Editorial
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 14, 2015; 21(10): 2865-2870
Published online Mar 14, 2015. doi: 10.3748/wjg.v21.i10.2865
Mesopancreas: A boundless structure, namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma
Nadia Peparini
Nadia Peparini, Azienda Sanitaria Locale Roma H- Distretto 3, 00043 Ciampino (Rome), Italy
Author contributions: Peparini N conceived the study, contributed to acquisition, analysis and interpretation of data, drafted and critically revised the manuscript, gave final approval of the article to be published.
Conflict-of-interest: The author declares no conflicting interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Nadia Peparini, MD, PhD, Azienda Sanitaria Locale Roma H-Distretto 3, via Mario Calò, 5-00043 Ciampino (Rome), Italy. nadiapeparini@yahoo.it
Telephone: +39-6-93275421 Fax: +39-6-79321150
Received: November 10, 2014
Peer-review started: November 12, 2014
First decision: December 11, 2014
Revised: December 27, 2014
Accepted: February 5, 2015
Article in press: February 5, 2015
Published online: March 14, 2015
Processing time: 125 Days and 19.1 Hours
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.

Keywords: Pancreatic carcinoma; Mesopancreas; Mesopancreas resection; Paraaortic area; Paraaortic dissection

Core tip: The rationale for dissection of the 16a2 and 16b1 paraaortic areas in pancreaticoduodenectomy for pancreatic head carcinoma is to control tumor spread along the mesopancreatic resection margin (R factor), rather than to control or stage the nodal spread (N factor).