Challenges and outcomes of pancreato-duodenectomy in portal annular pancreas: A single center experience with a systematic review of the literature

Backgrounds/Aims: Portal annular pancreas (PAP) is an anomaly where pancreatic tissue surrounds the portal vein (PV). We present a case series from our institution and a systematic review of PAP patients who underwent pancreatoduodenectomy (PD). Methods: We conducted a retrospective review of patient records from a tertiary referral center, from January 2014 to June 2024, who underwent PD to identify those with PAP. Additionally, a literature search was performed and articles discussing PAP patients who underwent PD were included. Results: The incidence of PAP was 0.4% (7 out of 1,750 PD cases). Of these, three (42.85%) patients developed clinically relevant post operative pancreatic fistula (CR-POPF). Following the literature review, 34 articles with 57 patients (including our study) were consid ered. Reconstruction of the dominant stump, which included the main pancreatic duct, was performed using pancreatojejunostomy in 88.88% of cases and pancreatogastrostomy in 11.11% of cases. The non-dominant stump was managed with en-bloc extended resection (ER) of PAP, leftward of the PV, offering a single-cut surface for pancreatojejunostomy (41.51%), by stapling (26.41%) or suturing the stump (16.98%), stump-pancreatogastrostomy (5.66%), and electrocautery (5.66%). CR-POPFrates for ER, suturing and stapling were 22.72%, 37.5%, and 53.85%, respectively (p = 0.12). Conclusions: Preoperative recognition of PAP is crucial to customize surgical procedures to effectively manage the non-dominant stump.