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World J Gastrointest Oncol. Sep 15, 2014; 6(9): 344-350
Published online Sep 15, 2014. doi: 10.4251/wjgo.v6.i9.344
Tricks and tips in pancreatoduodenectomy
Anna Pallisera, Rafael Morales, Jose Manuel Ramia
Anna Pallisera, Rafael Morales, Department of Surgery, Hospital Son Llatzer, 07198 Palma de Mallorca, Spain
Jose Manuel Ramia, HPB Unit, Department of Surgery, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain
Author contributions: Pallisera A wrote the introduction and the section on the artery-first approach; Ramia JM wrote the section on arterial complications during pancreatoduodenectomy; Morales R wrote the section on extended lymphadenectomy for pancreatic head adenocarcinoma.
Correspondence to: Jose Manuel Ramia, MD, PhD, FACS, HPB Unit, Department of Surgery, Hospital Universitario de Guadalajara, C/General Moscardó 26, 5-1, Madrid 28020, Spain. jose_ramia@hotmail.com
Telephone: +34-616-292056 Fax: +34-616-292056
Received: August 8, 2013
Revised: September 23, 2013
Accepted: March 17, 2014
Published online: September 15, 2014
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.

Keywords: Pancreas, Pancreaticoduodenectomy, Artery-first, Surgery, Lymphadenectomy, Celiac axis, Hepatic artery

Core tip: The “artery-first approach” prioritized the dissection of the origin of the superior mesenteric artery (SMA), allowing complete lymphadenectomy, safe dissection of the SMA, and accurate identification of the most frequent anatomic variations such as a hepatic artery originating in the SMA. It has been demonstrated that patients with intraoperative arterial complications have longer operative time, higher transfusion rate and more postoperative complications. Another controversial issue is the extent of lymphadenectomy in the pancreaticoduodenectomy. The randomized trials published do not recommend radical lymphadenectomy as a standard approach for pancreatic ductal adenocarcinoma.

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[1-3]. Since its initial description in 1935 by Whipple et al[4], this complex surgical technique has evolved and, although the mortality rate has been reduced by regionalizing interventions in high volume centers[1,3], morbidity remains high, with a rate close to 40%[5,6]. Various modifications of the classical PD have been proposed to reduce morbidity [7].

We review three key issues in PD: (1) the initial approach to the superior mesenteric artery (SMA), known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery (HA) or celiac artery stenosis; and (3) the extent of lymphadenectomy.