Background : Pancreatoduodenectomy cephalic in the presence of portal annular pancreas is challenging and the preoperative identification is helpful to deal with it technically intraoperatively. Here, we report a technique to protect the gastroduodenal artery stump and to close the posterior pancreatic stump

Methods : A 56 years old woman was diagnosed with localized ampullary adenocarcinoma. A portal annular pancreas was identified in the preoperative CT scan with no accessory pancreatic canal. Two pancreatic anastomosis were planned. Intraoperatively, it was impossible to identify any pancreatic canal in the posterior part of the pancreas so we decided to take a free falciform patch to cover the posterior pancreatic stump using continuous suture of 4-0 non-absorbable polypropylene. The suture goes through the whole thickness of the pancreas. We cover as well the gastroduodenal stump with a free parietal peritoneal sheath harvested from the upper right lateral abdominal wall. The sheath measures around 5*3 cm and it is used to wrap the gastroduodenal stump with 1.5 cm extension proximally and distally. The omentoplasty was made as well to make a barrier between the pancreatic anastomosis and the surrounding major blood vessels

Results : The operation time was 540 minutes and the blood loss was estimated as 500 ml. Postoperatively, the patient developed grade B postoperative pancreatic leak and the patient required no further intervention. The drain was kept in place for 2.5 months and subsequently progressively removed

Conclusions : A closure of posterior pancreatic stump with gastroduodenal artery stump protection in case of portal annular pancreas is a technique which should be further evaluated to avoid grade C postoperative pancreatic leak