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Vol. 87. Issue 1.
Pages 116-118 (January - March 2022)
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4064
Vol. 87. Issue 1.
Pages 116-118 (January - March 2022)
Scientific letter
Open Access
Ampullary adenocarcinoma in a patient with portal annular pancreas: Relevance of the surgical approach in the Whipple procedure
Adenocarcinoma ampular en un paciente con páncreas anular portal: relevancia del abordaje quirúrgico en el procedimiento de Whipple
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E. Castroa, G.E. Sánchez-Moralesa, J.D. Hernández-Acevedoa, E. Sánchez García-Ramosa, C. Chanb,
Corresponding author
chancarlos@me.com

Corresponding author at: Departamento de Cirugía General, Servicio de Cirugía Hepatopancreatobiliar, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga, 15 col. sección XVI. Del. C.P. 14080, Mexico City, Mexico. Tel.: 01 (52) 54 87 09 00 ext. 2133.
a Departamento de Cirugía General, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
b Departamento de Cirugía Hepatopancreatobiliar, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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A 41-year-old woman with an unremarkable medical history presented with abdominal pain, associated with jaundice and weight loss of 10 kg in one month, as well as elevated transaminase levels.

In the initial approach, endoscopic retrograde cholangiopancreatography was performed, with transpapillary biliary drainage via a stent. An ampullary lesion was identified and the histopathologic report stated moderately differentiated adenocarcinoma. The patient was referred to our hospital. A computed tomography scan revealed a dilated common bile duct secondary to an ampullary lesion. The main pancreatic duct (MPD) was situated in a retroportal position and pancreatic tissue encircled the portal vein and the splenoportal confluence (Fig. 1).

Figure 1.

Abdominal computed tomography scan showing: A) a hypodense lesion on the head of the pancreas (arrowhead) and B-F) pancreas divisum with a retroportal main pancreatic duct (black arrow) and an anteportal accessory pancreatic duct (white arrow). Portal vein (*).

(0.22MB).

The patient underwent a pylorus-preserving Whipple procedure (pancreaticoduodenectomy), with a 2-step resection of the pancreas. First, the anteportal portion was divided, revealing an accessory pancreatic duct, with a 5 mm diameter. The retroportal portion was then divided, revealing the MPD, with a 1.5 mm diameter. Gross pathologic examination identified a tumor measuring 1.6 × 1.6 cm, located on the ampulla of Vater, 1/10 positive lymph nodes (peripancreatic), and tumor-free surgical margins. Microscopic examination showed a moderately differentiated intestinal-type adenocarcinoma. The patient’s postoperative course was uneventful, and she received 8 cycles of capecitabine/gemcitabine adjuvant chemotherapy. The patient is currently in active follow-up with the oncology service and the latest control imaging study revealed local recurrence of the disease, 27 months from the initial diagnosis.

Annular pancreas is a rare condition characterized by circumferential involvement of another anatomical structure. Portal annular pancreas (PAP) is the rarest congenital anomaly of the pancreas, with an incidence around 1.14%.1,2 This anatomic variant is the result of an aberrant fusion of the uncinate process of the pancreas, with complete portal encasement and/or splenoportal confluence.3,4 PAP is classified depending on the running patterns of the MPD: type 1 (retroportal MPD), type 2 (type 1 associated with pancreas divisum), and type 3 (anteportal MPD); or in accordance with its relation to the portal confluence: suprasplenic, infrasplenic, and mixed types, respectively.1–5

In Mexico, there are no publications related to PAP. Ours is the first report in Latin America on pancreaticoduodenectomy in a patient with the anomaly. PAP is usually asymptomatic and tends to be an incidental finding. However, its preoperative diagnosis is crucial for identifying the precise topography of the MPD and planning the surgical strategy well, thus reducing the risk of the main complication: postoperative pancreatic fistula.

Care must be taken in the parenchymal resection, so that there is a lower risk of postoperative pancreatic fistula, as well as better short-term and long-term results.6 In cases of PAP, preoperative and intraoperative confirmation of pancreatic ductal system integrity is of the utmost importance, to avoid technical problems at the time of pancreatoduodenectomy.

Ethical considerations

Informed consent for receiving treatment was requested from the patient. The authors obtained informed consent from the patient for the publication of data/images and the present scientific letter was approved by the institutional ethics committee.

Financial disclosure

No financial support was received in relation to this article.

Conflict of interest

The authors declare that there is no conflict of interest.

References
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Portal annular pancreas, a notable pancreatic malformation: frequency, morphology, and implications for pancreatic surgery.
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[2]
I. Matsumoto, M. Shinzeki, T. Fukumoto, et al.
An extremely rare portal annular pancreas for pancreaticoduodenectomy with a special note on the pancreatic duct management in the dorsal pancreas.
Surgery, 153 (2013), pp. 434-436
[3]
G. Marjanovic, R. Obermaier, S. Benz, et al.
Complete pancreatic encasement of the portal vein—surgical implications of an extremely rare anomaly.
Langenbecks Arch Surg, 392 (2007), pp. 489-491
[4]
F.J. Foo, U. Gill, J.A. Guthrie, et al.
Ampullary carcinoma associated with an annular pancreas.
JOP, 8 (2007), pp. 50-54
[5]
P. Joseph, R.S. Raju, F.L. Vyas, et al.
Portal annular pancreas. A rare variant and a new classification.
JOP, 11 (2010), pp. 453-455
[6]
H. Yamaguchi, Y. Kimura, M. Nagayama, et al.
Central pancreatectomy in portal annular pancreas for metastatic renal cell carcinoma: a case report.
World J Surg Oncol, 30 (2019), pp. 76

Please cite this article as: Castro E, Sánchez-Morales GE, Hernández-Acevedo JD, Sánchez García-Ramos E, Chan C. Adenocarcinoma ampular en un paciente con páncreas anular portal: relevancia del abordaje quirúrgico en el procedimiento de Whipple. Revista de Gastroenterología de México. 2022;87:116–118.

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