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Nguyen HH, Nguyen TK, Trinh HS, Do HD, Luong TH, Pham HM, Le VD, Do VM, Chantha P, Pham HQ, Nguyen DV. Feasibility of middle colic artery as a landmark for superior mesenteric artery - first approach in laparoscopic pancreatoduodenectomy: a prospective study. World J Surg Oncol 2024; 22:141. [PMID: 38802849 PMCID: PMC11131284 DOI: 10.1186/s12957-024-03416-3] [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: 03/05/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND SMA-first approach in pancreatoduodenectomy (PD) has been widely applied in open surgery as well as laparoscopy. Finding the superior mesenteric artery (SMA), inferior pancreatoduodenal artery (IPDA), first jejunal artery (J1A) has become a great challenge in laparoscopic PD (LPD). Meanwhile, exposing the midde colic artery (MCA) might be a feasible approach to determine SMA, IPDA, and J1A. Our study aims to find the anatomical correlation between MCA and SMA, IPDA, J1A, especially in SMA-first approach LPD from the left. METHODS Uncontrolled clinical trial with 33 patients undergoing LPD had preoperative contrast abdominal CT scan to analyze the anatomical relevance between MCA and SMA, J1A, IPDA. The operation was performed starting with exposing MCA in advance to find SMA, J1A and IPDA. The data was analyzed by SPSS 25.0. RESULTS 90.9% of MCA started at 12-3 o'clock from SMA, the mean distance from the SMA root to the MCA and J1A was 56.4 mm and 37.4 mm, respectively. The distance between SMA and J1A was 19 mm. 72.7% J1A started at 9-12 o'clock, 69.7% J1A and IPDA had a common trunk. 78.8% IPDA started at 3-6 o'clock. 100% of the cases had J1A controlled intraoperatively, 81.8% for IPDA when approached from the left, 3% had MCA injury. The mean time to approach from the left was 98 min, median blood loss was 100 ml. CONCLUSION Exposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of the mesopancreas and lymph nodes.
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Affiliation(s)
- Ham Hoi Nguyen
- Hanoi Medical University, Hanoi, Vietnam
- Center of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Thanh Khiem Nguyen
- Center of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam.
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam.
| | - Hong Son Trinh
- Deparment of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Hai Dang Do
- Organ Transplantation Center, Viet Duc University Hospital, Hanoi, Vietnam
| | - Tuan Hiep Luong
- Center of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Van Duy Le
- Center of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Van Minh Do
- Center of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Hong Quang Pham
- Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
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Nguyen TK, Nguyen HH, Luong TH, Dang KK, Le VD, Tran DD, Do VM, Pham HQ, Pham HM, Tran TL, Nguyen CT, Trinh HS, Inoue Y. Pancreaticoduodenectomy with superior mesenteric artery first-approach combined total meso-pancreas excision for periampullary malignancies: A high-volume single-center experience with short-term outcomes. Ann Hepatobiliary Pancreat Surg 2024; 28:59-69. [PMID: 38049111 PMCID: PMC10896681 DOI: 10.14701/ahbps.23-068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 12/06/2023] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is the only radical treatment for periampullary malignancies. Superior mesenteric artery (SMA) first approach combined with total meso-pancreas (MP) excision was conducted to improve the oncological results. There has not been any previous research of a technique that combines the SMA first approach and total MP excision with a detailed description of the MP macroscopical shape. Methods We prospectively assessed 77 patients with periampullary malignancies between October 2020 and March 2022 (18 months). All patients had undergone PD with SMA first approach combined total MP excision. The perioperative indications, clinical data, intra-operative index, R0 resection rate of postoperative pathological specimens (especially mesopancreatic margin), postoperative complications, and follow-up results were evaluated. Results The median operative time was 289.6 min (178-540 min), the median intraoperative blood loss was 209 mL (30-1,600 mL). Microscopically, there were 19 (24.7%) cases with metastatic MP, and five cases (6.5%) with R1-resection of the MP. The number of lymph nodes (LNs) harvested and metastatic LNs were 27.2 (maximum was 74) and 1.8 (maximum was 16), respectively. Some (46.8%) patients had pancreatic fistula, but mostly in grade A, with 7 patients (9.1%) who required re-operations. Some 18.2% of cases developed postoperative refractory diarrhea. The rate of in-hospital mortality was 1.3%. Conclusions The PD with SMA first approach combined TMpE for periampullary malignancies was effective in achieving superior oncological statistics (rate of MP R0-resection and number of total resected LNs) with non-inferior short-term outcomes. It is necessary to evaluate survival outcomes with long-term follow-up.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Hiep Luong
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Van Duy Le
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Duc Dung Tran
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
| | - Van Minh Do
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Hong Quang Pham
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
| | | | - Thi Lan Tran
- Pathology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Cuong Thinh Nguyen
- 108 Institute of Clinical Medical and Pharmaceutical Sciences, Hanoi, Vietnam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Khiem T, Hoi H, Hiep T, Khue K, Duy V, Inoue Y, Son H, Dung D. Total laparoscopic pancreaticoduodenectomy with left posterior superior mesenteric artery first-approach and plexus-preserving circumferential lymphadenectomy: step-by-step technique with a surgical case report (with video). World J Surg Oncol 2022; 20:269. [PMID: 36028841 PMCID: PMC9419321 DOI: 10.1186/s12957-022-02730-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of the Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “superior mesenteric artery (SMA)-first approach,” “systematic mesopancreas dissection,” and “circumferential lymphadenectomy around SMA” in increasing R0 resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly. Case presentation Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10-mm-sized mass in distal bile duct referred to as Vater’s tumor. We used 5 trocars, and the patient was placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, and lymph node groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated as well as the extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, which was 1 of 7 LN no. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative. Conclusions This technique was safe and effective to perform precise level 2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02730-y.
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Affiliation(s)
- Thanh Khiem
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Ham Hoi
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Hiep
- Department of Surgery, Hanoi Medical University, 1st Ton That Tung Street, Dong Da, Ha Noi, 11521, Vietnam.
| | - Kim Khue
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Van Duy
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hong Son
- Department of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Duc Dung
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
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Feng P, Cheng B, Wang ZD, Liu JG, Fan W, Liu H, Qi CY, Pan JJ. Application and progress of medical imaging in total mesopancreas excision for pancreatic head carcinoma. World J Gastrointest Surg 2021; 13:1315-1326. [PMID: 34950422 PMCID: PMC8649561 DOI: 10.4240/wjgs.v13.i11.1315] [Citation(s) in RCA: 3] [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: 02/13/2021] [Revised: 05/11/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic head carcinoma (PHC) is one of the common gastrointestinal malignancies with a high morbidity and poor prognosis. At present, radical surgery is still the curative treatment for PHC. However, in clinical practice, the actual R0 resection rate, the local recurrence rate, and the prognosis of PHC are unsatisfactory. Therefore, the concept of total mesopancreas excision (TMpE) is proposed to achieve R0 resection. Although there have various controversies and discussions on the definition, the range of excision, and clinical prognosis of TMpE, the concept of TMpE can effectively increase the R0 resection rate, reduce the local recurrence rate, and improve the prognosis of PHC. Imaging is of importance in preoperative examination for PHC; however, traditional imaging assessment of PHC does not focus on mesopancreas. This review discusses the application of medical imaging in TMpE for PHC, to provide more accurate preoperative evaluation, range of excision, and more valuable postoperative follow-up evaluation for TMpE through imaging. It is believed that with further extensive research and exploratory application of TMpE for PHC, large-sample and multicenter studies will be realized, thus providing reliable evidence for imaging evaluation.
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Affiliation(s)
- Pei Feng
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Bo Cheng
- Department of Pathology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Zhen-Dong Wang
- Department of Ultrasound, Beijing Sihui Hospital of Traditional Chinese Medicine, Beijing 100022, China
| | - Jun-Gui Liu
- Department of Hepatobiliary Surgery, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Wei Fan
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Heng Liu
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Chao-Ying Qi
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Jing-Jing Pan
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
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Quero G, Fiorillo C, De Sio D, Laterza V, Menghi R, Cina C, Schena CA, Rosa F, Galiandro F, Alfieri S. The role of mesopancreas excision for ampullary carcinomas: a single center propensity-score matched analysis. HPB (Oxford) 2021; 23:1557-1564. [PMID: 33933343 DOI: 10.1016/j.hpb.2021.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/10/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few evidences are available on the prognostic role of mesopancreas excision(MPe) for ampullary cancers(ACs). Aim of this study was to compare the long-term outcomes between pancreaticoduodenectomy(PD) with(PD-MPe group) and without(sPD group) MP. METHODS Thirty-seven sPDs were matched and compared to 37 PD-MPes for perioperative outcomes, recurrence rate, disease-free(DFS) and overall survival(OS). RESULTS The PD-MPe technique related to a significantly higher number of harvested lymph nodes[16 (±6)] as compared to the sPD [10 (±5); p < 0.0001]. Tumor recurrence was more frequent in the sPD cohort[21 (56.8%) vs 12 (32.4%) in the PD-MPe population; p = 0.03]. Although not statistically different, PD-MPe was associated with a better DFS(40% vs 35.7% for sPD; p = 0.08) and OS(59.3% vs 39.1% for sPD; p = 0.07). At the multivariate analysis, a higher number of lymph nodes retrieved and a more extensive lymphovascular clearance reached with the MPe technique, together with lymph nodes metastases, were recognized as independent prognostic factors for a worse OS and DFS. CONCLUSION The PD-MPe technique is associated with a better oncological radicality thanks to the higher number of retrieved lymph nodes and to the more appropriate tumor clearance. This reflects in a lower incidence of tumor relapse and in improved outcomes in terms of OS and DFS.
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Affiliation(s)
- Giuseppe Quero
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Claudio Fiorillo
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy.
| | - Davide De Sio
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Vito Laterza
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Roberta Menghi
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Caterina Cina
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Carlo Alberto Schena
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Fausto Rosa
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Federica Galiandro
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy
| | - Sergio Alfieri
- Pancreatic Surgery Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Roma, Italy
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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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The mesopancreas and pancreatic head plexus: morphological, developmental, and clinical perspectives. Surg Radiol Anat 2020; 42:1501-1508. [PMID: 32797265 DOI: 10.1007/s00276-020-02547-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/07/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE Total mesopancreas excision has been found to be helpful for increasing no residual tumor resection rate and improving the prognosis of pancreatic cancer. This study analyzed the relationships among the mesopancreas and pancreatic head plexus from the morphological, developmental, and clinical perspectives. METHODS Twenty-four cadavers were employed. The upper abdominal viscera were resected en-bloc with the hepatoduodenal ligament, abdominal aorta, and nerve plexuses, and the innervation of the pancreas was dissected. Ten additional cadavers were used for histological examination of the pancreatic head and neck, part of the duodenum, the superior mesenteric artery (SMA) and its surrounding tissues, and the related arteries and veins. RESULTS As results, cross-sections of the SMA revealed 6-9 layers of membranous structures resembling the layers of an onion, and the nerve fibers of the superior mesenteric plexus ran between the layers. Loose areolar tissue, adipose tissue, and lymphatics existed between the SMA and the pancreatic head/uncinate process, along with abundant thin blood vessels and capillaries, but very few nerves were found approaching the pancreas. Several parallel layers of collagen fibers (so-called Treitz's fusion fascia) existed between the dorsal aspect of the pancreatic head and the aortocaval plane. CONCLUSION The mesopancreas was continuous and connected with the para-aortic area. It may be better termed the mesopancreatoduodenum than the mesopancreas, as the duodenum-pancreas-SMA forms a complex morphological, developmental, functional, and pathological structure.
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Quero G, Fiorillo C, Menghi R, Cina C, Galiandro F, Longo F, Sofo F, Rosa F, Tortorelli AP, Giustiniani MC, Inzani F, Alfieri S. Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes. Langenbecks Arch Surg 2020; 405:303-312. [PMID: 32333095 DOI: 10.1007/s00423-020-01873-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Few comparative studies are available on the long-term prognostic role of mesopancreas (MP) excision after pancreaticoduodenectomy (PD). We compared the long-term outcomes of patients undergoing standard PD (sPD) and PD with MP excision (PD-MPe). METHODS Sixty sPDs were compared to 60 matched PD-MPe patients for intraoperative and postoperative data, histopathological findings, and long-term outcomes. RESULTS R0 rate was similar in the two groups (p = 0.17). However, PD-MPe related to a lower rate of MP resection margin positivity (16.7% vs 5%; p = 0.04) and to a higher harvested lymph nodes number (19.8 ± 7.6 vs 10.1 ± 5.1; p < 0.0001). Local tumor recurrence was more frequent in the sPD cohort (55.5% vs 26.8% in the PD-MPe group; p = 0.002), with a consequent worse disease-free survival (DFS) (14.8% vs 22.3%; p = 0.04). An inferior 5-year overall survival (OS) was noted in case of MP margin positivity compared with MP margin negativity (0% vs 29%; p < 0.0001). MP positivity resulted as an independent prognostic factor for both a worse OS and DFS at the multivariate analysis. CONCLUSION PD-MPe offers clinical advantages in terms of MP resection margin status, local recurrence, long-term mortality, and DFS. The lower MP positivity rate, achieved with PD-MPe, leads to better outcomes both in terms of OS and DFS.
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Affiliation(s)
- Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Roberta Menghi
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Caterina Cina
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Federica Galiandro
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Francesco Sofo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Antonio Pio Tortorelli
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Maria Cristina Giustiniani
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Frediano Inzani
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CRMPG (Advanced Pancreatic Research Center), Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
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9
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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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10
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Ishikawa Y, Ban D, Matsumura S, Mitsunori Y, Ochiai T, Kudo A, Tanaka S, Tanabe M. Surgical pitfalls of jejunal vein anatomy in pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:394-400. [PMID: 28342263 DOI: 10.1002/jhbp.451] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is the standard surgical procedure for treating pancreatic head cancers. Considerable knowledge of proximal jejunal and pancreatic vein anatomy is a prerequisite for performing PD surgery safely, yet there appear to be no detailed descriptions of first and second jejunal vein (J1V, J2V) anatomy available in the literature. STUDY DESIGN Adults with hepatobiliary-pancreatic disease underwent multidetector-row computed tomography with intravenous contrast (n = 155), and SYNAPSE 3D (Fujifilm Medical, Tokyo, Japan) was used to generate 3D-CT images. RESULTS In 84% of patients, J1V and J2V formed a common trunk (FJT). There were three patterns of branches, related to the presence or absence of FJT formation and the anatomical relationships between the superior mesenteric artery (SMA) and the jejunal veins, as follows: Type 1 (n = 98, 63%) characterized by an FJT located dorsal to SMA; Type 2 (n = 32, 21%), where the FJT was located ventral to the SMA; and Type 3 (n = 25, 16%), where J1V and J2V each drained separately into the SMV. CONCLUSIONS J1V and J2V usually formed an FJT, and separate J1V and J2V drainage into the SMV was uncommon. Preoperative information on individual patient venous anatomy would increase the safety of the PD procedure.
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Affiliation(s)
- Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Matsumura
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Mitsunori
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanori Ochiai
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinji Tanaka
- Department of Molecular Oncology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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11
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Kawabata Y, Hayashi H, Yano S, Tajima Y. Liver parenchyma transection-first approach in hemihepatectomy with en bloc caudate lobectomy for hilar cholangiocarcinoma: A safe technique to secure favorable surgical outcomes. J Surg Oncol 2017; 115:963-970. [PMID: 28334429 DOI: 10.1002/jso.24612] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/20/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although hemihepatectomy with total caudate lobectomy (hemiHx-tc) is essential for the surgical treatment of hilar cholangiocarcinoma, the advantage of an anterior approach for hemiHx-tc has not been fully discussed technically; the significance of an anterior approach without liver mobilization for preventing infectious complications also remains unknown. METHODS The liver parenchyma transection-first approach (Hp-first) technique is an early transection of the hepatic parenchyma without mobilization of the liver that utilizes a modified liver-hanging maneuver to avoid damaging the future remnant liver. RESULTS Between May 2010 and August 2016, a total of 40 consecutive patients underwent surgery for hilar cholangiocarcinoma. Of these, 19 patients underwent a conventional hemihepatectomy with total caudate lobectomy (cHx), while 21 patients received a Hp-first. The patients in the Hp-first group had significantly less intraoperative blood loss (P < 0.001) and blood transfusion (P < 0.001), a lower incidence of postoperative hyperbilirubinemia (p = 0.023), a lower incidence of liver failure (p = 0.038), a lower hospital death rate (p = 0.042), and a better 2-year disease-free survival rate (p = 0.010) than those in the cHx group. CONCLUSIONS The liver parenchyma transection-first approach is the preferred technique for hemiHx-tc in hilar cholangiocarcinoma because it resulted in improved surgical outcomes as compared with the conventional approach.
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Affiliation(s)
- Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Hikota Hayashi
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Seiji Yano
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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