein. We found a bulky pancreas in a 51-year-old male during an autopsy. After careful dissection, we observed that the pancreas was completely encircling around the portal vein cranial to its formation. The encircled tissue was confirmed as normal pancreatic tissue by H and E and immunohistochemical staining. Pancreatic ductal pattern was observed anterior to the portal vein. This condition is usually asymptomatic; most of the time, the same was diagnosed incidentally during surgery. However, in cases of the malignant lesion in the head of the pancreas, the PAP is usually confused as the tumor's extension (pseudotumor). The management of posttransection pancreatic stump is challenging and usually results in complications such as pancreatic fistula. Knowledge about the PAP is necessary for the surgeon and radiologist for accurate diagnosis and prior planning to prevent the postoperative complications.

How to divide the pancreatic parenchyma in patients with a portal annular pancreas: laparoscopic spleen-preserving distal pancreatectomy for serous cystic neoplasms

BackgroundPortal annular pancreas (PAP) is a rare pancreatic anomaly in which the uncinate process wraps annularly around the portal vein and fuses to the body of the pancreas. PAP is highly relevant to the development of postoperative pancreatic fistula (POPF) in pancreatic surgery. Here, we describe our experience and surgical technique of laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure for patients with the PAP.Case presentationA 49-year-old woman with PAP was referred to our hospital for a suspicious mucinous cystic neoplasms 1.5 cm in diameter in the pancreatic tail. Laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure was performed. Mobilization of the pancreatic tail was first performed, and then, the splenic artery was cut. After dividing the pancreatic tail from the splenic hilum, the ventral pancreatic parenchyma was divided using a stapler. After cutting the splenic vein, complete mobilization of the pancreatic body and tail enabled easy division of the PAP. Finally, the PAP was also divided using the stapler. Although grade B POPF occurred, she was discharged on the 9th postoperative day.ConclusionsSurgeons should understand the anatomical characteristics of PAP and be aware of the possibility of POPF.

Portal Annular Pancreas with portal cavernoma formation wtih associated dorsal pancreatic agenesis-A rare case report

Portal annular pancreas is a uncommon congenital anomaly resulting from fusion of the pancreatic parenchyma around the portal vein. Its causing portal cavernoma formation and association with dorsal pancreatic agenesis is rare Case report We report a 51-year-old female who underwent contrast enhanced computed tomography for vague right hypochndrial pain.On CECT abdomen images there was presence of rind of pancreatic tissue around the portal vein causin its luminal narrowing with proximal dilation of portal vein tributaries with cavernoma formation.There was also presence of agenesis of dorsal pancreas in this patient.Conclusion This variant of portal annular pancreas with cavernoma formation associated with dorsal pancreatic agenesis has not yet been reported and we propose a new CT classification of the same.

Management of portal annular pancreas during laparoscopic pancreaticoduodenectomy

Background: Portal annular pancreas (PAP) is a rare congenital anomaly consequent of an aberrant fusion of the ventral and dorsal fetal pancreas. When surgery is planned, accurate identification of this anomaly could be crucial to avoid postoperative pancreatic fistula (POPF) related to the possibility of leaving undrained a portion of pancreatic parenchyma. Methods: The present is a case report describing the operative management of PAP during laparoscopic pancreaticoduodenectomy (LPD). Results: A 77 year-old male patient with a recent diagnosis of ampullary adenocarcinoma underwent LPD. Due to PAP presence, two pancreatic transections of the parenchyma respectively located anterior and posterior to portal vein (PV) and superior mesenteric vein (SMV), were required. We decided to perform a further parenchymal transection at the pancreatic body, removing about 2 cm of pancreatic parenchyma in order to obtain a single pancreatic stump. So pancreatic-intestinal continuity was restored performing a minilaparotomy assisted double purse-string pancreatico-gastrostomy at the end of the operation Conclusion: This report is the first case of LPD in a patient with PAP and the surgical technique we described herein proved to be feasible and safe.

Management of portal annular pancreas during laparoscopic pancreaticoduodenectomy

Background: Portal annular pancreas (PAP) is a rare congenital anomaly consequent of an aberrant fusion of the ventral and dorsal fetal pancreas. When surgery is planned, accurate identification of this anomaly could be crucial to avoid postoperative pancreatic fistula (POPF) related to the possibility of leaving undrained a portion of pancreatic parenchyma. Methods: The present is a case report describing the operative management of PAP during laparoscopic pancreaticoduodenectomy (LPD). Results: A 77 year-old male patient with a recent diagnosis of ampullary adenocarcinoma underwent LPD. Due to PAP presence, two pancreatic transections of the parenchyma respectively located anterior and posterior to portal vein (PV) and superior mesenteric vein (SMV), were required. We decided to perform a further parenchymal transection at the pancreatic body, removing about 2 cm of pancreatic parenchyma in order to obtain a single pancreatic stump. So pancreatic-intestinal continuity was restored performing a minilaparotomy assisted double purse-string pancreatico-gastrostomy at the end of the operation. Conclusion: This report is the first case of LPD in a patient with PAP and the surgical technique we described herein proved to be feasible and safe.

A Case of Distal Bile Duct Cancer with Portal Annular Pancreas

A Case of Distal Bile Duct Cancer with Portal Annular Pancreas

Circumportal pancreas: a diagnostic and therapeutic challenge

Background: Circumportal pancreas or portal annular pancreas, is a rare congenital fusion anomaly of the dorsal and ventral pancreas in which the pancreatic tissue encases the portal and/or superior mesenteric vein. The prevalence of this rare and overlooked anomaly is 1.4 to 2.5% on multidetector computed tomography series. Altough it is usually asymptomatic and incidentally detected, it can complicate cancer diagnosis and surgery of the periampullary region. On the diagnostic side it might look like tumor extension around major vessels imitating locally advanced cancer. On the surgical side, it necessitates complete resection of the posterior portion, complicating the surgery and likely increasing the fistula rate. Methods: Herein, we present a case of ampullary cancer accompanied by by circumportal pancreas, preoperatively diagnosed on radiological examination using ceCT and MRI and confirmed by intraoperative pancreaticography during surgical resection. A pylorus preserving Whipple operation was performed with resection of the aberrant portion of the pancreas. The merging of the anomalous duct was identified and sewn on the inferior portion of the pancreas. Results: Pathologic analysis of the specimen confirmed the diagnosis of circumportal pancreas and a pT2N1M0 ampullary tumor. Postoperative period was complicated with a Grade B/C pancreatic fistula that was managed by percutaneous drainage of the fluid collection. Conclusion: Circuportal pancreas is a rare anomaly complicating pancreatic surgery.

Portal Annular Pancreas with Portal Cavernoma Formation with Associated Dorsal Pancreatic Agenesis - A Rare Case Report

Portal Annular Pancreas with Portal Cavernoma Formation with Associated Dorsal Pancreatic Agenesis - A Rare Case Report

Radical antegrade modular pancreatosplenectomy for adenocarcinomaof the body of the pancreas in a patient with portal annular pancreas, aberrant hepatic artery, and absence of the celiac trunk: A case report.

Portal annular pancreas is a rare anatomic variation, where the uncinated process of the pancreas connects with the dorsal pancreas and the pancreas tissue encases the portal vein (PV), superior mesenteric vein (SMV) or splenic vein (SV). Malignancies are quite uncommon in the patients, who have an annular pancreas especially portal annular pancreas. Ectopic common hepatic artery and absence of the celiac trunk (CT) are the other infrequent abnormalities. A 74-year-old man suffered from upper abdominal and back pain. Contrast enhanced computed tomography indicated a low-density mass in the body of the pancreas. Pathological report showed adenocarcinoma of the body of pancreas after radical antegrade modular pancreatosplenectomy (RAMPS). In the operation, we found the superior vein and portal vein was surrounded by the pancreatic tissue. The left gastric artery and splenic artery originated respectively from abdominal aorta, and celiac trunk was not viewed. In addition, the common hepatic artery was a branch from the superior mesenteric artery. In general, this is a novel clinical case of pancreatic carcinoma happening in the portal annular pancreas which was accompanied with aberrant hepatic artery and absence of the celiac trunk at the same time. Confronted with the pancreatic neoplasms, the possibility of coexistent annular pancreas and arterial variations should be considered.

胆管癌に対する膵頭十二指腸切除時に指摘された門脈輪状膵の1例

症例は83歳，女性．腹痛と肝機能障害の精査目的に，当院に紹介された．精査にて胆管癌の診断となり，膵頭十二指腸切除術が施行された．門脈前面で膵を切離した後に膵頭部を門脈右側から剥離した．その際，膵鈎部が門脈の背側に延長していることが確認された．さらに剥離を左に進めると，膵鈎部は門脈左縁で膵体部に癒合することが確認された．術前CTを再検討すると指摘可能であり，門脈輪状膵と診断した．膵管は1本で門脈腹側を通過していた．膵頭部を門脈と脾静脈から剥離授動し，癒合部より左の膵体部で再切離した．これにより，通常通りの膵管空腸吻合と膵空腸密着縫合が可能になった．術後，膵瘻を合併したが保存治療で軽快し退院した．門脈輪状膵を有する患者に膵頭十二指腸切除術を施行する際は，膵の切離再建方法について検討を要する．しかし，同様の症例は非常に稀であり，標準的な手術方法は確立されていないため，文献的考察を加えて自験例を報告する．

Pancreaticogastrostomy Prevents Postoperative Pancreatic Fistula of Portal Annular Pancreas During Pancreaticoduodenectomy

Portal annular pancreas (PAP) is an asymptomatic congenital pancreatic anomaly in which the uncinate process of the pancreas extends and fuses to the dorsal surface of the body of the pancreas by surrounding the portal vein and or the superior mesenteric vein. During pancreaticoduonectomy (PD), the presence of PAP significantly increased risk for postoperative pancreatic fistula (POPF) because specific management of 2 pancreatic resection planes with 1 or 2 pancreatic ducts is required for pancreatico-intestinal reconstruction. To reduce the risk of POPF, a shift of the resection plain to the left for 1 anastomosis is recommended. We report a case of PAP that was successfully performed PD with pancreaticogastrostomy (PG). PG was conducted with invagination of the 2 resected pancreatic planes together into the stomach to minimize resected volume of the pancreas. A 78-year-old male patient with PAP underwent PD due to a duodenal adenocarcinoma. Intraoperatively, the uncinate process extended extensively behind the portal vein and fused with the dorsal surface of the pancreatic body above the splenic vein. For pancreatico-intestinal reconstruction, PG was performed with invagination of the 2 resected pancreatic planes together into the stomach. The postoperative course was uneventful, and he was discharged on postoperative day 12. Endocrine and exocrine function of the pancreas were maintained well at 10 months after surgery. PG is one of the useful choices for patients with PAP to prevent POPF while maintaining the pancreatic endocrine and exocrine function after PD.