Laparoscopic Total Pancreatectomy After Laparoscopic Whipple

BackgroundThe incidence of a second de novo pancreatic ductal adenocarcinoma (PDAC) among patients with prior cancer has been reported to be 6%.1,2 however, as survival increases through improvements in systemic therapy, this incidence of a de novo PDAC after prior PDAC may become more prevalent.3-8 In this context, a structured and stepwise approach to a total pancreatectomy for a second de novo PDAC after a prior PDAC treated with a pancreaticoduodenectomy is detailed.PatientsWe present two similar cases. The first patient was a 71-year-old female with de novo body PDAC, and the second was a 50-year-old female with de novo tail PDAC. To rule out recurrence, immunohistochemical staining as well as the review of biopsies by two experienced pathologists were employed. Both patients had undergone a laparoscopic pancreatoduodenectomy for PDAC 4 and 3 years prior. Each patient received four cycles of neoadjuvant chemotherapy and underwent a safe laparoscopic total pancreatectomy.TechniquePrior to surgery, three-dimensional anatomic and port site modeling is performed to optimize the understanding of the spatial relationship between the tumor, blood vessels, and adjacent organs involved. The port site modeling (including pneumoperitoneum simulation) focuses on the optimal port set-up for dissecting the biliopancreatic limb off the portal vein. Following complete mobilization of the biliopancreatic limb, the biliopancreatic limb is staple-divided between the hepatico- and pancreaticojejunostomy. Great care must be taken to avoid accidental staple injury to the hepatic artery or celiac trunk. The remainder of the dissection is akin to a standard distal pancreaticosplenectomy.ConclusionVirtual pancreatectomy modeling facilitates an optimal set-up for the critical step of this case, i.e. dissection of the pancreaticojejunostomy off the portal vein. Early division of the biliopancreatic limb between hepatico- and pancreatojejunostomy is crucial to facilitating the remainder of the dissection. Laparoscopic total pancreatectomy for a de novo PDAC after laparoscopic pancreaticoduodenectomy may become more common as survival of patients with prior PDAC improves over time.