Laparoscopic Total Pancreatectomy After Laparoscopic Whipple

Area of Science:

• Surgical Oncology
• Gastroenterology
• Minimally Invasive Surgery

Background:

• The incidence of a second de novo pancreatic ductal adenocarcinoma (PDAC) after prior cancer is 6%.
• Improved systemic therapies are increasing patient survival, potentially leading to a higher prevalence of de novo PDAC following a previous PDAC diagnosis.
• This necessitates a structured approach for managing secondary PDAC after initial treatment.

Purpose of the Study:

• To detail a structured, stepwise approach for performing a total pancreatectomy in patients with a second de novo PDAC after a prior PDAC treated with pancreaticoduodenectomy.
• To present two cases illustrating the described surgical technique.

Main Methods:

• Two patients with de novo PDAC (body and tail) underwent laparoscopic total pancreatectomy after prior laparoscopic pancreaticoduodenectomy for PDAC.
• Pre-operative 3D virtual modeling was used to optimize surgical planning, focusing on spatial relationships and port site selection.
• Immunohistochemical staining and pathological review confirmed the absence of recurrence in both cases.

Main Results:

• Both patients received neoadjuvant chemotherapy and successfully underwent a safe laparoscopic total pancreatectomy.
• Virtual pancreatectomy modeling facilitated optimal surgical setup, particularly for dissecting the pancreaticojejunostomy off the portal vein.
• Early division of the biliopancreatic limb was crucial for simplifying the subsequent dissection.

Conclusions:

• Laparoscopic total pancreatectomy is a viable approach for de novo PDAC in patients with a history of PDAC.
• Virtual surgical modeling enhances planning and execution of complex minimally invasive pancreatic surgeries.
• As survival rates for PDAC patients improve, the incidence of secondary de novo PDAC is expected to rise, making this technique increasingly relevant.