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1
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Ke J, Liu F, Ke J, Cai H, Liu Y, Ji B. Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: A literature review. Heliyon 2024; 10:e27500. [PMID: 38533026 PMCID: PMC10963198 DOI: 10.1016/j.heliyon.2024.e27500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is a complicated surgical procedure that has recently been performed safely. A superior mesenteric artery (SMA)-first approach can allow complete mesopancreas resection, maximizing surgical margins and R0 resection rates. Therefore, the SMA-first approach is recommended. This review is a literature summary of recent updates of the SMA approaches for LPD and informs clinical practice of the advantages of its various approach. METHODS A systematic literature search was performed on the PubMed (MEDLINE) database using truncated word searches and medical subject headings to identify all pertinent published studies. RESULTS After searching PubMed, 303 studies were identified and reviewed, of which 25 described the SMA-first approach, including the anterior, posterior, right, and left approaches, fully described in 5, 6, 13, and 6 articles, respectively. CONCLUSIONS The SMA-first approach is the standard surgical technique for LPD. This review summarized each SMA-first approach's distinct advantages and indications.
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Affiliation(s)
- Jianji Ke
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Feiqi Liu
- Department of Critical Care Medicine, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Jianjia Ke
- School of Business and Management of Jilin University, 2699 Qianjin Street, Changchun 130021, China
| | - Hongqiao Cai
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Bai Ji
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
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2
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Mizumoto T, Takahara T, Nishimura A, Mii S, Uchida Y, Iwama H, Kojima M, Kato Y, Uyama I, Suda K. Challenge in optimizing robotic pancreaticoduodenectomy including nerve plexus hanging maneuver: a Japanese single center experience of 76 cases. Surg Endosc 2024; 38:1077-1087. [PMID: 38168732 DOI: 10.1007/s00464-023-10653-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is technically demanding, and 20-50 cases are required to surpass the learning curve. This study aimed to show our experience of 76 cases from the introduction of RPD and report the changes in surgical results owing to the accumulation of cases and optimization of surgical techniques. METHODS A total of 76 patients who underwent RPD between November 2009 and May 2023 at the Fujita Health University Hospital were divided into three groups: competency (n = 23, Nov 2009-Mar 2020), proficiency (n = 31, Apr 2020-Jun 2022), and mastery (n = 22, Jul 2022-May 2023) phases. In the mastery phase, for the education of new surgeons and maintenance of surgical quality, optimization of the procedure, including hanging maneuver with or without stapling transection of the retropancreatic tissue was implemented. The surgical outcomes were compared between the groups. RESULTS The mean operation time decreased over time despite of the participation of newly started operators in mastery phase [competency: 921.5 min (IQR 775-996 min) vs. proficiency: 802.8 min (IQR 715-887 min) vs. mastery: 609.2 min (IQR 514-699 min), p < 0.001]. Additionally, Clavien-Dindo ≥ grade IIIa complications decreased from 52.2% in competency phase to 35.5% and 9.1% in proficiency and mastery phases, respectively (p = 0.005). CONCLUSION Operation time and major complications decreased along the learning curve from the introduction of RPD. In addition, optimization of the procedure, including hanging maneuver of the retropancreatic tissue seemed to be effective in reducing operation time and educating new RPD surgeons.
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Affiliation(s)
- Takuya Mizumoto
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Takeshi Takahara
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan.
| | - Akihiro Nishimura
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Satoshi Mii
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Yuichiro Uchida
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Hideaki Iwama
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Masayuki Kojima
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Yutaro Kato
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Ichiro Uyama
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Koichi Suda
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
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Fossaert V, Mimmo A, Rhaiem R, Rached LJ, Brasseur M, Brugel M, Pegoraro F, Sanchez S, Bouché O, Kianmanesh R, Piardi T. Neoadjuvant chemotherapy for borderline resectable and upfront resectable pancreatic cancer increasing overall survival and disease-free survival? Front Oncol 2022; 12:980659. [PMID: 36387257 PMCID: PMC9640996 DOI: 10.3389/fonc.2022.980659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/06/2022] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic neoplasm. Surgery is the factual curative option, but most patients present with advanced disease. In order to increase resectability, results of neoadjuvant chemotherapy (NAC) on metastatic disease were extrapolated to the neoadjuvant setting by many centers. The aim of our study was to retrospectively evaluate the outcome of patients who underwent upfront surgery (US)-PDAC and borderline (BR)-PDAC, and those resected after NAC to determine prognostic factors that might affect the outcome in these resected patients. METHODS One hundred fifty-one patients between January 2012 and March 2021 in our department were reviewed. Epidemiological characteristics and pre-operative induction treatment were assessed. Pathological reports were analyzed to evaluate the quality of oncological resection (R0/R1). Post-operative mortality and morbidity and survival data were reviewed. RESULTS One hundred thirteen patients were addressed for US, and 38 were considered BR and referred for surgery after induction chemotherapy. The pancreatic resection R0 was 71.5% and R1 28.5%. pT3 rate was significantly higher in the US than BR (58,4% vs 34,2%, p= 0.005). The mean OS and DFS rates were 29.4 months 15.9 months respectively. There was no difference between OS and DFS of US vs BR patients. N0 patients had significantly longer OS and DFS (p=<0.001). R0 patients had significantly longer OS (p=0.03) and longer DFS (P=0.08). In the multivariate analysis, the presence of postoperative pancreatic fistula, R1 resection, N+ and not access to adjuvant chemotherapy were bad prognostic factors of OS. CONCLUSIONS Our study suggests the benefits of NAC for BR patients in downstaging tumors and rendering them amenable to resection, with same oncological result compared to US.
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Affiliation(s)
- Violette Fossaert
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Antonio Mimmo
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Rami Rhaiem
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Linda J. Rached
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Mathilde Brasseur
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Mathias Brugel
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Francesca Pegoraro
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Stephane Sanchez
- Pôle Territorial Santé Publique et Performance des Hôpitaux Champagne Sud, University Reims Champagne-Ardenne, Troyes, France
| | - Olivier Bouché
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Reza Kianmanesh
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Tullio Piardi
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
- Department of Surgery, Hepato-Bilio-Pancreatic and Metabolic Unit, University Reims Champagne-Ardenne, Troyes, France
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Quero G, Fiorillo C, De Sio D, Laterza V, Menghi R, Cina C, Schena CA, Rosa F, Galiandro F, Alfieri S. The role of mesopancreas excision for ampullary carcinomas: a single center propensity-score matched analysis. HPB (Oxford) 2021; 23:1557-1564. [PMID: 33933343 DOI: 10.1016/j.hpb.2021.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/10/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few evidences are available on the prognostic role of mesopancreas excision(MPe) for ampullary cancers(ACs). Aim of this study was to compare the long-term outcomes between pancreaticoduodenectomy(PD) with(PD-MPe group) and without(sPD group) MP. METHODS Thirty-seven sPDs were matched and compared to 37 PD-MPes for perioperative outcomes, recurrence rate, disease-free(DFS) and overall survival(OS). RESULTS The PD-MPe technique related to a significantly higher number of harvested lymph nodes[16 (±6)] as compared to the sPD [10 (±5); p < 0.0001]. Tumor recurrence was more frequent in the sPD cohort[21 (56.8%) vs 12 (32.4%) in the PD-MPe population; p = 0.03]. Although not statistically different, PD-MPe was associated with a better DFS(40% vs 35.7% for sPD; p = 0.08) and OS(59.3% vs 39.1% for sPD; p = 0.07). At the multivariate analysis, a higher number of lymph nodes retrieved and a more extensive lymphovascular clearance reached with the MPe technique, together with lymph nodes metastases, were recognized as independent prognostic factors for a worse OS and DFS. CONCLUSION The PD-MPe technique is associated with a better oncological radicality thanks to the higher number of retrieved lymph nodes and to the more appropriate tumor clearance. This reflects in a lower incidence of tumor relapse and in improved outcomes in terms of OS and DFS.
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Affiliation(s)
- Giuseppe Quero
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Claudio Fiorillo
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy.
| | - Davide De Sio
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Vito Laterza
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Roberta Menghi
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Caterina Cina
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Carlo Alberto Schena
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Fausto Rosa
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Federica Galiandro
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Sergio Alfieri
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Roma, Italy
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Azagra JS, Rosso E, Pascotto B, de Blasi V, Henrard A, González González L. Real robotic total mesopancreas excision (TMpE) assisted by hanging manoeuver (HM): Standardised technique. Int J Med Robot 2021; 17:e2259. [PMID: 33825351 DOI: 10.1002/rcs.2259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/06/2021] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is one of the most demanding interventions for digestive surgeons. R0 resection is a key point for the overall survival and disease-free survival. Total mesopancreas excision (TMpE) has been described by laparotomy but laparoscopy did not provide good results probably because of the technical difficulties of the approach. We propose a standardised total robotic approach. METHODS In this step-by-step technical description, we propose as example, a case of a 53-year-old man with a pancreatic head adenocarcinoma with doubts about the invasion of the mesopancreas surrounding superior mesenteric artery. The mesopancreas hanging manoeuver allows us to perform a TMpE. RESULTS The surgery performed was a robotic artery first pancreaticoduodenectomy with TMpE. The pathological result was pancreatic ductal adenocarcinoma pT2, N1 (1/23), M0, V0, L0, Pn0, R0. CONCLUSIONS Robotic approach is safe, effective and reproductible. Through a standardised technique, it may overcome some of the technical difficulties of laparoscopic PD.
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Affiliation(s)
- Juan Santiago Azagra
- Department of General and Minimally Invasive Surgery (Laparoscopy and Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Edoardo Rosso
- Department of General and Minimally Invasive Surgery (Laparoscopy and Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Beniamino Pascotto
- Department of General and Minimally Invasive Surgery (Laparoscopy and Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Vito de Blasi
- Department of General and Minimally Invasive Surgery (Laparoscopy and Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Alexandre Henrard
- Department of General and Minimally Invasive Surgery (Laparoscopy and Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Lucia González González
- Department of General and Minimally Invasive Surgery (Laparoscopy and Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
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Kang MJ, Kim SW. En bloc proximal peri-mesenteric clearance for pancreatic head cancer surgery. Ann Hepatobiliary Pancreat Surg 2020; 24:389-395. [PMID: 33234741 PMCID: PMC7691194 DOI: 10.14701/ahbps.2020.24.4.389] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 01/02/2023] Open
Abstract
The superior mesenteric artery (SMA) first approach and meso-pancreas excision (MPE) during pancreatoduodenectomy (PD) for pancreatic head cancer have been suggested for complete local tumor control, less operative blood loss, and early determination of resectability. However, SMA-first approach is merely a mode of approach and the concept of MPE has been challenged due to its anatomical obscurity. Dissection around proximal mesenteric vessels, superior mesenteric vein and SMA, is a critical procedure point for local tumor control as tumor infiltration is frequently observed both at the time of initial diagnosis and recurrence. The meso-pancreas, which encompasses the soft tissue between the uncinated process and SMA, does not include all the aforementioned points of proximal mesenteric areas. Therefore, the authors propose a new terminology named, “en bloc proximal peri-mesenteric clearance (PPMC)”, to describe the removal of all the lymph nodes including soft tissue around proximal mesenteric vessels, especially the SMA, to ensure complete local tumor control of pancreatic head cancer. The SMA-first approach applied either by the mesenteric approach or supra-colic approach can make this procedure more feasible. The extent of the circumferential dissection of the peri-SMA nerve plexus can be adjusted according to the primary disease. PPMC including the removal of all lymph nodes around the proximal SMA may be considered as a standard extent of PD for pancreatic head cancer.
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Affiliation(s)
- Mee Joo Kang
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Sun-Whe Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
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7
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Lin R, Lin X, Lu F, Yang Y, Wang C, Fang H, Wen S, Chen Y, Huang H. Combination of anterior superior mesenteric vein-first and right posterior superior mesenteric artery-first approaches for uncinate process dissection in minimally invasive pancreaticoduodenectomy. Gland Surg 2020; 9:1396-1405. [PMID: 33224815 DOI: 10.21037/gs-20-228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Uncinate process dissection is a key step in minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic procedures, which increase the intraoperative blood loss and operative time and decrease the R0 resection rate if improperly handled. However, few studies have reported the operative skills in detail. Methods We performed uncinate process dissection using a combination of the anterior superior mesenteric vein (SMV)-first approach and the right posterior superior mesenteric artery (SMA)-first approach in MIPD for 138 patients with periampullary tumors between March 2017 and October 2019. The demographic and perioperative data of all the patients were collected to evaluate the efficacy of this method. Results All patients underwent an uneventful operation. An assistant incision was performed to separate extensive adhesion between the tumor and the SMV in 3 patients. The combined approach had a notably shorter operation time and resection time, less intraoperative blood loss and a shorter postoperative hospital stay than the traditional approach (P<0.05). There were no significant differences in conversion rate, numbers of harvested lymph node or postoperative complications, including postoperative pancreatic fistula, bile leakage, delayed gastric emptying, postoperative bleeding and reoperation between the two groups (P>0.05). There were no deaths during the perioperative period. Conclusions The combination of the anterior SMV-first approach and the right posterior SMA-first approach is a safe and feasible technique for uncinate process dissection in MIPD.
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Affiliation(s)
- Ronggui Lin
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xianchao Lin
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Fengchun Lu
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Yang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Congfei Wang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haizong Fang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shi Wen
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanchang Chen
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Heguang Huang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Yamamoto J, Kudo H, Kyoden Y, Ajiro Y, Hiyoshi M, Okuno T, Kawasaki H, Nemoto M, Yoshimi F. An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer. Surg Today 2020; 51:872-879. [PMID: 32964249 DOI: 10.1007/s00595-020-02150-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/08/2020] [Indexed: 02/07/2023]
Abstract
When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.
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Affiliation(s)
- Junji Yamamoto
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan.
| | - Hiroki Kudo
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Yusuke Kyoden
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Yoshinori Ajiro
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Masaya Hiyoshi
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Takayuki Okuno
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Hiroshi Kawasaki
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Masaru Nemoto
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
| | - Fuyo Yoshimi
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan
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Dokmak S, Aussilhou B, Rebai W, Cauchy F, Belghiti J, Soubrane O. Up-to-down open and laparoscopic liver hanging maneuver: an overview. Langenbecks Arch Surg 2020; 406:19-24. [PMID: 32743680 DOI: 10.1007/s00423-020-01945-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The liver hanging maneuver (LHM) was described by Belghiti et al. to facilitate liver resection and is done classically by creating a space between the caudate lobe and the inferior vena cava starting on the edge of caudate lobe and extending cranially, in a para-caval fashion, towards the space between the right and middle hepatic veins. LHM facilitates liver transection, guides anatomical resections, decreases blood loss, facilitates harvesting of the liver graft in live donors, and also has oncological advantages. STUDY DESIGN We describe a new approach named "up-to-down" to perform LHM in open and laparoscopic liver resections. This approach was mainly used in obese patients, in laparoscopic liver resections and in cases of failure of the classic approach. The advantages/disadvantages, complications, and different modalities of LHM are also summarized. RESULTS The peritoneal layer between the liver capsule and the infrahepatic vena cava is opened, and a short blind dissection is initiated on the right anterolateral aspect of the inferior vena cava to the left of the hepatic vein of segment VI. The suprahepatic vena cava is exposed, and the space between the right and middle hepatic veins and the vena cava is created by gentle dissection. A 16-Fr nasogastric tube is positioned in the space between the right and middle hepatic vein, pointing inferiorly, and pushed downwards, in a para-caval manner caudally until it is seen inferiorly. The results of this approach are given. CONCLUSION LHM facilitates liver resection, and many variations have been described worldwide in open and laparoscopic liver surgery. The up-to-down approach should be part of the surgical armamentarium in order to offer a safer way to achieve LHM in some patients.
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Affiliation(s)
- Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris VII, Clichy, France.
| | - Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris VII, Clichy, France
| | - Wael Rebai
- Department of digestive surgery, Hospital La Rabta, Tunis, Tunisia
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris VII, Clichy, France
| | - Jacques Belghiti
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris VII, Clichy, France
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris VII, Clichy, France
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10
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Crippa S, Guarneri G, Belfiori G, Partelli S, Pagnanelli M, Gasparini G, Balzano G, Lena MS, Rubini C, Doglioni C, Zamboni G, Falconi M. Positive neck margin at frozen section analysis is a significant predictor of tumour recurrence and poor survival after pancreatodudenectomy for pancreatic cancer. Eur J Surg Oncol 2020; 46:1524-1531. [DOI: 10.1016/j.ejso.2020.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/09/2020] [Accepted: 02/12/2020] [Indexed: 01/04/2023] Open
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11
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Weniger M, Miksch RC, Maisonneuve P, Werner J, D'Haese JG. Improvement of survival after surgical resection of pancreatic cancer independent of adjuvant chemotherapy in the past two decades – A meta-regression. Eur J Surg Oncol 2020; 46:1516-1523. [DOI: 10.1016/j.ejso.2020.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
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12
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Quero G, Fiorillo C, Menghi R, Cina C, Galiandro F, Longo F, Sofo F, Rosa F, Tortorelli AP, Giustiniani MC, Inzani F, Alfieri S. Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes. Langenbecks Arch Surg 2020; 405:303-312. [PMID: 32333095 DOI: 10.1007/s00423-020-01873-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Few comparative studies are available on the long-term prognostic role of mesopancreas (MP) excision after pancreaticoduodenectomy (PD). We compared the long-term outcomes of patients undergoing standard PD (sPD) and PD with MP excision (PD-MPe). METHODS Sixty sPDs were compared to 60 matched PD-MPe patients for intraoperative and postoperative data, histopathological findings, and long-term outcomes. RESULTS R0 rate was similar in the two groups (p = 0.17). However, PD-MPe related to a lower rate of MP resection margin positivity (16.7% vs 5%; p = 0.04) and to a higher harvested lymph nodes number (19.8 ± 7.6 vs 10.1 ± 5.1; p < 0.0001). Local tumor recurrence was more frequent in the sPD cohort (55.5% vs 26.8% in the PD-MPe group; p = 0.002), with a consequent worse disease-free survival (DFS) (14.8% vs 22.3%; p = 0.04). An inferior 5-year overall survival (OS) was noted in case of MP margin positivity compared with MP margin negativity (0% vs 29%; p < 0.0001). MP positivity resulted as an independent prognostic factor for both a worse OS and DFS at the multivariate analysis. CONCLUSION PD-MPe offers clinical advantages in terms of MP resection margin status, local recurrence, long-term mortality, and DFS. The lower MP positivity rate, achieved with PD-MPe, leads to better outcomes both in terms of OS and DFS.
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Affiliation(s)
- Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Roberta Menghi
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Caterina Cina
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Federica Galiandro
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Francesco Sofo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Antonio Pio Tortorelli
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Maria Cristina Giustiniani
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Frediano Inzani
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
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13
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Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: A meta-analysis. Int J Surg 2019; 73:14-24. [PMID: 31751791 DOI: 10.1016/j.ijsu.2019.11.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/05/2019] [Accepted: 11/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Superior mesenteric artery (SMA) first approach was a new improvement for pancreaticoduodenectomy (PD), but there is no evidence whether this approach is advantageous to PD. This meta-analysis aimed to determine the effects of the superior mesenteric artery (SMA) first approach on outcomes of pancreaticoduodenectomy (PD). METHODS Literature searches were conducted on PubMed, The Cochrane Library, EMBASE, Web of Science, Clinical Trials Registry and China Biology Medicine disc. We completed a meta-analysis of the SMA first approach in PD, assessing overall survival, R0 resection, blood loss, postoperative complications, operation time and postoperative stay. The odds ratios and weighted mean differences with 95% confidence intervals (CIs) were pooled. RESULTS Eighteen studies comprising 1483 participants were included. Patients who received SMA-PD had significantly lower overall complication rate (OR 0.62, 95% CI 0.47 to 0.81, P = 0.001) and less blood loss (WMD -264.84, 95% CI -336.1 to -193.58, P < 0.001). The obviously increased R0 resection rate (OR 2.92, 95% CI 1.72 to 4.96, P < 0.001) and 3-year OS (OR 2.15, 95% CI 1.34 to 3.43, P = 0.001) were found in the SMA-PD group. CONCLUSION The SMA-PD group had better clinical outcomes, particularly in long-term survival of pancreatic cancer patients; furthermore, the patients acquired superior clinical efficacy via the posterior approach in SMA-PD.
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14
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Mora-Oliver I, Garcés-Albir M, Dorcaratto D, Muñoz-Forner E, Izquierdo Moreno A, Carbonell-Aliaga MP, Sabater L. Pancreatoduodenectomy with artery-first approach. MINERVA CHIR 2019; 74:226-236. [PMID: 30600965 DOI: 10.23736/s0026-4733.18.07944-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
"Artery-first approach" encompasses different aspects for the surgical treatment of pancreatic cancer. It is a surgical technique or set of techniques which share in common the dissection of the main arterial vasculature involved in pancreatic cancer, before any irreversible surgical step is performed. On the other hand it represents the need for a meticulous dissection of the arterial planes and clearing of the retropancreatic tissue between the superior mesenteric artery, the common hepatic artery and portal vein in an attempt to achieve R0 resections. The recent expansion of this approach is based mainly on three factors: venous involvement should not be considered a contraindication for resection, most of the pancreatic resections performed with a standard procedure may be in fact non-oncological (R1) resections and the postero-medial or vascular margin is the most frequently invaded by the tumor. This review aimed to summarize and update the artery-first approach in pancreaticoduodenectomy.
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Affiliation(s)
- Isabel Mora-Oliver
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Marina Garcés-Albir
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Dimitri Dorcaratto
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Elena Muñoz-Forner
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Ana Izquierdo Moreno
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Mari P Carbonell-Aliaga
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Luis Sabater
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain - .,Biomedical Research Institute INCLIVA, Valencia, Spain
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15
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Xu J, Tian X, Chen Y, Ma Y, Liu C, Tian L, Wang J, Dong J, Cui D, Wang Y, Zhang W, Yang Y. Total mesopancreas excision for the treatment of pancreatic head cancer. J Cancer 2017; 8:3575-3584. [PMID: 29151943 PMCID: PMC5687173 DOI: 10.7150/jca.21341] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/01/2017] [Indexed: 12/13/2022] Open
Abstract
Mesopancreas is a controversial structure. This study aimed to explore the anatomical characteristics of the mesopancreas, define the range of the total mesopancreas excision (TMpE), and evaluate the feasibility, safety and effectivity of TMpE in the treatment of pancreatic head cancer. The clinical and pathological data of 58 consecutive patients undergoing TMpE for pancreatic head carcinoma from January 2013 to December 2015 were analyzed prospectively. The perioperative morbidity, mortality and clinical outcomes of patients undergoing TMpE were compared with the patients undergoing conventional pancreaticoduodenectomy. The mesopancreas was located in the retropancreatic area, extending from the head, neck, and uncinated process of pancreas to the aorto-caval groove, in which there were loose areolar tissue, adipose tissue, nerve plexus, lymphatic and capillaries. We observed significantly higher R0 rate (94.8% vs. 81.4%, P=0.035), more lymph nodes (16.2 vs. 11.4, P=0.000), lower total and local recurrence rate (half-year local recurrence rate 7.8% vs. 23.7%, P=0.036, one-year 18.2% vs. 39.5%, P=0.018) and longer disease-free survival (16.9 vs. 13.4 months, P=0.044) in TMpE group than in control group. In conclusion, mesopancreas is different from mesorectum because there is no fascial envelop or anatomical boundary in this area. TMpE could be safely and feasibly performed for the treatment of pancreatic head cancer to increase the R0 resection rate and improve the clinical outcomes.
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Affiliation(s)
- Jingyong Xu
- Department of General Surgery, Peking University First Hospital, 100034, Beijing, China.,Department of General Surgery, Beijing Hospital, National Centre of Gerontology, China, 100730, Beijing, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, 100034, Beijing, China
| | - Yiran Chen
- Department of General Surgery, Peking University First Hospital, 100034, Beijing, China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, 100034, Beijing, China
| | - Chang Liu
- Department of General Surgery, Peking University First Hospital, 100034, Beijing, China
| | - Long Tian
- Department of Human Anatomy, Health Science Centre, Peking University, 100191, China
| | - Jianwei Wang
- Department of Human Anatomy, Health Science Centre, Peking University, 100191, China
| | - Jianqiang Dong
- Department of Pathology, Peking University People's Hospital, Beijing, 100044, China
| | - Di Cui
- Department of Pathology, Beijing Hospital, National Center of Gerontology, China Beijing, 100730, China
| | - Yang Wang
- Medical research and Biometrics Center, Fuwai Hospital, Peking Union Medical College, Beijing, 100730, China
| | - Weiguang Zhang
- Department of Human Anatomy, Health Science Centre, Peking University, 100191, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, 100034, Beijing, China
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16
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Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2017; 16:127-138. [PMID: 28381375 DOI: 10.1016/s1499-3872(16)60134-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The superior mesenteric artery (SMA) first approach was proposed recently as a new modification of the standard pancreaticoduodenectomy. Increasing evidence showed that a periadventiceal dissection of the SMA with early transection of the inflow during pancreaticoduodenectomy associates better early perioperative results, and setup the scene for long-term oncological benefits. The objectives of the current study are to compare the operative results and long-term oncological outcomes of SMA first approach pancreaticoduodenectomy (SMA-PD) with standard pancreaticoduodenectomy (S-PD). DATA SOURCES Electronic search of the PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Library was performed until July 2015. We considered randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) comparing SMA-PD with S-PD to be eligible if they included patients with periampullary cancers. RESULTS A total of one RCT and thirteen NRCSs met the inclusion criteria, involving 640 patients with SMA-PD and 514 patients with S-PD. The SMA-PD was associated with less intraoperative bleeding, less blood transfusions and higher rate of associated venous resections. The pancreatic fistula and delayed gastric emptying had a significantly lower rate in the SMA-PD group. There were no differences between the two approaches regarding overall complications, major complication rates and in-hospital mortality. There was no difference regarding R0 resection rate, and one-, two- or three-year overall survival. The SMA-PD was associated with a lower local, hepatic and extrahepatic metastatic rate. CONCLUSIONS The SMA-PD is associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, and delayed gastric emptying. Although the one-, two- or three-year overall survival rate is not superior, the SMA-PD has a lower local and metastatic recurrence rate.
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17
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Fujioka S, Misawa T, Yanaga K. Isolating tape method is useful for an early judgment of curability during pancreaticoduodenectomy for pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:E20-E24. [PMID: 27561734 DOI: 10.1002/jhbp.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 07/20/2016] [Indexed: 11/08/2022]
Abstract
Positive surgical margin of extrapancreatic nerve plexus (ENP) is a major cause of non-curative resection during pancreaticoduodenectomy (PD) for periampullary carcinoma (PC), which is difficult to detect at the early stage of PD. We describe a novel surgical technique using an isolating tape (iTape)-oriented ENP-first dissection (IOEFD) during PD. The iTape is firstly passed through the retroperitoneal space between ENP and inferior vena cava. Then, the iTape is further extracted from major vessels such as the common hepatic and superior mesenteric artery. Consequently, the iTape encircles ENP alone. By tugging both ends of the iTape and vessel tapes to various directions from the caudal and cranial side of the pancreas, ENP is individually dissected without dividing any organ or tissue. Ten patients with periampullary carcinomas, consisting of one distal bile duct carcinoma, four ampullary carcinomas and five pancreatic head carcinomas underwent IOEFD during PD. Among these, nine underwent PDs after confirming negative surgical margin of ENP by IOEFD, while in the other case, PD was abandoned and converted to digestive bypass because of positive ENP margin during IOEFD. By final pathological diagnosis, R0 resection has been established in all nine patients who underwent PD with IOEFDs. Our pilot study indicated that inappropriate non-curative resection can be avoided by IOEFD during PD.
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Affiliation(s)
- Shuichi Fujioka
- Department of Surgery, Jikei University Kashiwa Hospital, 163-1 Kashiwa-shita, Kashiwa, Chiba, 277-8567, Japan.
| | - Takeyuki Misawa
- Department of Surgery, Jikei University Kashiwa Hospital, 163-1 Kashiwa-shita, Kashiwa, Chiba, 277-8567, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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18
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Pessaux P, Méméo R, Ferreira N, Hargat J, Mutter D, Marescaux J. Pancreaticoduodenectomy with mesenterico-portal vein resection (with video). J Visc Surg 2016; 153:227-228. [PMID: 27032317 DOI: 10.1016/j.jviscsurg.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- P Pessaux
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
| | - R Méméo
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - N Ferreira
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - J Hargat
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - D Mutter
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - J Marescaux
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
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19
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Pessaux P, Memeo R, Ferreira N, Hargat J, Mutter D, Marescaux J. Duodéno-pancréatectomie céphalique avec résection veineuse mésentérico-portale (avec vidéo). JOURNAL DE CHIRURGIE VISCÉRALE 2016; 153:233-234. [DOI: 10.1016/j.jchirv.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2025]
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20
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Virgilio E, Amodio PM, Scorsi A, Goglia A, Macarone Palmieri R. Advantages of the Maneuver of Intestinal Derotation for Pancreaticoduodenectomy. J INVEST SURG 2016; 29:359-365. [PMID: 27096254 DOI: 10.3109/08941939.2016.1160166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Edoardo Virgilio
- Division of Medical and Surgical Sciences and Translational Medicine, Department of Emergency Surgery, Faculty of Medicine and Psychology “Sapienza”, St. Andrea Hospital, Rome, Italy
| | | | - Alessandro Scorsi
- Division of Medical and Surgical Sciences and Translational Medicine, Department of Emergency Surgery, Faculty of Medicine and Psychology “Sapienza”, St. Andrea Hospital, Rome, Italy
| | - Angelo Goglia
- Department of General Surgery, Belcolle Hospital, Viterbo, Italy
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21
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Abstract
Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.
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22
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Abstract
BACKGROUND Pancreatic cancer is notoriously one of the most aggressive cancers and still has a poor prognosis. Surgical resection is the only chance for a curative therapy approach, with which at least a 5‑year survival can be achieved for 25% of patients. Recent advances in surgical techniques have led to a change in the criteria for resectability. OBJECTIVE This review summarizes the currently available evidence on the criteria for resectability of pancreatic cancer and discusses the treatment options. MATERIAL AND METHODS The study was based on a selective literature search and a summary of the latest data on criteria for resectability is given. RESULTS Patients with pancreatic cancer must be differentiated into those with primarily resectable disease, borderline resectable disease, locally advanced (primarily unresectable) and metastatic disease. While infiltration into the major surrounding venous vessels (e.g. superior mesenteric vein, portal vein and confluence of splenic vein) used to be a criterion for unresectable disease, these tumors can nowadays be safely resected in specialized centers. Tumor infiltration into adjacent arteries (e.g. hepatic artery, superior mesenteric artery and celiac artery) remains a clinical problem and surgical resection is often technically possible but associated with an increased morbidity and mortality and therefore not generally recommended. Borderline resectable tumors represent a special group for which neoadjuvant treatment concepts are increasingly being implemented. Radiological therapy response evaluation is challenging after neoadjuvant therapy as it is not usually associated with a radiologically detectable reduction in tumor volume. CONCLUSION Pancreatic resections can nowadays be more radically performed due to advances in surgical techniques. This has led to a change in the criteria for resectability, especially concerning venous tumor infiltration.
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Affiliation(s)
- J G D'Haese
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - J Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
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23
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Clinical impact of intraoperative navigation using a Doppler ultrasonographic guided vessel tracking technique for pancreaticoduodenectomy. Int Surg 2016; 99:770-8. [PMID: 25437586 DOI: 10.9738/intsurg-d-14-00060.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
During pancreaticoduodenectomy (PD), early ligation of critical vessels such as the inferior pancreaticoduodenal artery (IPDA) has been reported to reduce blood loss. Color Doppler flow imaging has become the useful diagnostic methods for the delineation of the anatomy. In this study, we assessed the utility of the intraoperative Doppler ultrasonography (Dop-US) guided vessel detection and tracking technique (Dop-Navi) for identifying critical arteries in order to reduce operative bleeding. Ninety patients who received PD for periampullary or pancreatic disease were enrolled. After 14 patients were excluded because of combined resection of portal vein or other organs, the remaining were assigned to 1 of 2 groups: patients for whom Dop-Navi was used (n = 37) and those for whom Dop-Navi was not used (n = 39; controls). We compared the ability of Dop-Navi to identify critical vessels to that of preoperative multi-detector computed tomography (MD-CT), using MD-CT data, as well as compared the perioperative status and postoperative outcome between the 2 patient groups. Intraoperative Dop-US was significantly superior to MD-CT in terms of identifying number of vessels and the ability to discriminate the IPDA from the superior mesenteric artery (SMA) based on blood flow velocity. The Dop-Navi patients had shorter operation times (531 min versus 577 min; no significance) and smaller bleeding volumes (1120 mL versus 1590 mL; P < 0.01) than the control patients without increasing postoperative complications. Intraoperative Dop-Navi method allows surgeons to clearly identify the IPDA during PD and to avoid injuries to major arteries.
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24
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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Pancreatoduodenectomy With Systematic Mesopancreas Dissection Using a Supracolic Anterior Artery-first Approach. Ann Surg 2016; 262:1092-101. [PMID: 25587814 DOI: 10.1097/sla.0000000000001065] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the details of the surgical technique of pancreatoduodenectomy (PD) with systematic mesopancreas dissection (SMD-PD), using a supracolic anterior artery-first approach. BACKGROUND An artery-first approach in PD has been advocated in pancreatic cancer to judge resectability, clear the superior mesenteric artery margin from invasion, or reduce blood loss. However, the efficacy of an artery-first approach in mesopancreas dissection remains unclear. METHODS This study involved 162 consecutive patients who underwent PD with curative intent. The patients were divided into 82 SMD-PDs and 80 conventional PDs (CoPD) and then stratified further according to the dissection level, that is, level 1 was applied to 24 simple mesopancreas divisions for early inflow occlusion including 11 SMD-PDs, level 2 for 63 en bloc mesopancreas resections (26 SMD-PDs), and level 3 for 75 patients who underwent a hemicircumferential superior mesenteric artery plexus resection to keep the margin free from cancer invasion (45 SMD-PDs). The clinical and imaging results were collected to assess the feasibility and validity of SMD-PD with an artery-first approach. RESULTS Blood loss and operation duration were significantly less in the SMD-PD group than in the CoPD group among the total 162 patients. The imaging analysis showed that four fifths of pancreatic arterial branches came from the right dorsal aspect of the superior mesenteric artery and cancer abutment occurred exclusively from the same direction indicating the validity of an artery-first approach. CONCLUSIONS SMD-PD using an SAA is feasible across PD cases, with acceptable short-term outcomes, and we propose this procedure as a promising option for PD.
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Pandanaboyana S, Bell R, Windsor J. Artery first approach to pancreatoduodenectomy: current status. ANZ J Surg 2015; 86:127-32. [PMID: 26246127 DOI: 10.1111/ans.13249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The need for an early determination of resectability and before an irreversible step is taken during pancreatoduodenectomy promoted the development of an 'artery first approach' (AFA). The aim of this study was to review the current evidence related to this approach, with particular reference to margins and survival. METHODS An electronic search was performed in MEDLINE, EMBASE and PubMed databases from 1960 to 2015 using both subject headings (MeSH) and truncated word searches to identify all published related articles to this topic. RESULTS Six different AFAs have been published. Four studies evaluated the impact of AFA on perioperative outcomes and survival. Three studies showed no difference in the perioperative outcomes, margin status, lymph node yield and survival while one study showed improved margin status and survival comparing AFA with standard resection. CONCLUSION The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.
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Affiliation(s)
- Sanjay Pandanaboyana
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Richard Bell
- Department of Hepatobiliary and Pancreatic Surgery, St James Hospital, Leeds, UK
| | - John Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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Gluth A, Werner J, Hartwig W. Surgical resection strategies for locally advanced pancreatic cancer. Langenbecks Arch Surg 2015; 400:757-65. [DOI: 10.1007/s00423-015-1318-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 02/07/2023]
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Pallisera A, Morales R, Ramia JM. Tricks and tips in pancreatoduodenectomy. World J Gastrointest Oncol 2014; 6:344-350. [PMID: 25232459 PMCID: PMC4163732 DOI: 10.4251/wjgo.v6.i9.344] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 03/18/2014] [Indexed: 02/05/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy. Since its initial description in 1935 by Whipple et al, this complex surgical technique has evolved and undergone several modifications. We review three key issues in PD: (1) the initial approach to the superior mesenteric artery, known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis; and (3) the extent of lymphadenectomy.
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Mizuno S, Isaji S, Tanemura A, Kishiwada M, Murata Y, Azumi Y, Kuriyama N, Usui M, Sakurai H, Tabata M. Anterior approach to the superior mesenteric artery by using nerve plexus hanging maneuver for borderline resectable pancreatic head carcinoma. J Gastrointest Surg 2014; 18:1209-1215. [PMID: 24664421 DOI: 10.1007/s11605-014-2495-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 03/03/2014] [Indexed: 01/31/2023]
Abstract
To achieve R0 resection for pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head, complete resection of the retropancreatic nerve plexus around the superior mesenteric artery (SMA) is thought to be required. Twenty-five patients with borderline resectable right-sided PDAC were divided into two groups after neoadjuvant chemoradiotherapy: those with portal vein (PV) invasion alone (n = 12), and those with invasion of both PV and SMA (n = 13). A tape for guidance was passed in a space ventral to the SMA and behind the pancreatic parenchyma, followed by resection of the pancreatic parenchyma with the splenic vein. Another tape was passed behind the nerve plexus lateral to the hepatic artery and the SMA ventral to the inferior vena cava and the nerve plexus was dissected, resulting in complete resection of the nerve plexus around the SMA. Pathological findings revealed that the rates of R0, R01 (a margin less than 1 mm) and R1 were 58.3 %, 41.7 % and 0 % in PV group, and 53.8 %, 30.8 % and 15.4 % in PV/A group, respectively. The median survival time was 23.3 and 22.8 months in PV and PV/A groups, respectively. The plexus hanging maneuver for PDAC of the pancreatic head achieved complete resection of the retropancreatic nerve plexus around the SMA, helping to secure a negative surgical margin.
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Affiliation(s)
- Shugo Mizuno
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan,
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Mesopancreas in pancreatic cancer: where do we stand - review of literature. Indian J Surg Oncol 2014; 6:69-74. [PMID: 25937767 DOI: 10.1007/s13193-014-0294-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/21/2014] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is associated with poor prognosis and surgery remains the main modality of treatment. Negative resection margin is an important prognostic factor for survival. Retropancreatic margin or the medial margin is the most common site of positive resection margin. Mesopancreas was proposed in analogy with mesorectum, which is considered as a fusion fascia formed embryologically during the development of pancreas. This mesopancreas lies posterior to the pancreas and contains pancreaticoduodenal vessels, lymphatics, nerve plexus and loose areolar tissue. Various technical modifications were proposed for better dissection of mesopancreas like posterior approach and artery first approach. There is an increased rate of R0 resection by these technical modifications but whether this will turn to increase in survival rates is yet to be established.
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Bachellier P, Rosso E, Fuchshuber P, Addeo P, David P, Oussoultzoglou E, Lucescu I. Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension. Surgery 2014; 155:449-56. [PMID: 24462078 DOI: 10.1016/j.surg.2013.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 09/12/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Our aim was to evaluate the perioperative morbidity and survival of a selected group of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC) and malignant obstruction of portal axis inducing portal hypertension (PH) who underwent a curative intent pancreatic resection, after neoadjuvant chemotherapy, adopting a new type of temporary intraoperative mesentericoportal shunt (TMPS). METHODS We analyzed the perioperative data and survival outcome of 15 patients with locally advanced PDAC and PH who underwent pancreatoduodenectomy combined with vascular resections between October 2008 and October 2012 using this TMPS. RESULTS There was no perioperative mortality. Postoperative morbidity occurred in 7 patients without any postoperative liver failure. All patients underwent mesentericoportal venous resection, 11 of whom had a concomitant arterial resection. The mean ± SD follow-up was 16 ± 10 months (range, 4-40; median 15). Overall survival rates of patients were 78% and 11% at 1 and at 3 years, respectively. Median survival was 17 months. The 1-year disease-free survival was 36%. CONCLUSION The use of this form of TMPS allowed us to achieve PD or total pancreatectomy in patients with locally advanced PDAC and PH without postoperative mortality but with increased morbidity. The relevance of such an aggressive approach is yet to be determined.
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Affiliation(s)
- Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Edoardo Rosso
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Pascal Fuchshuber
- Department of Surgical Oncology, The Permanente Medical Group, Walnut Creek, CA
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Patrice David
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Elie Oussoultzoglou
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Ionut Lucescu
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Marzano E, Piardi T, Soler L, Diana M, Mutter D, Marescaux J, Pessaux P. Augmented reality-guided artery-first pancreatico-duodenectomy. J Gastrointest Surg 2013; 17:1980-1983. [PMID: 23943389 DOI: 10.1007/s11605-013-2307-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 07/29/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Augmented Reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative work-up and real-time patient images with the aim to visualize unapparent anatomical details. The potential of AR navigation as a tool to improve safety of the surgical dissection is presented in a case of pancreatico-duodenectomy (PD). METHODS A 77-year-old male patient underwent an AR-assisted PD. The 3D virtual anatomical model was obtained from thoraco-abdominal CT scan using customary software (VR-RENDER®, IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM®, Karl Storz, Tüttlingen, Germany) as well as different visible landmarks (inferior vena cava, left renal vein, aorta, superior mesenteric vein, inferior margin of the pancreas). A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. Dissection of the superior mesenteric artery and the hanging maneuver were performed under AR guidance along the hanging plane. RESULTS AR allowed for precise and safe recognition of all the important vascular structures. Operative time was 360 min. AR display and fine registration was performed within 6 min. The postoperative course was uneventful. The pathology was positive for ampullary adenocarcinoma; the final stage was pT1N0 (0/43 retrieved lymph nodes) with clear surgical margins. CONCLUSIONS AR is a valuable navigation tool that can enhance the ability to achieve a safe surgical resection during PD.
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Affiliation(s)
- Ettore Marzano
- IRCAD-IHU University Hospital of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
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Peparini N, Chirletti P. Mesopancreas: a boundless structure, namely R1 risk in pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2013; 39:1303-8. [PMID: 24188796 DOI: 10.1016/j.ejso.2013.10.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 09/28/2013] [Accepted: 10/12/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The mesopancreatic resection margin after pancreaticoduodenectomy for carcinoma of the head of the pancreas is of great interest with respect to curative resection, since the neoplastic involvement of this margin was shown to be the primary site for R1 resection. In this review the current knowledges of the surgical anatomy of the so-called mesopancreas and the mesopancreas excision techniques are summarized. METHODS References were identified by searching Pubmed database using the search terms "mesopancreas" and "meso-pancreatoduodenum" until June 2013 and through searches of the authors' own files. Five studies were included in this review. RESULTS Original contributions with regard to the anatomy of the retropancreatic area and specific technical descriptions of so-called "total mesopancreas excision" provided by published studies are pointed out. CONCLUSIONS Because there is no "meso" of the pancreas, and due to the continuity of the mesopancreatic and para-aortic areas, surgical dissection should be extended to the left of the superior mesenteric artery and include the para-aortic area to achieve the most complete possible resection of the so-called mesopancreas and minimize the rate of R1 resections due to mesopancreatic margin involvement. This extended mesopancreatic resection cannot be accomplished en bloc even if the removal of the dissected mesopancreatic tissues is performed en bloc with the head, uncus, and neck of the pancreas, i.e., with the pancreaticoduodenectomy specimen.
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Affiliation(s)
- N Peparini
- Azienda Sanitaria Locale Roma H, Distretto H3, via Mario Calò, 5, Ciampino, 00043 Rome, Italy.
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Hartwig W, Werner J, Jäger D, Debus J, Büchler MW. Improvement of surgical results for pancreatic cancer. Lancet Oncol 2013; 14:e476-e485. [DOI: 10.1016/s1470-2045(13)70172-4] [Citation(s) in RCA: 273] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Werner J, Combs SE, Springfeld C, Hartwig W, Hackert T, Büchler MW. Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 2013; 10:323-33. [PMID: 23629472 DOI: 10.1038/nrclinonc.2013.66] [Citation(s) in RCA: 171] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma is one of the most aggressive cancers, and surgical resection is a requirement for a potential cure. However, the majority of patients are diagnosed with advanced-stage disease, either metastatic (50%) or locally advanced cancer (30%). Although palliative chemotherapy is the standard of care for patients with metastatic disease, management of locally advanced adenocarcinoma is controversial. Several treatment options, including extended surgical resections, neoadjuvant therapy with subsequent resections, as well as palliative radiotherapy and/or chemotherapy, should be considered. However, there is little evidence available to support treatment options for locally advanced disease. As valid predictive biomarkers for stratification of therapy are not available today, future trials need to define the role of the different treatment options. This Review summarizes the current evidence and discusses available treatment options for both locally advanced and metastatic pancreatic adenocarcinoma.
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Affiliation(s)
- Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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36
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Marzano E, Piardi T, Marescaux J, Pessaux P. Combined posterior and anterior approach to the superior mesenteric artery: the advantages of the "hanging maneuver". Langenbecks Arch Surg 2012; 397:1023-1024. [PMID: 22628049 DOI: 10.1007/s00423-012-0957-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 04/24/2012] [Indexed: 11/29/2022]
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null,null,null,null#] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null,null,null-- boqx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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39
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null,null,null,null,null,null-- lhhv] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null-- krvm] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 waitfor delay '0:0:5'-- yckn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null-- gyaq] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022] Open
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 order by 1-- tjwi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.04.007 waitfor delay '0:0:5'] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022] Open
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Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.04.007 and 5806=dbms_pipe.receive_message(chr(72)||chr(67)||chr(116)||chr(71),5)-- lnzj] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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46
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Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null,null-- bbzg] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null,null,null,null-- qabi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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48
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49
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Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null,null-- pwwr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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50
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Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.04.007 union all select null,null-- eotf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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