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Safi SA, David S, Haeberle L, Vaghiri S, Luedde T, Roderburg C, Esposito I, Fluegen G, Knoefel WT. Most oncological pancreas resections must consider the mesopancreas. BMC Cancer 2025; 25:200. [PMID: 39905374 PMCID: PMC11796116 DOI: 10.1186/s12885-025-13599-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Accepted: 01/28/2025] [Indexed: 02/06/2025] Open
Abstract
BACKGROUND In preoperative staging for patients with a ductal adenocarcinoma of the pancreatic head (PDAC), resectability is anatomically characterized by the possible clearance of the medial vascular grove. Borderline resectable PDAC patients who retain an increased risk of infiltration to the portomesenteric system and/or arterial vasculate are candidates for neoadjuvant therapy. However, redefined pathological analysis revealed the dorsal resection margin to be similar at risk for R1 resection. Mesopancreatic excision (MPE) aims to secure the integrity of the dorsal and ventral resection margins. The existence of the mesopancreas (MP) is inevitable, since the pancreas is of a secondary retroperitoneal nature and the dorsal as well as ventral fascial coverings define the peripancreatic compartment anatomy. It remains unknown if the MP area is only infiltrated in high-risk PDAC patients or if MPE during pancreatoduodenectomy should be employed for localized PDAC patients as well. METHODS Patients who underwent upfront pancreatoduodenectomy were included. CRM evaluation and analysis of the MP was standardized in all patients. Patients were sub-grouped by the infiltration status of the vascular groove (localized disease: LOC). In LOC patients there was evidently no cancerous infiltration into the medial vascular groove (true + primary resectable). RESULTS Two hundred eighty-four consecutive patients who underwent pancreatoduodenectomy were included (169 LOC patients). In LOC patients the MP infiltration rate remained high but was significantly lower when compared to advanced PDAC patients (MP + 69.2% vs. 83.5%, p = 0.005). In LOC patients, CRM resection status of the dorsal resection status remained significantly affected by the MP infiltration status (R0CRM- 80.5% vs. 62.8%, p = 0.019). CONCLUSION These important findings clearly show underestimated tumor extensions into the mesopancreas even in localized, primary resectable PDAC patients who are currently amenable for upfront resection. Synergistically to total mesorectal or mesocolic excision, which is applied to all stages of colorectal disease, MPE is justified in primary resectable patients as well. Therefore, MPE should be employed in all PDAC patients. Since the infiltration status of the mesopancreas was a significant factor for incomplete resection in primary resectable PDAC patients, neoadjuvant treatment options for must be discussed.
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Affiliation(s)
- S A Safi
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - S David
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - L Haeberle
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - S Vaghiri
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - T Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - C Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - I Esposito
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - G Fluegen
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - W T Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
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Safi SA, Alexander A, Neuhuber W, Haeberle L, Rehders A, Luedde T, Esposito I, Fluegen G, Knoefel WT. Defining distal splenopancreatectomy by the mesopancreas. Langenbecks Arch Surg 2024; 409:127. [PMID: 38625602 PMCID: PMC11021282 DOI: 10.1007/s00423-024-03320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/10/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND The implementation of the pathologic CRM (circumferential resection margin) staging system for pancreatic head ductal adenocarcinomas (hPDAC) resulted in a dramatic increase of R1 resections at the dorsal resection margin, presumably because of the high rate of mesopancreatic fat (MP) infiltration. Therefore, mesopancreatic excision (MPE) during pancreatoduodenectomy has recently been promoted and has demonstrated better local disease control, fueling the discussion of neoadjuvant downsizing regimes in MP + patients. However, it is unknown to what extent the MP is infiltrated in patients with distal pancreatic (tail/body) carcinomas (dPDAC). It is also unknown if the MP infiltration status affects surgical margin control in distal pancreatectomy (DP). The aim of our study was to histopathologically analyze MP infiltration and elucidate the influence of resection margin clearance on recurrence and survival in patients with dPDAC. Furthermore, the results were compared to a collective receiving MPE for hPDAC. METHOD Clinicopathological and survival parameters of 295 consecutive patients who underwent surgery for PDAC (n = 63 dPDAC and n = 232 hPDAC) were evaluated. The CRM evaluation was performed in a standardized fashion and the specimens were examined according to the Leeds pathology protocol (LEEPP). The MP area was histopathologically evaluated for cancerous infiltration. RESULTS In 75.4% of dPDAC patients the MP fat was infiltrated by vital tumor cells. The rates of MP infiltration and R0CRM- resections were similar between dPDAC and hPDAC patients (p = 0.497 and 0.453 respectively). MP- infiltration status did not correlate with CRM implemented resection status in dPDAC patients (p = 0.348). In overall survival analysis, resection status and MP status remained prognostic factors for survival. In follow up analysis. surgical margin clearance in dPDAC patients was associated with a significant improvement in local recurrence rates (5.2% in R0CRM- resected vs. 33.3 in R1/R0CRM + resected, p = 0.002). CONCLUSION While resection margin status was not affected by the MP status in dPDAC patients, the high MP infiltration rate, as well as improved survival in MP- dPDAC patients after R0CRM- resection, justify mesopancreatic excision during splenopancreatectomy. Larger scale studies are urgently needed to validate our results and to study the effect on neoadjuvant treatment in dPDAC patients.
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Affiliation(s)
- S-A Safi
- Departments of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - A Alexander
- Departments of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - W Neuhuber
- Institute of Anatomy I, Friedrich-Alexander University Erlangen-Nuremberg, Universitätsstr. 1, Erlangen, Germany
| | - L Haeberle
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - A Rehders
- Departments of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - T Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - I Esposito
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - G Fluegen
- Departments of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - W T Knoefel
- Departments of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
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Ono Y, Inoue Y, Kato T, Kobayashi K, Takamatsu M, Atsushi O, Sato T, Ito H, Takahashi Y. New approach of circumferential lymph node dissection around the superior mesenteric artery for pancreatic cancer during pancreaticoduodenectomy (with video). Langenbecks Arch Surg 2023; 408:422. [PMID: 37910224 DOI: 10.1007/s00423-023-03159-x] [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: 06/15/2023] [Accepted: 10/18/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Various approaches have been reported for the resection of the nervous and lymphatic tissues around the superior mesenteric artery (SMA) during pancreaticoduodenectomy (PD) for pancreatic cancer. We developed a new procedure for circumferential lymph node dissection around the SMA to minimize local recurrence. METHODS We included 24 patients who underwent PD with circumferential lymph node dissection around the SMA (circumferential dissection) and 94 patients who underwent classical mesopancreatic dissection (classical dissection) between 2019 and 2021. The technical details of this new method are described in the figures and videos, and the clinical characteristics and outcomes of this technique were compared with those of classical dissection. RESULTS The median follow-up durations in the circumferential and classical dissection groups were 39 and 36 months, respectively. The patients' characteristics, including tumor resectability, preoperative and adjuvant chemotherapy rates, postoperative complication rates, and tumor stage, were similar between the two groups. No differences were observed in recurrence-free survival and overall survival between the two groups; however, the classical dissection group tended to have more local recurrences than the circumferential dissection group (8.3% vs. 33.3%, P = 0.168). Although no case of nodular-type recurrence after circumferential dissection was observed, 61.1% of local recurrences after classical dissection were of the nodular-type, and 36.4% were located on the left side of the SMA. CONCLUSIONS Performing circumferential lymph node dissection around the SMA during PD can be conducted safely with minimal risks of local recurrence and may enhance the completeness of local resection.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Manabu Takamatsu
- Department of Pathology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Oba Atsushi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan.
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Shen Z, Chen H, Zhao S, Ji Y, Zhou Y, Weng Y, Zhang J, Deng X, Peng C, Wang W, Shen B. The Impact of Additional Para-aortic Dissection During Pancreaticoduodenectomy for Resectable Pancreatic Cancer. Ann Surg Oncol 2023; 30:1474-1482. [PMID: 36305986 DOI: 10.1245/s10434-022-12700-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The short-term outcome and long-term survival of pancreaticoduodenectomy with additional para-aortic dissection (PAD) for patients with resectable pancreatic cancer remain obscure. PATIENTS AND METHODS Consecutive patients who underwent radical pancreaticoduodenectomy for resectable pancreatic cancer in a single high-volume center during a 7-year period were included retrospectively. Both short- and long-term effects of PAD were compared between the PAD group and the no PAD group. Then, the PAD group was divided into the non-metastatic para-aortic lymph node (PALN-) group and the metastatic PALN (PALN+) group to further analyze the prognosis of PALN+. RESULTS Of the 909 included patients, 280 (30.8%) underwent PAD during pancreaticoduodenectomy. The PAD group had a higher rate of intra-abdominal infection compared with the no PAD group (28.6% vs. 20.7%, P = 0.009) but no differences were found in the incidence of other complications. The overall survival (OS) and recurrence-free survival (RFS) were also comparable between the two groups. Subgroup analysis showed that patients with PALN+ had a worse OS than patients in the PALN- group (median of 14 vs. 20 months, P = 0.048). Multivariate Cox regression analysis further revealed that PALN+ was an independent adverse predictor of OS (hazard ratio: 1.70, P = 0.007). CONCLUSIONS This study suggests that the addition of PAD during pancreaticoduodenectomy does not improve the prognosis of patients with resectable pancreatic cancer and may lead to an increased risk of infection. However, the accurate preoperative assessment and appropriate treatment strategy for patients with PALN+ need further investigation due to the poor prognosis.
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Affiliation(s)
- Ziyun Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shiwei Zhao
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuchen Ji
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiran Zhou
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. .,Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. .,Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China. .,State Key Laboratory of Oncogenes and Related Genes, Shanghai, China. .,Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China.
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5
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Shen Z, Chen H, Ji Y, Wang W, Shen B. ASO Author Reflections: The Clinical Dilemma of Para-Aortic Dissection in Pancreaticoduodenectomy for Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:1483-1484. [PMID: 36303081 DOI: 10.1245/s10434-022-12748-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Ziyun Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuchen Ji
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Livani A, Angelis S, Skandalakis PN, Filippou D. The Story Retold: The Kocher Manoeuvre. Cureus 2022; 14:e29409. [PMID: 36304342 PMCID: PMC9586190 DOI: 10.7759/cureus.29409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/05/2022] Open
Abstract
The Kocher manoeuvre is used for mobilization of the duodenum and head of the pancreas and bears the name of Theodor Kocher, who published it in 1903. We describe the embryology of the duodenum and pancreas, relating it to surgical anatomy applied during the procedure. Finally, we present the key points of the procedure, providing more insights into the anatomical structures that are mainly involved.
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Affiliation(s)
- Anastasia Livani
- Department of Surgery, Agia Sophia Children's Hospital, Athens, GRC
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Stavros Angelis
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Panagiotis N Skandalakis
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Dimitrios Filippou
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
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Kajiwara M, Nakashima R, Sasaki T, Naito S, Hasegawa S. Dissection Around the Superior Mesenteric Artery (SMA) Using LigaSure Maryland During Left Posterior Approach for Pancreaticoduodenectomy. Cureus 2022; 14:e27034. [PMID: 35989809 PMCID: PMC9387940 DOI: 10.7759/cureus.27034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/05/2022] Open
Abstract
R0 resection for pancreatic head cancer without exposing the tumor demands complete resection of “mesopancreas”. In other words, dividing the proximal jejunal artery and vein at their roots of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) respectively during pancreaticoduodenectomy (PD) is absolutely essential. We present here our standardized dissection procedures around the SMA during the left posterior approach for PD. This procedure is safe and reproducible owing to the secure sealing performance of LigaSureTM Maryland.
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8
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Bacalbasa N, Balescu I, Diaconu C, Socea B, Gherghiceanu F, Stiru O, Brasoveanu V. Portal vein reconstruction with interposition of cryopreserved aortic graft: A case report and literature review. Exp Ther Med 2021; 23:184. [DOI: 10.3892/etm.2021.11107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/05/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Nicolae Bacalbasa
- Department of Visceral Surgery, Center of Excellence in Translational Medicine, ‘Fundeni’ Clinical Institute, 022328 Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, ‘Ponderas’ Academic Hospital, 021188 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Florentina Gherghiceanu
- Department of Marketing and Medical Technology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, ‘Prof. Dr. C.C. Iliescu’ Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Vladislav Brasoveanu
- Department of Visceral Surgery, Center of Excellence in Translational Medicine, ‘Fundeni’ Clinical Institute, 022328 Bucharest, Romania
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9
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Kang MJ, Kim S. Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of "art" and "science". Ann Gastroenterol Surg 2021; 5:738-746. [PMID: 34755005 PMCID: PMC8560610 DOI: 10.1002/ags3.12494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 12/18/2022] Open
Abstract
Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long-term survival outcomes, and various challenges in obtaining high-level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long-term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high-level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico-enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called "art" when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered "surgical artists," "surgical scientists," and "surgical practitioners." We look forward to more "surgical artists" educating future "surgical artists and scientists" to create a richer "spirit of innovation," leading to a more beautiful integration of art and science in the field of pancreatic surgery.
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Affiliation(s)
- Mee Joo Kang
- Department of SurgeryCenter for Liver and Pancreato‐Biliary CancerNational Cancer CenterGoyang‐siKorea
| | - Sun‐Whe Kim
- Department of SurgeryCenter for Liver and Pancreato‐Biliary CancerNational Cancer CenterGoyang‐siKorea
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10
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Peparini N. Paraaortic dissection in "total mesopancreas excision" and "mesopancreas-first resection" pancreaticoduodenectomies for pancreatic cancer: Useless, optional, or necessary?A systematic review. Surg Oncol 2021; 38:101639. [PMID: 34375818 DOI: 10.1016/j.suronc.2021.101639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/21/2021] [Accepted: 08/01/2021] [Indexed: 01/06/2023]
Abstract
The mesopancreas does not have well-defined boundaries but is continuous and connected through its components with the paraaortic area. The mesopancreatic resection margin has been indicated as the primary site for R1 resection after PD in pancreatic head cancer and total mesopancreas excision has been proposed to achieve adequate retropancreatic margin clearance and to minimize the likelihood of R1 resection. However, the anatomy of the mesopancreas requires extended dissection of the paraaortic area to maximize posterior clearance. The artery-first surgical approach has been developed to increase local radicality at the mesopancreatic resection margin. During PD, the artery-first approach begins with dissection of the connective tissues around the SMA. However, the concept of the mesopancreas as a boundless structure that includes circumferential tissues around the SMA, SMV, and paraaortic tissue highlights the need to shift from artery-first PD to mesopancreas-first PD to reduce the risk of R1 resection. From this perspective the "artery-first" approach, which allows for the avoidance of R2 resection risk, should be integrated into the "mesopancreas-first" approach to improve the R0 resection rate. In total mesopancreas excision and mesopancreas-first pancreaticoduodenectomies, the inclusion of the paraaortic area and circumferential area around the SMA in the resection field is necessary to control the tumour spread along the mesopancreatic resection margin rather than to control or stage the spread in the nodal basin.
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Affiliation(s)
- Nadia Peparini
- Azienda Sanitaria Locale Roma 6, Distretto 3, via Mario Calo' 5, 00043, Ciampino (Rome), Italy.
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11
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Franceschilli M, Vinci D, Di Carlo S, Sensi B, Siragusa L, Guida A, Rossi P, Bellato V, Caronna R, Sibio S. Central vascular ligation and mesentery based abdominal surgery. Discov Oncol 2021; 12:24. [PMID: 35201479 PMCID: PMC8777547 DOI: 10.1007/s12672-021-00419-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.
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Affiliation(s)
- M Franceschilli
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - D Vinci
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy.
| | - S Di Carlo
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - B Sensi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - L Siragusa
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - A Guida
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - P Rossi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - V Bellato
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - R Caronna
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
| | - S Sibio
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
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12
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Reconsideration of the Appropriate Dissection Range Based on Japanese Anatomical Classification for Resectable Pancreatic Head Cancer in the Era of Multimodal Treatment. Cancers (Basel) 2021; 13:cancers13143605. [PMID: 34298818 PMCID: PMC8303207 DOI: 10.3390/cancers13143605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/06/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022] Open
Abstract
Patients with resectable pancreatic cancer are considered to already have micro-distant metastasis, because most of the recurrence patterns postoperatively are distant metastases. Multimodal treatment dramatically improves prognosis; thus, micro-distant metastasis is considered to be controlled by chemotherapy. The survival benefit of "regional lymph node dissection" for pancreatic head cancer remains unclear. We reviewed the literature that could be helpful in determining the appropriate resection range. Regional lymph nodes with no suspected metastases on preoperative imaging may become areas treated with preoperative and postoperative adjuvant chemotherapy. Many studies have reported that the R0 resection rate is associated with prognosis. Thus, "dissection to achieve R0 resection" is required. The recent development of high-quality computed tomography has made it possible to evaluate the extent of cancer infiltration. Therefore, it is possible to simulate the dissection range to achieve R0 resection preoperatively. However, it is often difficult to distinguish between areas of inflammatory changes and cancer infiltration during resection. Even if the "dissection to achieve R0 resection" range is simulated based on the computed tomography evaluation, it is difficult to identify the range intraoperatively. It is necessary to be aware of anatomical landmarks to determine the appropriate dissection range during surgery.
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13
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Cinelli L, Felli E, Muttillo EM, Fiorentini G, Diana M, Pessaux P, Felli E. Prepancreatic common hepatic artery arising from superior mesenteric artery: an exceptional but important finding during pancreaticoduodenectomy. Surg Radiol Anat 2021; 43:1413-1420. [PMID: 34117902 DOI: 10.1007/s00276-021-02786-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The hepato-mesenteric trunk is an extremely rare condition in which the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA). Usually, CHA passes behind the head of the pancreas. A systematic review was performed to provide guidelines for the perioperative management of patients with this anatomical variation who underwent a pancreaticoduodenectomy (PD). A case report was also included. METHODS A systematic search of the literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. The risk of bias within individual studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Case report was structured according to the CARE guidelines. RESULTS After an initial selection of 141 titles, 9 articles were included in the study (n = 10 patients). A postoperative surgical complication which required a reintervention occurred only one time. In four patients, CHA had a posterior position relative to pancreas, while in three cases, it was anterior. The remaining three patients had an intrapancreatic course. The CHA was resected in two patients, with an end-to-end reconstruction or using the splenic artery stump. In only three patients, a preoperative multidisciplinary presentation was performed and in four cases, the CHA variation was not described by radiologists in formal CT-scan reports. CONCLUSION Although there are no definitive guidelines, improvements in the preoperative knowledge of such a rare anatomical variation may ensure better postoperative outcomes, avoiding intraoperative accidents and life-threatening postoperative complications.
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Affiliation(s)
- Lorenzo Cinelli
- IRCCS San Raffaele Scientific Institute, Milan, Italy.,Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France
| | - Eric Felli
- Hepatology, Department of Biomedical Research, Inselspital, Bern University, Bern, Switzerland
| | | | - Guido Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele Diana
- Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France.,University of Strasbourg, Strasbourg, France
| | - Patrick Pessaux
- HPB Unit, Digestive Surgery Department, Nouvel Hopital Civil, University of Strasbourg, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Emanuele Felli
- HPB Unit, Digestive Surgery Department, Nouvel Hopital Civil, University of Strasbourg, 1 Place de l'Hôpital, 67091, Strasbourg, France.
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14
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Fernandes EDSM, Strobel O, Girão C, Moraes-Junior JMA, Torres OJM. What do surgeons need to know about the mesopancreas. Langenbecks Arch Surg 2021; 406:2621-2632. [PMID: 34117891 DOI: 10.1007/s00423-021-02211-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 05/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatoduodenectomy is the only treatment with a promise of cure for patients with pancreatic head adenocarcinoma, and a negative resection margin is an important factor related to overall survival. Complete clearance of the medial margin with removal of the so-called mesopancreas may decrease the recurrence rate after pancreatic resection. Here, we present some important information about the mesopancreas, total mesopancreas excision, and technical aspects to achieve negative resection margins. The area named mesopancreas is defined as the tissue located between the head of the pancreas and the superior mesenteric vessels and the celiac axis and consists of the nerve plexus, lymphatic tissue, and connective tissue. The superior mesenteric and celiac arteries define the border of the mesopancreas. En bloc resection of anterior and posterior pancreatoduodenal nodes, hepatoduodenal nodes, along the superior mesenteric artery nodes, pyloric nodes, and nodes along the common hepatic artery is necessary. CONCLUSIONS Improved knowledge of the surgical anatomy of the region and technical refinements of excision of the mesopancreas along with standardized pathological examination are important to increase and to determine radical resection of pancreatic head cancer.
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Affiliation(s)
- Eduardo de Souza M Fernandes
- Department of Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil.,Department of Surgery, São Lucas Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Camila Girão
- Department of Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil.,Department of Surgery, São Lucas Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
| | - Jose Maria A Moraes-Junior
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Presidente Dutra Hospital, São Luiz, Brazil.,Department of Hepatopancreatobiliary Surgery, Hospital São Domingos-Rede Dasa, São Luiz, Brazil
| | - Orlando Jorge M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Presidente Dutra Hospital, São Luiz, Brazil. .,Department of Hepatopancreatobiliary Surgery, Hospital São Domingos-Rede Dasa, São Luiz, Brazil.
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15
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Safi SA, Haeberle L, Fluegen G, Lehwald-Tywuschik N, Krieg A, Keitel V, Luedde T, Esposito I, Rehders A, Knoefel WT. Mesopancreatic excision for pancreatic ductal adenocarcinoma improves local disease control and survival. Pancreatology 2021; 21:787-795. [PMID: 33775563 DOI: 10.1016/j.pan.2021.02.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Survival in ductal adenocarcinoma of the pancreatic head (hPDAC) is poor. After implementation of the circumferential resection margin (CRM) into standard histopathological evaluation, the margin negative resection rate has drastically dropped. However, the impact of surgical radicality on survival and the influence of malignant infiltration of the mesopancreatic fat remains unclear. At our institution, a standardized dissection of the mesopancreatic lamina and peri-pancreatic vessels are obligatory components of radical pancreatoduodenectomy. The aim of our study was to histopathologically analyze mesopancreatic tumor infiltration and the influence of CRM-evaluated resection margin on relapse-free and overall survival. METHOD Clinicopathological and survival parameters of 264 consecutive patients who underwent surgery for hPDAC were evaluated. RESULTS The rate of R0 resection R0(CRM-) was 48.5%, after the implementation of CRM. Mesopancreatic fat infiltration was evident in 78.4% of all consecutively treated patients. Patients with mesopancreatic fat infiltration were prone to lymphatic metastases (N1 and N2) and had a higher rate of positive resection margin (R1/R0(CRM+)). In multivariate analysis, only R0 resection was shown to be an independent prognostic parameter. Local recurrence was diagnosed in only 21.1% and was significantly lower in patients with R0(CRM-) resected hPDACs (10.9%, p < 0.001). CONCLUSION Mesopancreatic excision is justified, since mesopancreatic fat invasion was evident in the majority of our patients. It is associated with a significantly improved local tumor control as well as longer relapse-free and overall survival.
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Affiliation(s)
- S-A Safi
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - L Haeberle
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - G Fluegen
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - N Lehwald-Tywuschik
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - A Krieg
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - V Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - T Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - I Esposito
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - A Rehders
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - W T Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
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16
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Weyhe D, Obonyo D, Uslar VN, Stricker I, Tannapfel A. Predictive factors for long-term survival after surgery for pancreatic ductal adenocarcinoma: Making a case for standardized reporting of the resection margin using certified cancer center data. PLoS One 2021; 16:e0248633. [PMID: 33735191 PMCID: PMC7971889 DOI: 10.1371/journal.pone.0248633] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/02/2021] [Indexed: 12/15/2022] Open
Abstract
Factors for overall survival after pancreatic ductal adenocarcinoma (PDAC) seem to be nodal status, chemotherapy administration, UICC staging, and resection margin. However, there is no consensus on the definition for tumor free resection margin. Therefore, univariate OS as well as multivariate long-term survival using cancer center data was analyzed with regards to two different resection margin definitions. Ninety-five patients met inclusion criteria (pancreatic head PDAC, R0/R1, no 30 days mortality). OS was analyzed in univariate analysis with respect to R-status, CRM (circumferential resection margin; positive: ≤1mm; negative: >1mm), nodal status, and chemotherapy administration. Long-term survival >36 months was modelled using multivariate logistic regression instead of Cox regression because the distribution function of the dependent data violated the requirements for the application of this test. Significant differences in OS were found regarding the R status (Median OS and 95%CI for R0: 29.8 months, 22.3–37.4; R1: 15.9 months, 9.2–22.7; p = 0.005), nodal status (pN0 = 34.7, 10.4–59.0; pN1 = 17.1, 11.5–22.8; p = 0.003), and chemotherapy (with CTx: 26.7, 20.4–33.0; without CTx: 9.7, 5.2–14.1; p < .001). OS according to CRM status differed on a clinically relevant level by about 12 months (CRM positive: 17.2 months, 11.5–23.0; CRM negative: 29.8 months, 18.6–41.1; p = 0.126). A multivariate model containing chemotherapy, nodal status, and CRM explained long-term survival (p = 0.008; correct prediction >70%). Chemotherapy, nodal status and resection margin according to UICC R status are univariate factors for OS after PDAC. In contrast, long-term survival seems to depend on wider resection margins than those used in UICC R classification. Therefore, standardized histopathological reporting (including resection margin size) should be agreed upon.
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Affiliation(s)
- Dirk Weyhe
- University Hospital for Visceral Surgery, Pius-Hospital, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Dennis Obonyo
- University Hospital for Visceral Surgery, Pius-Hospital, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Verena Nicole Uslar
- University Hospital for Visceral Surgery, Pius-Hospital, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- * E-mail:
| | - Ingo Stricker
- Institute for Pathology, Ruhr University Bochum, Bochum, Germany
| | - Andrea Tannapfel
- Institute for Pathology, Ruhr University Bochum, Bochum, Germany
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17
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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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18
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Peparini N. Beyond "artery-first" pancreaticoduodenectomy for pancreatic carcinoma: Cattell-Braasch maneuver in "mesopancreas-first" pancreaticoduodenectomy. J Surg Oncol 2020; 122:1830. [PMID: 32893362 DOI: 10.1002/jso.26198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Nadia Peparini
- Distretto 3, Azienda Sanitaria Locale Roma 6, Ciampino, Italy
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19
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Nagakawa Y, Yi SQ, Takishita C, Sahara Y, Osakabe H, Kiya Y, Yamaguchi H, Miwa Y, Sato I, Tsuchida A. Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:342-351. [PMID: 32048456 DOI: 10.1002/jhbp.725] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/24/2020] [Accepted: 02/02/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of the present study was to investigate the feasibility of resection based on the nerve and fibrous tissue (NFT) structures around the superior mesenteric artery (SMA) for resectable pancreatic adenocarcinoma (R-PDAC) patients. METHODS NFTs around the SMA were classified into four "intensive NTFs area" with spreading the NFTs around the SMA and three SMA nerve plexus regions without branching nerves according to autopsy findings. Complete dissection of four "intensive NTFs areas" was performed by pre-exposing three SMA nerve plexus regions without branching nerves as "dissection-guiding points" with SMA nerve plexus preservation (NFT-based resection). Among 157 R-PDAC patients undergoing pancreaticoduodenectomy, surgical outcomes of 78 patients with NFT-based resection were compared with 59 patients with half-SMA nerve plexus dissection and 20 patients without NFTs dissection. RESULTS In the NFT-based resection group, 76.5% had tumor involvement and metastasis in each intensive NTFs area. Operative time, blood loss, and postoperative diarrhea rate were significantly lower in NFT-based resection than in half-SMA nerve plexus group (321 vs 390 min; P < .01, 228 vs 550 mL; P < .01, 5.1% vs 15.3%; P = .04, respectively). R0 rate and median overall survival significantly improved in NFT-based resection than in non-NFT dissection group (93.6% vs 65.0%; P < .01, 49.6 vs 23.6 months, P = .01). CONCLUSION NFT-based resection may become a novel method for R-PDAC patients.
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Affiliation(s)
- Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Shuang-Qin Yi
- Department of Frontier Health Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yatsuka Sahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yoshitaka Kiya
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | | | - Yoko Miwa
- Department of Anatomy, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan
| | - Iwao Sato
- Department of Anatomy, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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20
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Dolay K, Malya FU, Akbulut S. Management of pancreatic head adenocarcinoma: From where to where? World J Gastrointest Surg 2019; 11:143-154. [PMID: 31057699 PMCID: PMC6478601 DOI: 10.4240/wjgs.v11.i3.143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.
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Affiliation(s)
- Kemal Dolay
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery, Istinye University, Liv Hospital, Istanbul 34340, Turkey
| | - Fatma Umit Malya
- Department of Surgery, Bezmialem Vakif University Faculty of Medicine, Istanbul 34093, Turkey
| | - Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
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21
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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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22
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Ramia JM, De-la-Plaza R, Manuel-Vazquez A, Lopez-Marcano A, Morales R. Systematic review of the mesopancreas: concept and clinical implications. Clin Transl Oncol 2018; 20:1385-1391. [PMID: 29675778 DOI: 10.1007/s12094-018-1869-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP. METHODS An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian). RESULTS The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series. CONCLUSION MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.
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Affiliation(s)
- J M Ramia
- Department of Surgery, Guadalajara University Hospital, University of Alcala, Guadalajara, Spain.
| | - R De-la-Plaza
- Department of Surgery, Guadalajara University Hospital, University of Alcala, Guadalajara, Spain
| | - A Manuel-Vazquez
- Department of Surgery, Guadalajara University Hospital, University of Alcala, Guadalajara, Spain
| | - A Lopez-Marcano
- Department of Surgery, Guadalajara University Hospital, University of Alcala, Guadalajara, Spain
| | - R Morales
- Department of Surgery, Hospital Son Espases, Palma de Mallorca, Spain
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23
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Maplanka C. A comprehensive study of the mesopancreas as an extension of the pancreatic circumferential resection margin. Eur Surg 2018. [DOI: 10.1007/s10353-018-0535-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Negoi I, Beuran M, Hostiuc S, Negoi RI, Inoue Y. Surgical Anatomy of the Superior Mesenteric Vessels Related to Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2018; 22:802-817. [PMID: 29363018 DOI: 10.1007/s11605-018-3669-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/02/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery. METHODS We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017. RESULTS Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases. CONCLUSIONS Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.
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Affiliation(s)
- Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania.
- Department of General Surgery, Emergency Hospital of Bucharest, Romania, Bucharest, Romania.
| | - Mircea Beuran
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania
- Department of General Surgery, Emergency Hospital of Bucharest, Romania, Bucharest, Romania
| | - Sorin Hostiuc
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania
- Department of Legal Medicine and Bioethics, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania
| | - Ruxandra Irina Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania
| | - Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Zhu J, Li X, Kou J, Ma J, Li L, Fan H, Lang R, He Q. Proposed Chaoyang vascular classification for superior mesenteric-portal vein invasion, resection, and reconstruction in patients with pancreatic head cancer during pancreaticoduodenectomy - A retrospective cohort study. Int J Surg 2018; 53:292-297. [PMID: 29654962 DOI: 10.1016/j.ijsu.2018.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 04/01/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with pancreatic head cancer involving the superior mesenteric-portal vein can benefit from vascular resection and reconstruction. We aimed to propose our vascular classification and assess its effect in this study. MATERIAL AND METHODS Data of consecutive patients, who were diagnosed with pancreatic head cancer, and underwent radical pancreaticoduodenectomy combined with superior mesenteric-portal vein resection and reconstruction at our institute between October 2013 and August 2016, were retrospectively collected. On a scale of one to four, our classification was proposed. Perioperative parameters were then analyzed among the four types. RESULTS There were a total of 52 patients with 11 in type Ⅰ, 15 in type Ⅱ, 18 in type Ⅲ, 8 in type Ⅳ. The respective operative time and estimated blood loss of types Ⅲ (425-990 min, 265-1820 mL) and Ⅳ (480-1036 min, 330-1690 mL) were greater than those of types Ⅰ (300-824 min, 200-1255 mL) and Ⅱ (369-875 min, 305-1400 mL) (p < 0.05). Type Ⅳ had larger tumors (4-7 cm) than type Ⅰ (1.5-4 cm) (p < 0.05). Percentage of tunica intima involvement and the median survival time of type Ⅰ (9.1%, 22 months) were lower and longer than those of types Ⅱ (46.7%, 17 months) and Ⅲ (44.4%, 16 months; p < 0.05), and even lower and longer than those of type Ⅳ (87.5%, 10 months; p < 0.01), respectively. CONCLUSIONS Our classification can provide a system to grade patients with venous invasion in order of surgical difficulty and survival.
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Affiliation(s)
- Jiqiao Zhu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Xianliang Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Jiantao Kou
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Jun Ma
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Lixin Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Hua Fan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China.
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Liu DN, Lv A, Tian ZH, Tian XY, Guan XY, Dong B, Zhao M, Hao CY. Superior mesenteric artery margin in pancreaticoduodenectomy for pancreatic adenocarcinoma. Oncotarget 2018; 8:7766-7776. [PMID: 27999192 PMCID: PMC5352359 DOI: 10.18632/oncotarget.13950] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/01/2016] [Indexed: 12/15/2022] Open
Abstract
The aim of this study is trying to describe more details of superior mesenteric artery margin in pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, to evaluate biological and prognostic implications of tumor budding in this margin, and to provide more evidence for evaluation of R0 surgery in pancreaticoduodenectomy. 46 patients in 5-years period are included in this study. Immunochemistry and immunofluorescence are used to analyze tumor budding and epithelial-mesenchymal transition. Superior mesenteric artery margin might be described from four aspects including location, gross appearance, microscopic appearance and tumor budding. We find that 1mm rule for R1 surgery is more appropriate to predict prognosis (P = 0.009) than 0mm rule (P = 0.141). Expression of cytokeratin in tumor budding is significantly lower than primary tumor (P = 0.001), and it suggests that tumor budding may participate the procedure of epithelial-mesenchymal transition. High-grade tumor budding and decreasing cytokeratin of tumor budding correlate with distant metastasis and has negative influence on prognosis. So superior mesenteric artery margin might be not only an area that tumor cells may invade, but also a pathway for distant metastasis. It is necessary to evaluate superior mesenteric artery margin in pancreaticoduodenectomy for pancreatic cancer.
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Affiliation(s)
- Dao-Ning Liu
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Ang Lv
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Zhi-Hua Tian
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Beijing, People's Republic of China
| | - Xiu-Yun Tian
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Xiao-Ya Guan
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Bin Dong
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Beijing, People's Republic of China
| | - Min Zhao
- Department of Pathology, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Chun-Yi Hao
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
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Pędziwiatr M, Pisarska M, Małczak P, Major P, Wierdak M, Radkowiak D, Kulawik J, Dembiński M, Budzyński A. Laparoscopic uncinate process first pancreatoduodenectomy-feasibility study of a modified 'artery first' approach to pancreatic head cancer. Langenbecks Arch Surg 2017; 402:917-923. [PMID: 28699023 PMCID: PMC5563330 DOI: 10.1007/s00423-017-1597-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/31/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study was to discuss the feasibility of laparoscopic 'uncinate first' pancreatoduodenectomy. METHODS The analysis included prospectively collected data from 12 consecutive patients undergoing elective pure laparoscopic 'uncinate process first' pancreatoduodenectomy (Group 1). They were compared with patients previously operated on with a classical laparoscopic approach (Group 2). The primary outcome was the quality of the resected specimen (lymph node (LN) yield, R0 rate, involved resection margins). Secondary outcomes were perioperative parameters. RESULTS The LN yield in Group 1 was 19.3 and in Group 2 it was 13.9 (p = 0.03). R0 resection rates did not vary (66.7 vs. 63.2%, p = 0.84). Although the involvement of the superior mesenteric artery margin and uncinate process margin seemed lower in Group 1, the difference was not significant. Total operative time (467 vs. 425 min, p = 0.13) and resection time (221 vs. 232 min, p = 0.34) were similar in both groups. The estimated blood loss in Group 1 was 408 ml, whereas in Group 2 it was 392 ml (p = 0.33). Complication rates were 66.7% in Group 1 and 63.2% in Group 2 (p = 0.84). Median length of stay was 9 days in both groups (p = 0.36). Postoperative complication rates did not differ between groups. CONCLUSIONS Laparoscopic uncinate first approach is a feasible method for pancreatic head neoplasms. Achieved quality of the specimen is comparable with the traditional laparoscopic approach, whereas intra- and postoperative course is not inferior. However, further studies on larger cohorts are required to fully establish whether the novel approach has potential advantages over classical access in pancreatic head cancer.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland.
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
| | - Dorota Radkowiak
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
| | - Jan Kulawik
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
| | - Marcin Dembiński
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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Hirono S, Kawai M, Okada KI, Miyazawa M, Shimizu A, Kitahata Y, Ueno M, Shimokawa T, Nakao A, Yamaue H. Mesenteric approach during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2017; 1:208-218. [PMID: 29863125 PMCID: PMC5881370 DOI: 10.1002/ags3.12013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/24/2017] [Indexed: 12/17/2022] Open
Abstract
Mesenteric approach is an artery‐first approach during pancreaticoduodenectomy (PD). In the present study, we evaluated clinical and oncological benefits of this procedure for pancreatic ductal adenocarcinoma (PDAC) of the pancreas head. Between 2000 and 2015, 237 consecutive PDAC patients underwent PD. Among them, 72 experienced the mesenteric approach (mesenteric group) and 165 the conventional approach (conventional group). A matched‐pairs group consisted of 116 patients (58 patients in each group) matched for age, gender, resectability status, and neoadjuvant therapy. Surgical and oncological outcomes were compared between the two groups in unmatched‐ and matched‐pair analyses. Intraoperative blood loss was lower in the mesenteric group than in the conventional group in both resectable PDAC (R‐PDAC) and borderline resectable PDAC (BR‐PDAC) on unmatched‐ and matched‐pairs analyses (R‐PDAC, unmatched: 312.5 vs 510 mL, P=.008; matched: 312.5 vs 501.5 mL, P=.023; BR‐PDAC, unmatched: 507.5 vs 935 mL, P<.001; matched: 507.5 vs 920 mL, P=.003). Negative surgical margins (R0) and overall survival (OS) rates in the mesenteric group were better in R‐PDAC patients (R0 rates, unmatched: 100% vs 87.7%, P=.044; matched: 100% vs 86.7%, P=.045; OS, unmatched: P=.008, matched: P=.021), although there were no significant differences in BR‐PDAC patients. Mesenteric approach might reduce blood loss by early ligation of the vessels to the pancreatic head. Furthermore, it might increase R0 rate, leading to improvement of survival for R‐PDAC patients. However, R0 and survival rates could not be improved only by the mesenteric approach for BR‐PDAC patients. Therefore, effective multidisciplinary treatment is essential to improve survival in BR‐PDAC patients.
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Affiliation(s)
- Seiko Hirono
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Manabu Kawai
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Ken-Ichi Okada
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Motoki Miyazawa
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Atsushi Shimizu
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Yuji Kitahata
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Masaki Ueno
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
| | - Toshio Shimokawa
- Clinical Study Support Center School of Medicine Wakayama Medical University Wakayama Japan
| | - Akimasa Nakao
- Department of Surgery Nagoya Central Hospital Nagoya Japan
| | - Hiroki Yamaue
- Second Department of Surgery School of Medicine Wakayama Medical University Wakayama Japan
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Sharma D, Isaji S. Mesopancreas is a misnomer: time to correct the nomenclature. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:745-749. [PMID: 27734589 DOI: 10.1002/jhbp.402] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/15/2016] [Indexed: 12/28/2022]
Abstract
Focused pathological attention to tumor invasion of the retroperitoneal resection margin after pancreaticoduodenectomy for cancer of head of the pancreas led to the knowledge of strong tendency of cancer cells to infiltrate into the retropancreatic tissue and to spread along the peripancreatic neural plexuses as the cause of local recurrence. The term 'mesopancreas' was coined to describe perineural lymphatic layer located dorsally to the pancreas and it was suggested that its complete resection will minimize loco-regional recurrence and improve outcome. This catchy title and concept attracted the attention of surgeons and "total meso-pancreas excision" was introduced by 'artery first' or 'posterior first' surgical techniques to ensure 'en-bloc' extended resection of retropancreatic lymphatics. However, mesopancreas is a misnomer and cannot be called a 'true' mesentery as it does not have a fascial envelope attaching the pancreas to the posterior wall of the abdomen and does not contain 'all' its blood vessels and 'all' its primary draining lymphatics and lymph nodes. Japan Pancreas Society's description of pancreatic head plexus II is anatomically consistent with 'mesopancreas' and it should be renamed as such. This nomenclature clearly illustrates its exact anatomical location and surgical relevance; and stands up to necessary rigorous scientific scrutiny.
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Affiliation(s)
- Dhananjaya Sharma
- Department of Surgery, Government Medical College and Allied Hospitals, Jabalpur, Madhya Pradesh 482 003, India
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
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30
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Rodríguez-Luna R, Guarneros-Zárate JE, Tueme-Izaguirre J. Reply to: #00291 Total Mesorectal Excision, an erroneous anatomical term for the gold standard in rectal cancer treatment'. Int J Surg 2016; 36:392-393. [PMID: 27793639 DOI: 10.1016/j.ijsu.2016.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Rita Rodríguez-Luna
- Hospital Angeles Mocel, Facultad Mexicana de Medicina, Universidad La Salle, Posgrado, Mexico.
| | - Joaquin E Guarneros-Zárate
- Hospital Angeles Mocel, Departamento de Anatomía, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico
| | - Jorge Tueme-Izaguirre
- Hospital Angeles Mocel, Facultad Mexicana de Medicina, Universidad La Salle, Posgrado, Mexico
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Hafeez Bhatti AB, Dar FS, Sahaab E, Khan NY, Zia H, Rana A, Salih M, Shah NH. Survival advantage with para aortic lymphadenectomy in peri-ampullary cancer: A retrospective cohort study. Int J Surg 2016; 31:58-62. [PMID: 27262530 DOI: 10.1016/j.ijsu.2016.05.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/15/2016] [Accepted: 05/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metastatic para aortic lymph nodes (PALN) in patients with peri ampullary cancer entail poor prognosis. Role of curative surgery in these patients remains debatable. The objective of the current study was to evaluate outcome after extended pancreaticoduodenectomy (PD) in patients with and without positive PALN. METHODS We reviewed 65 patients who underwent extended PD with PALN removal between 2011 and 2014. Patients were divided into two groups; those with positive PALN and those without. Patients were sub classified for pancreatic and non-pancreatic cancer. Outcome was determined based on median and estimated 3 year overall survival. RESULTS Median age was 57 (32-85) years. PALN were involved in 15 (23%) patients. Overall 3 year survival for patients with and without positive PALN was 60% and 54% (P = 0.7). Significant difference in survival was present between patients with pancreatic cancer and positive PALN [9 (3-12) months] versus non-pancreatic cancers with positive PALN [17.5 (13-38) months] (P = 0.02). Four out of five patients with pancreatic cancer and positive PALN had survival >6 months and 3 out of these 5 patients were alive at the last follow up. CONCLUSION Curative surgery may benefit some patients with pancreatic cancer and positive PALN and should be considered selectively.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan.
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Eraj Sahaab
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Pakistan
| | - Najmul Hassan Shah
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Pakistan
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Peparini N. Para-Aortic Dissection in Pancreaticoduodenectomy with Mesopancreas Excision for Pancreatic Head Carcinoma: Not Only an N-Staging Matter. J Gastrointest Surg 2016; 20:1080-1. [PMID: 27000126 DOI: 10.1007/s11605-016-3131-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/09/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Nadia Peparini
- Nadia Peparini, Azienda Sanitaria Locale Roma H-Distretto 3, via Mario Calò, 5, 00043, Ciampino, Rome, Italy.
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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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Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a malignant tumor of the digestive system with a high degree of malignancy, accounting for about 90% of cases of pancreatic cancer. It has an occult onset and progresses rapidly, with a poor treatment effect and prognosis. It is one of malignant tumors with the worst prognosis. Surgical resection, as the only effective treatment, can be performed in only 20%-30% of patients, and the average period of survival after surgery is still less than 2 years. The main treatment strategy for PDAC are surgery-based individualized treatment modalities under comprehensive multidisciplinary collaboration. Currently, the therapeutic effect on pancreatic cancer is still not satisfactory. In recent years, various treatments for PDAC is becoming a hot spot of research. This article reviews the progress in the treatment of PDAC in terms of radical surgery, palliative surgery, adjuvant therapy, and other treatment opinions.
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Welsch T, Bork U, Distler M, Weitz J. Top-down approach to the superior mesenteric artery and the mesopancreas during pancreatoduodenectomy for pancreatic cancer. J Surg Oncol 2016; 113:668-71. [PMID: 26898308 DOI: 10.1002/jso.24204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 02/03/2016] [Indexed: 01/02/2023]
Abstract
Complete surgical resection with microscopically tumor-free resection margins (R0) is the most important survival determinant for patients with localized pancreatic cancer. The medial and posterior resection margins are the dominant sites of microscopic tumor involvement, and outline the so-called mesopancreas. In this study, we present a modified surgical approach to the superior mesenteric artery, celiac trunc, and mesopancreas during pancreatoduodenectomy, which enables a comfortable exposure and radical en bloc clearance of the mesopancreas and the tissue adjacent to the superior mesenteric artery. The dissection of the mesopancreas is directed from the ventral aspect of the portal vein downward along the superior mesenteric artery and the celiac trunc, before the transection of the duodenal mesentery is accomplished. The described technique complements the established surgical approaches to pancreatic head tumors, and is indicated in the absence of portal vein infiltration. J. Surg. Oncol. 2016;113:668-671. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ulrich Bork
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Peparini N, Caronna R, Chirletti P. The "meso" of the rectum and the "meso" of the pancreas: similar terms but distinct concepts in surgical oncology. Hepatobiliary Pancreat Dis Int 2015; 14:548-551. [PMID: 26459733 DOI: 10.1016/s1499-3872(15)60417-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A correspondence between the "meso" of the rectum and of the pancreas has recently been reported. Here we highlight the differences between mesorectum and mesopancreas. Based on anatomical findings from a series of 89 consecutive pancreaticoduodenectomies and 71 consecutive total mesorectal excisions, we observed that in contrast to the mesorectum, the mesopancreas did not have well-defined anatomic boundaries and was continuous and connected through its components with the para-aortic area. In rectal cancer, tumor deposits and nodal involvement could be confined to the mesorectum (i.e., within the mesorectal fascia), whereas in pancreatic carcinoma, tumor deposits and nodal metastases occurred in the boundless mesopancreatic area. Total mesorectal excision was made en bloc with the rectum by dissecting along the mesorectal fascia; this was not the case for mesopancreatic excision since anatomical demarcation of the mesopancreas did not exist. Moreover, the growth pattern of pancreatic cancer showed greater dispersion, which was more prominent at the invasive front of the tumor and could potentially affect the status of the resection margin. These findings indicate that the mesorectum and mesopancreas are completely distinct from the pathological, surgical, and oncological standpoints.
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Affiliation(s)
- Nadia Peparini
- Azienda Sanitaria Locale Roma H-Distretto 3, via Mario Calo, 5-00043 Ciampino, Rome, Italy.
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Liu C, Chen R, Chen Y, Fu D, Hong D, Hao J, Liu D, Li J, Li S, Li Y, Mai G, Mou Y, Ni Q, Peng L, Qian H, Qin R, Sun B, Shao C, Sun Y, Tian B, Wang J, Wang W, Wang W, Zhao G, Yu X. Should a standard lymphadenectomy during pancreatoduodenectomy exclude para-aortic lymph nodes for all cases of resectable pancreatic head cancer? A consensus statement by the Chinese Study Group for Pancreatic Cancer (CSPAC). Int J Oncol 2015; 47:1512-1516. [PMID: 26314752 DOI: 10.3892/ijo.2015.3128] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/10/2015] [Indexed: 02/05/2023] Open
Abstract
Understanding and formulating an appropriate strategy for the para-aortic lymph nodes (LN16) during curative surgery for pancreatic head cancer have been controversial for some time. This study intended to provide a recommendation for surgeons to perform an optimal curative surgery on pancreatic cancer patients with or without LN16 involvement. Based on an updated literature search and review, the members of the Chinese Study Group for Pancreatic Cancer (CSPAC) from high-volume centers reached a consensus on the issue of LN16 in pancreatic head cancer. Metastasis to LN16 is quite common in pancreatic head cancer cases. Depending on the location of the tumor, including the ventral and dorsal pancreas, there could be various lymph node drainage pathways whereby LN16 does not necessarily belong to the Group 3 lymph node stations for all cases of pancreatic head cancer. Although LN16 involvement generally indicates a poor prognosis, some cohorts of LN16-involved cases have benefited from a curative surgery, and there is still a lack of level I evidence to convince surgeons to abandon all resectable cases with LN16 positivity. Resection of LN16 combined with a standard lymphadenectomy during pancreatoduodenectomy is recommended by CSPAC, except in patients with both positive LN16 and criteria based on: i) the resectability status of primary tumor; ii) the extent of involved para-aortic lymph nodes; and iii) the serum tumor burden assessed preoperatively.
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Affiliation(s)
- Chen Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Rufu Chen
- Department of Pancreaticobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yingtai Chen
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Defei Hong
- Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, P.R. China
| | - Jihui Hao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, P.R. China
| | - Dawei Liu
- Department of General Surgery of Heilongjiang Provincial Hospital, Harbin, Heilongjiang, P.R. China
| | - Jiangtao Li
- Department of Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Shengping Li
- Department of Hepatobiliary Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yixiong Li
- Department of Pancreatic-Bililary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Gang Mai
- Department of Hepatobiliopancreatic Surgery, The People's Hospital of Deyang, Deyang, P.R. China
| | - Yiping Mou
- Department of Gastroenterological and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, P.R. China
| | - Quanxing Ni
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Li Peng
- Department of Hepato-Pancreato-Biliary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Honggang Qian
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, P.R. China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P.R. China
| | - Chenghao Shao
- Department of Pancreatic-Biliary Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Bole Tian
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Wei Wang
- Department of Surgery, Huadong Hospital, Fudan University, Shanghai, P.R. China
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Gang Zhao
- The Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Xianjun Yu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
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Iannone F, Porzia A, Peruzzi G, Birarelli P, Milana B, Sacco L, Dinatale G, Peparini N, Prezioso G, Battella S, Caronna R, Morrone S, Palmieri G, Mainiero F, Chirletti P. Effect of surgery on pancreatic tumor-dependent lymphocyte asset: modulation of natural killer cell frequency and cytotoxic function. Pancreas 2015; 44:386-393. [PMID: 25621568 PMCID: PMC4358707 DOI: 10.1097/mpa.0000000000000288] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 09/03/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Tumor burden and invasiveness establish a microenvironment that surgery could alter. This study shows a comprehensive analysis of size, dynamics, and function of peripheral lymphocyte subsets in pancreatic cancer patients before and at different times after duodenopancreatectomy. METHODS Lymphocyte frequency and natural cytotoxicity were evaluated by flow cytometry and in vitro assay on peripheral blood from initial and advanced-stage pancreatic cancer patients before (BS), at day 7 (PS7), and at day 30 (PS30) after surgery. RESULTS An increase in natural killer (NK) cells and the diminution of B-cells occurred at PS30, whereas cytotoxicity decreased at PS7. The positive correlation between NK frequency and cytotoxicity at BS and PS7 revealed an altered NK behavior. The elevation of NK cell frequency at PS30, an initial defect in CD56bright NK, and the aberrant correlation between NK frequency and cytotoxicity remained significant in advanced-stage patients, whereas the diminution of NK cytotoxicity only affected initial stage patients. CONCLUSIONS The NK cell functional ability is altered in presurgery patients; duodenopancreatectomy is associated with short-term impairment of NK function and with a long-term NK cell augmentation and reversion of the aberrant NK behavior, which may impact on immunosurveillance against residual cancer.
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Affiliation(s)
- Francesco Iannone
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Alessandra Porzia
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Giovanna Peruzzi
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Patrizia Birarelli
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Bernardina Milana
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Luca Sacco
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Giuseppe Dinatale
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Nadia Peparini
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Giampaolo Prezioso
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Simone Battella
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Roberto Caronna
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Stefania Morrone
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Gabriella Palmieri
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Fabrizio Mainiero
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Piero Chirletti
- From the *Section of Interdisciplinary Surgery F. Durante, Department of Surgical Sciences, †Department of Molecular Medicine, ‡Istituto Italiano di Tecnologia, CLNS, and §Department of Experimental Medicine, Sapienza University of Rome, Italy
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Peparini N. Mesopancreas: A boundless structure, namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma. World J Gastroenterol 2015; 21:2865-2870. [PMID: 25780282 PMCID: PMC4356904 DOI: 10.3748/wjg.v21.i10.2865] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/27/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
This review highlights the rationale for dissection of the 16a2 and 16b1 paraaortic area during pancreaticoduodenectomy (PD) for carcinoma of the head of the pancreas. Recent advances in surgical anatomy of the mesopancreas indicate that the retropancreatic area is not a single entity with well defined boundaries but an anatomical site of embryological fusion of peritoneal layers, and that continuity exists between the neuro lymphovascular adipose tissues of the retropancreatic and paraaortic areas. Recent advances in surgical pathology and oncology indicate that, in pancreatic head carcinoma, the mesopancreatic resection margin is the primary site for R1 resection, and that epithelial-mesenchymal transition-related processes involved in tumor progression may impact on the prevalence of R1 resection or local recurrence rates after R0 surgery. These concepts imply that mesopancreas resection during PD for pancreatic head carcinoma should be extended to the paraaortic area in order to maximize retropancreatic clearance and minimize the likelihood of an R1 resection or the persistence of residual tumor cells after R0 resection. In PD for pancreatic head carcinoma, the rationale for dissection of the paraaortic area is to control the spread of the tumor cells along the mesopancreatic resection margin, rather than to control or stage the nodal spread. Although mesopancreatic resection cannot be considered “complete” or “en bloc”, it should be “extended as far as possible” or be “maximal”, including dissection of 16a2 and 16b1 paraaortic areas.
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Peparini N. Resection of the mesopancreas in pancreatic head adenocarcinoma: Is it outside of the International Study Group on Pancreatic Surgery definition and consensus statement for standard and extended pancreatectomy? Surgery 2015; 158:310-1. [PMID: 25704416 DOI: 10.1016/j.surg.2015.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 01/13/2015] [Indexed: 01/15/2023]
Affiliation(s)
- Nadia Peparini
- Azienda Sanitaria Locale Roma H- Distretto 3 Ciampino, via Mario Calò, 5-00043, Ciampino, Rome, Italy.
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Hind right approach pancreaticoduodenectomy: from skill to indications. Gastroenterol Res Pract 2014; 2014:210835. [PMID: 25221601 PMCID: PMC4142783 DOI: 10.1155/2014/210835] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 05/18/2014] [Accepted: 05/19/2014] [Indexed: 12/12/2022] Open
Abstract
Background. Pancreaticoduodenectomy is the potentially curative treatment for malignant and several benign conditions of the pancreatic head and periampullary region. While performing pancreaticoduodenectomy, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels, intraductal papillary mucinous neoplasm, and pancreatic head bleeding pseudoaneurysm. Our work aims to highlight a particular hind right approach pancreaticoduodenectomy in selected indications and assess the preliminary results. Methods. We describe our early hind right approach to the retropancreatic vasculature during pancreaticoduodenectomy by mesopancreas dissection before any pancreatic or digestive transection. Results. We used this approach in 52 patients. Thirty-two had hepatic artery anatomic variant and 2 had bleeding pancreatic head pseudoaneurysm. The hepatic artery variant was preserved in all cases out of 2 in which arterial reconstruction was performed. In nine patients with intraductal papillary mucinous neoplasms the pancreaticoduodenectomy was extended to the body in 6 and totalized in 3 patients. Seven patients with adenocarcinoma involving the portomesenteric axis required venous resection and reconstruction. Conclusions. Early hind right approach is advocated in selected cases of pancreaticoduodenectomy to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement.
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