Fluorescence-Guided Remnant-Sparing Laparoscopic Distal Pancreatectomy for Metachronous Pancreatic Cancer Following Whipple Procedure.

BACKGROUND

Completion total pancreatectomy is the traditional approach for metachronous pancreatic cancer developing after pancreaticoduodenectomy (PD). However, this method causes significant morbidity and leads to pancreatogenic diabetes. While preserving the pancreatic remnant can maintain its function, it is technically demanding due to postoperative adhesions and altered anatomy. This video demonstrates a standardized laparoscopic approach for remnant-sparing distal pancreatectomy utilizing fluorescence guidance to ensure remnant perfusion.

METHODS

A 69-year-old female, 2.5 years post-laparoscopic PD for ampullary cancer, presented with rising CA 19-9 levels and a new well-differentiated adenocarcinoma in the pancreatic tail confirmed by EUS-FNA. We planned a laparoscopic distal pancreatectomy with splenectomy, preserving the prior pancreaticojejunostomy. The 5-port procedure employed a medial-to-lateral approach, dissecting along embryologic fascial planes (Toldt's fascia) to maintain oncologic principles.1 Crucially, Indocyanine green fluorescence imaging was used intraoperatively to confirm adequate perfusion of the preserved pancreatic remnant.2 Standard en bloc lymphadenectomy was performed.

RESULTS

The procedure lasted 123 min, with estimated blood loss of 20 mL. Postoperative recovery was uneventful; drain fluid amylase was normal (23 U/L) on postoperative Day 5, allowing for discharge. Final pathology confirmed a 3.7 cm pT2N0M0 (Stage IB) ductal adenocarcinoma with negative margins. At 6-month follow-up, the patient showed no recurrence and maintained stable endocrine and exocrine function.

CONCLUSIONS

Laparoscopic remnant-sparing distal pancreatectomy is a feasible and safe oncologic approach for selected patients with metachronous cancer following PD. The combination of embryologic plane dissection and fluorescence imaging facilitates this complex reoperation, allowing for preservation of essential endocrine function without compromising oncologic principles.