Laparoscopic pancreaticoduodenectomy after endovascular repair for abdominal aortic aneurysm.

Introduction: Most gastroenterological surgeries, even pancreatic surgery, can now be performed laparoscopically. However, the management of concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy is controversial. The performance of endovascular repair (EVAR) for AAA has been increasing; however, there is no report of laparoscopic pancreaticoduodenectomy after EVAR.

Presentation Of Case: A pancreatic tumor was detected during follow-up after EVAR for AAA. The enlarging tumor was diagnosed as an intraductal papillary mucinous tumor with a nodule. Laparoscopic pancreaticoduodenectomy was safely performed. After laparoscopic dissection around the pancreas head, an additional incision was made in the upper abdomen, and pancreatic reconstruction was performed through the incision. In spite of grade B pancreatic fistulae, the patient recovered with medical therapy. The pathological diagnosis was intraductal papillary mucinous adenoma with small foci of carcinoma in situ. The patient has been well with neither recurrence of the tumor nor any cardiovascular events for 18 months.

Discussion: The management of concomitant malignancy and AAA is challenging, especially in patients with a pancreatic tumor. The reasons for the rarity of treatment include prognosis, anatomical vicinity, and postoperative complications. EVAR reduces retroperitoneal adhesions. A laparoscopic approach provides a small operative field and decreases mutual interference with AAA. Moreover, reconstruction is performed through an upper abdominal incision apart from the AAA. Hand-sewing provides more reliable stability of the anastomosis.

Conclusion: The increasing frequency of performance of EVAR for AAA and subsequent computed tomography may help to detect malignancy. Laparoscopic surgery appears to be a valid approach to malignancy after EVAR.