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Ke J, Liu F, Ke J, Cai H, Liu Y, Ji B. Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: A literature review. Heliyon 2024; 10:e27500. [PMID: 38533026 PMCID: PMC10963198 DOI: 10.1016/j.heliyon.2024.e27500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
Background Laparoscopic pancreaticoduodenectomy (LPD) is a complicated surgical procedure that has recently been performed safely. A superior mesenteric artery (SMA)-first approach can allow complete mesopancreas resection, maximizing surgical margins and R0 resection rates. Therefore, the SMA-first approach is recommended. This review is a literature summary of recent updates of the SMA approaches for LPD and informs clinical practice of the advantages of its various approach. Methods A systematic literature search was performed on the PubMed (MEDLINE) database using truncated word searches and medical subject headings to identify all pertinent published studies. Results After searching PubMed, 303 studies were identified and reviewed, of which 25 described the SMA-first approach, including the anterior, posterior, right, and left approaches, fully described in 5, 6, 13, and 6 articles, respectively. Conclusions The SMA-first approach is the standard surgical technique for LPD. This review summarized each SMA-first approach's distinct advantages and indications.
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Affiliation(s)
- Jianji Ke
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Feiqi Liu
- Department of Critical Care Medicine, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Jianjia Ke
- School of Business and Management of Jilin University, 2699 Qianjin Street, Changchun 130021, China
| | - Hongqiao Cai
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Bai Ji
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
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Wang X, Luo Q, Li S, Wu Y, Zhen T, Zhu F, Wang M, Pan S, Qin R. A comparative study of the "superior mesenteric artery first" approach versus the conventional approach in short-term and long-term outcomes in patients with pancreatic ductal adenocarcinoma undergoing laparoscopic pancreaticoduodenectomy. Surg Endosc 2023; 37:9326-9338. [PMID: 37891371 PMCID: PMC10709234 DOI: 10.1007/s00464-023-10470-7] [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: 04/14/2023] [Accepted: 09/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The use of laparoscopic pancreaticoduodenectomy (LPD) in pancreatic head cancer remains controversial, and an appropriate surgical approach can help improve perioperative safety and oncological outcomes. This study aimed to assess the short-term outcomes and long-term survival of the superior mesenteric artery first (SMA-first) approach in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing LPD. METHODS The data of 91 consecutive PDAC patients who underwent LPD from June 2014 to June 2021 were retrospectively analyzed. Patients were divided into two groups, the modified SMA-first approach group, using a combined posterior and anterior approach, and the conventional approach group. Perioperative outcomes, pathologic results, and overall survival (OS) were compared between groups, and propensity score-matched (PSM) analysis was performed. RESULTS The number of lymph nodes harvested was greater in the SMA-first approach group (19 vs. 15, P = 0.021), as did the results in the matched cohort (21 vs. 15, P = 0.046). No significant difference was observed in the R0 resection rate (93.3% vs. 82.6%, P = 0.197), but the involvement of the SMA margin was indeed lower in the SMA-first approach group (0 vs. 13%). There were no obvious variances between the two groups in terms of intraoperative bleeding, operative time, overall and major postoperative complication rates, and mortality in either the original cohort or matched cohort. The median OS was 21.8 months in the SMA-first group, whereas it was 19.8 months in the conventional group (P = 0.900). Survival also did not differ in the matched cohort (P = 0.558). TNM stage, resection margin, overall complications, and adjuvant therapy were independent risk factors affecting OS. CONCLUSION The modified SMA-first approach is safe and feasible for PDAC patients undergoing LPD. It had a slight advantage in specimen quality, but OS was not significantly prolonged.
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Affiliation(s)
- Xiaoxiang Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Qilan Luo
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Shizhen Li
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Yi Wu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Tingting Zhen
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Feng Zhu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Shutao Pan
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
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Wang S, Liu Y, Jiang P. Application of Retrocolic Approach with Uncinate Process Priority in Laparoscopic Pancreaticoduodenectomy. J Laparoendosc Adv Surg Tech A 2023; 33:487-492. [PMID: 36946976 DOI: 10.1089/lap.2022.0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Background: Pancreaticoduodenectomy (PD) is a complex operative procedure, which remains the primary curative treatment for pancreatic, distal bile duct, and periampullary cancers. In recent years, with the continuous development of laparoscopic technology and equipment, laparoscopic pancreaticoduodenectomy (LPD) has been performed gradually in many high-volume surgical centers. However, it is still challenging even for experienced pancreatic surgeons to perform LPD, at the same time, with the accumulation of surgical experience, different surgical approaches are also constantly discussed. Methods: We retrospectively analyzed the clinical data of 323 patients who received LPD at a single institution. Among them, 200 patients received operations with retrocolic approach, 123 patients were treated with traditional approach. In this study, we analyzed perioperative data and compared survival time for patients with pancreatic cancers in two groups. Result: Compared with traditional approach, retrocolic approach with uncinate process priority has a shorter operative time (94.25 ± 6.46 minutes versus 116.43 ± .4.78 minutes, P = .009) and less intraoperative blood loss (80 mL versus 150 mL, P = .562). However, there is no statistical significance in the incidence of postoperative complications (≥ Clavien-Dindo [CD] III) (65 [32.5%] versus 45 [36.58%], P = .871), R0 resection rates (41 versus 38, P = .826), and the number of lymph nodes harvested (16.64 ± 5.93 versus 15.37 ± 4.65, P = .785) between two groups. Meanwhile, the median survival time of patients with pancreatic cancers in posterior approach group was longer than those in traditional approach group (30.34 months versus 28.54 months, P > .05); however, there was no statistical significance between them. Conclusion: Retrocolic approach with uncinate process priority is a feasible method for pancreatic cancer, which could reduce operating time and intraoperative bleeding, meanwhile, not increase the incidence of postoperative complications. Retrocolic approach with uncinate process priority can be generalized to larger group sizes.
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Affiliation(s)
- Shupeng Wang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
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Li J, Wang YH, Zheng FL, Chen XY, Lin Y, Zhu CR, Wu YF, Xu Q, Jin ZY, Xue HD. Feasibility of utilizing ultra-low-dose contrast medium for pancreatic artery depiction using the combination of advanced virtual monoenergetic imaging and high-concentration contrast medium: an intra-patient study. Insights Imaging 2021; 12:166. [PMID: 34767101 PMCID: PMC8589906 DOI: 10.1186/s13244-021-01079-2] [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: 03/01/2021] [Accepted: 07/18/2021] [Indexed: 11/10/2022] Open
Abstract
Objectives The least amount of contrast medium (CM) should be used under the premise of adequate diagnosis. The purpose of this study is to evaluate the feasibility of utilizing ultra-low-dose (224 mgI/kg) CM for pancreatic artery depiction using the combination of advanced virtual monoenergetic imaging (VMI+) and high-concentration (400 mgI/mL) CM.
Materials and methods 41 patients who underwent both normal dose CM (ND-CM, 320 mgI/kg) and low dose CM (LD-CM, 224 mgI/kg) thoracoabdominal enhanced CT for tumor follow-up were prospectively included. The VMI+ at the energy level of 40-kev for LD-CM images was reconstructed. CT attenuation, signal-to-noise ratios (SNRs), and contrast-to-noise ratios (CNRs) of the abdominal artery, celiac artery, and superior mesenteric artery (SMA) and qualitative scores of pancreatic arteries depiction were recorded and compared among the three groups (ND-CM, LD-CM, and VMI+ LD-CM images). ANOVA and Friedman tests were used for statistical analysis. Results All quantitative and qualitative parameters on LD-CM images were lower than that on ND-CM images (all p < 0.01). There were no significant differences of all arteries’ qualitative scores between ND-CM and VMI+ LD-CM images (all p > 0.05). VMI+ LD-CM images had the highest mean CT and CNR values of all arteries (all p < 0.0001). The CM volume was 52.6 ± 9.4 mL for the ND-CM group and 37.0 ± 6.7 mL for the LD-CM group. Conclusion Ultra-low-dose CM (224 mgI/kg) was feasible for depicting pancreatic arteries. Inferior angiographic image quality could be successfully compensated by VMI+ and high-concentration CM.
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Affiliation(s)
- Juan Li
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yu-Hong Wang
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fu-Ling Zheng
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | | | - Yun Lin
- Global Medical and Regulatory Affairs, Bracco Imaging Medical Technologies Co., Ltd, Shanghai, China
| | - Cai-Rong Zhu
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yi-Fan Wu
- Global Medical and Regulatory Affairs, Bracco Imaging Medical Technologies Co., Ltd, Shanghai, China
| | - Qiang Xu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zheng-Yu Jin
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
| | - Hua-Dan Xue
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Terasawa M, Mise Y, Yoshioka R, Oba A, Ono Y, Inoue Y, Imamura H, Hiromichi I, Takahashi Y, Kawasaki S, Saiura A. Preoperative Decision to Perform Portal Vein Resection Improves Survival in Patients With Resectable Pancreatic Head Cancer Adjacent to Portal Vein. ANNALS OF SURGERY OPEN 2021; 2:e064. [PMID: 37636553 PMCID: PMC10455064 DOI: 10.1097/as9.0000000000000064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/28/2021] [Indexed: 11/26/2022] Open
Abstract
Objective We hypothesized that preoperatively planned portal vein resection (PVR), which prevents from approaching tumors, improves survival in patients with resectable pancreatic head cancer adjacent to the portal vein (PhC-PV). Summary The decision to perform PVR is difficult in patients with resectable PhC-PV. Methods This is a retrospective, bi-institutional study of patients undergoing pancreatoduodenectomy (PD) for resectable PhC-PV from 2009 to 2018. We compared clinical data of patients who underwent PD with preoperatively planned PVR (planned PVR group) and those who underwent conventional PD (cPD) in which decision to perform PVR was made intraoperatively (cPD group). Results Among the study population of 176 patients, 53 patients (30.1%) underwent PD with planned PVR. The remaining 123 patients (69.9%) underwent cPD. Tumor characteristics were similar between the 2 groups. Operation time and major complication rates did not differ between the 2 groups. The local recurrence rate of patients in the planned PVR group (28.3%) was lower than that of the cPD group (44.7%; P = 0.041). Median overall survival (OS) was longer in the planned PVR group than in the cPD group (32 vs 27 months; P = 0.011). Multivariate analysis revealed that having undergone planned PVR was an independent factor for favorable OS (hazard ratio = 1.65; 95% confidence interval = 1.08-2.61; P = 0.021). Conclusions The preoperative decision to perform PVR improves survival by enhancing local control of resectable PhC-PV.
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Affiliation(s)
- Muga Terasawa
- From the Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshihiro Mise
- From the Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryuji Yoshioka
- From the Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsushi Oba
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroshi Imamura
- From the Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Ito Hiromichi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Seiji Kawasaki
- Department of Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Akio Saiura
- From the Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Sugiyama M, Suzuki Y, Nakazato T, Yokoyama M, Kogure M, Matsuki R, Abe N. Vascular Anatomy of Mesopancreas in Pancreatoduodenectomy Using an Intestinal Derotation Procedure. World J Surg 2021; 44:3441-3448. [PMID: 32474625 DOI: 10.1007/s00268-020-05605-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Mesopancreas excision in pancreatoduodenectomy is technically complicated because of the anatomical complexity of the mesopancreas with the inferior peripancreatic blood vessels which is caused by intestinal rotation in fetal life. We have developed a novel artery-first approach (the intestinal derotation procedure) for facilitating mesopancreas excision. The aim of this study was to clarify the vascular anatomy of the mesopancreas after derotation. METHODS The right-sided colon and small intestine are mobilized from the retroperitoneum, and the intestinal loop is then derotated. In 136 cases of pancreatoduodenectomy employing the derotation procedure, we analyzed the vascular anatomy of the mesopancreas. RESULTS After derotation, the anatomy was simplified. The mesopancreas extended from the right aspect of the superior mesenteric artery (SMA), forming a horizontal plane. The first jejunal trunk (FJT) was situated in parallel with the second jejunal artery and was anterior (91%) or posterior (9%) to the SMA. The inferior pancreaticoduodenal vein (IPDV) entered the right side of the FJT (83%) or the superior mesenteric vein (17%). Besides the IPDV, 1-4 tributaries entered the right wall of the FJT, in 89% of cases. The inferior pancreaticoduodenal artery was observed to originate from the right wall of the SMA, sharing a common stem with the first jejunal artery (70%) or branching directly from the SMA (29%). CONCLUSIONS Intestinal derotation simplifies the mesopancreas anatomy and reveals the anatomical details of the inferior peripancreatic blood vessels in pancreatoduodenectomy.
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Affiliation(s)
- Masanori Sugiyama
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan. .,Tokyo Rosai Hospital, 4-13-21 Omori-Minami, Ota-ku, Tokyo, 143-0013, Japan.
| | - Yutaka Suzuki
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Tetsuya Nakazato
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Masaaki Yokoyama
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Masaharu Kogure
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Ryota Matsuki
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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Tatsuoka T, Noie T, Noro T, Nakata M, Yamada H, Harihara Y. Dorsal Pancreatic Artery—a Study of Its Detailed Anatomy for Safe Pancreaticoduodenectomy. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02255-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
AbstractEarly division of the dorsal pancreatic artery (DPA) or its branches to the uncinate process during pancreaticoduodenectomy (PD) in addition to early division of the gastroduodenal artery and inferior pancreaticoduodenal artery should be performed to reduce blood loss by completely avoiding venous congestion. However, the significance of early division of DPA or its branches to the uncinate process has not been reported. The aim of this study was to investigate the anatomy of DPA and its branches to the uncinate process using the currently available high-resolution dynamic computed tomography (CT) as the first step to investigate the significance of DPA in the artery-first approach during PD. Preoperative dynamic thin-slice CT data of 160 consecutive patients who underwent hepato–pancreato–biliary surgery were examined focusing on the anatomy of DPA and its branches to the uncinate process. DPA was recognized in 103 patients (64%); it originated from the celiac axis or its branches in 70 patients and from the superior mesenteric artery or its branches in 34 patients. The branches to the uncinate process were visualized in 82 patients (80% of those with DPA), with diameters of 0.5–1.5 mm in approximately 80% of the 82 patients irrespective of DPA origin. DPA branches to the uncinate process were recognized using high-resolution CT in approximately half of the patients.
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Pham H, Nahm CB, Hollands M, Pang T, Johnston E, Pleass H, Richardson A, Lam V, Yuen L. Hybrid laparoscopic pancreaticoduodenectomy: an Australian experience and a proposed process for implementation. ANZ J Surg 2020; 90:1422-1427. [DOI: 10.1111/ans.15802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Helen Pham
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
| | - Christopher B. Nahm
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Michael Hollands
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Tony Pang
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Emma Johnston
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Henry Pleass
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Arthur Richardson
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Sydney Adventist Hospital Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Vincent Lam
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Lawrence Yuen
- Department of Hepato‐Biliary Pancreatic/Upper Gastrointestinal SurgeryWestmead Hospital Sydney New South Wales Australia
- Faculty of Medical and Health Sciences, Western Clinical SchoolThe University of Sydney Sydney New South Wales Australia
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Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: A meta-analysis. Int J Surg 2019; 73:14-24. [PMID: 31751791 DOI: 10.1016/j.ijsu.2019.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/05/2019] [Accepted: 11/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Superior mesenteric artery (SMA) first approach was a new improvement for pancreaticoduodenectomy (PD), but there is no evidence whether this approach is advantageous to PD. This meta-analysis aimed to determine the effects of the superior mesenteric artery (SMA) first approach on outcomes of pancreaticoduodenectomy (PD). METHODS Literature searches were conducted on PubMed, The Cochrane Library, EMBASE, Web of Science, Clinical Trials Registry and China Biology Medicine disc. We completed a meta-analysis of the SMA first approach in PD, assessing overall survival, R0 resection, blood loss, postoperative complications, operation time and postoperative stay. The odds ratios and weighted mean differences with 95% confidence intervals (CIs) were pooled. RESULTS Eighteen studies comprising 1483 participants were included. Patients who received SMA-PD had significantly lower overall complication rate (OR 0.62, 95% CI 0.47 to 0.81, P = 0.001) and less blood loss (WMD -264.84, 95% CI -336.1 to -193.58, P < 0.001). The obviously increased R0 resection rate (OR 2.92, 95% CI 1.72 to 4.96, P < 0.001) and 3-year OS (OR 2.15, 95% CI 1.34 to 3.43, P = 0.001) were found in the SMA-PD group. CONCLUSION The SMA-PD group had better clinical outcomes, particularly in long-term survival of pancreatic cancer patients; furthermore, the patients acquired superior clinical efficacy via the posterior approach in SMA-PD.
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Does the Artery-first Approach Improve the Rate of R0 Resection in Pancreatoduodenectomy? Ann Surg 2019; 270:738-746. [DOI: 10.1097/sla.0000000000003535] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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11
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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: 1.0] [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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Kauffmann EF, Napoli N, Menonna F, Iacopi S, Lombardo C, Bernardini J, Amorese G, Cacciato Insilla A, Funel N, Campani D, Cappelli C, Caramella D, Boggi U. A propensity score-matched analysis of robotic versus open pancreatoduodenectomy for pancreatic cancer based on margin status. Surg Endosc 2019; 33:234-242. [PMID: 29943061 DOI: 10.1007/s00464-018-6301-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND No study has shown the oncologic non-inferiority of robotic pancreatoduodenectomy (RPD) versus open pancreatoduodenectomy (OPD) for pancreatic cancer (PC). METHODS This is a single institution propensity score matched study comparing RPD and ODP for resectable PC, based on factors predictive of R1 resection (≤ 1 mm). Only patients operated on after completion of the learning curve in both procedures and for whom circumferential margins were assessed according to the Leeds pathology protocol were included. The primary study endpoint was the rate of R1 resection. Secondary study endpoints were as follows: number of examined lymph nodes (N), rate of perioperative transfusions, percentage of patients receiving adjuvant therapies, occurrence of local recurrence, overall survival, disease-free survival, and sample size calculation for randomized controlled trials (RCT). RESULTS Factors associated with R1 resection were tumor diameter, number of positive N, N ratio, logarithm odds of positive N, and duodenal infiltration. The matching process identified 20 RPDs and 24 OPDs. All RPDs were completed robotically. R1 resection was identified in 11 RPDs (55.0%) and in 10 OPDs (41.7%) (p = 0.38). There was no difference in the rate of R1 at each margin as well as in the proportion of patients with multiple R1 margins. RPD and OPD were also equivalent with respect to all secondary study endpoints, with a trend towards lower rate of blood transfusions in RPD. Based on the figures presented herein, a non-inferiority RCT comparing RPD and OPD having the rate of R1 resection as the primary study endpoint requires 3355 pairs. CONCLUSIONS RPD and OPD achieved the same rate of R1 resections in resectable PC. RPD was also non-inferior to OPD with respect to all secondary study endpoints. Because of the high number of patients required to run a RCT, further assessment of RPD for PC would require the implementation of an international registry.
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Affiliation(s)
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Francesca Menonna
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Sara Iacopi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Carlo Lombardo
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Juri Bernardini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, University of Pisa, Pisa, Italy
| | | | - Niccola Funel
- Division of Pathology, University of Pisa, Pisa, Italy
| | | | | | | | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy. .,Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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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. [DOI: 10.1002/jhbp.451] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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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Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2017; 16:127-138. [PMID: 28381375 DOI: 10.1016/s1499-3872(16)60134-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The superior mesenteric artery (SMA) first approach was proposed recently as a new modification of the standard pancreaticoduodenectomy. Increasing evidence showed that a periadventiceal dissection of the SMA with early transection of the inflow during pancreaticoduodenectomy associates better early perioperative results, and setup the scene for long-term oncological benefits. The objectives of the current study are to compare the operative results and long-term oncological outcomes of SMA first approach pancreaticoduodenectomy (SMA-PD) with standard pancreaticoduodenectomy (S-PD). DATA SOURCES Electronic search of the PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Library was performed until July 2015. We considered randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) comparing SMA-PD with S-PD to be eligible if they included patients with periampullary cancers. RESULTS A total of one RCT and thirteen NRCSs met the inclusion criteria, involving 640 patients with SMA-PD and 514 patients with S-PD. The SMA-PD was associated with less intraoperative bleeding, less blood transfusions and higher rate of associated venous resections. The pancreatic fistula and delayed gastric emptying had a significantly lower rate in the SMA-PD group. There were no differences between the two approaches regarding overall complications, major complication rates and in-hospital mortality. There was no difference regarding R0 resection rate, and one-, two- or three-year overall survival. The SMA-PD was associated with a lower local, hepatic and extrahepatic metastatic rate. CONCLUSIONS The SMA-PD is associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, and delayed gastric emptying. Although the one-, two- or three-year overall survival rate is not superior, the SMA-PD has a lower local and metastatic recurrence rate.
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15
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Oguro S, Yoshimoto J, Imamura H, Ishizaki Y, Kawasaki S. Three hundred and sixty-eight consecutive pancreaticoduodenectomies with zero mortality. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:226-234. [PMID: 28103418 DOI: 10.1002/jhbp.433] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Only a limited number of reports have documented zero mortality in consecutive pancreaticoduodenectomy series. The aim of this study is to review and verify our management aiming to eliminate mortality after pancreaticoduodenectomy. METHODS Three hundred and sixty-eight consecutive patients undergoing pancreaticoduodenectomy between 2002 and 2015 were retrospectively reviewed. During this period, in order to enhance the safety of pancreaticoduodenectomy, we have used a consistent strategy consisting of early ligation of the inferior pancreatoduodenal artery, mucosal sutureless pancreaticojejunostomy combined with external pancreatic duct stenting, conditional two-stage pancreaticojejunostomy, jejunal decompression using tube jejunostomy, application of an omental flap to cover the stump of the gastroduodenal artery, and careful postoperative drain management. RESULTS Major postoperative complications (Clavien-Dindo grade ≥ IIIa) occurred in 20 patients (5%). Grade A/B/C pancreatic fistula was observed in 49/29/4 patients (13%/8%/1%), respectively. Reoperation and readmission was necessary in five and four patients (1% and 1%), respectively. There was no in-hospital or 90-day mortality. CONCLUSIONS To achieve zero mortality in pancreaticoduodenectomy, it is crucial to incorporate various strategies to minimize the degree of surgical invasiveness and the damage caused by pancreatic fistula with a meticulous approach to perioperative management.
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Affiliation(s)
- Seiji Oguro
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Jiro Yoshimoto
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoichi Ishizaki
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Seiji Kawasaki
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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16
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Sugiyama M, Suzuki Y, Nakazato T, Yokoyama M, Kogure M, Abe N, Masaki T, Mori T. Intestinal derotation procedure for facilitating pancreatoduodenectomy. Surgery 2016; 159:1325-32. [DOI: 10.1016/j.surg.2015.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/05/2015] [Accepted: 11/21/2015] [Indexed: 01/03/2023]
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17
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Pittau G, Sànchez-Cabùs S, Laurenzi A, Gelli M, Cunha AS. Laparoscopic Pancreaticoduodenectomy: Right Posterior Superior Mesenteric Artery "First" Approach. Ann Surg Oncol 2015; 22 Suppl 3:S345-8. [PMID: 26471492 DOI: 10.1245/s10434-015-4913-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Indexed: 12/13/2022]
Abstract
Pancreaticoduodenectomy (PD) is considered one of the most challenging abdominal operations for several reasons, including the anatomy, which is surrounded by vital vascular structures and also because of the serious complications that are possible in the postoperative period. Nowadays, thanks to the development of minimally invasive surgery and improvement of patients' selection, laparoscopic pancreatic resections have been proven to be technically feasible and safe especially in the case of left pancreatectomies. More recently, many series of laparoscopic PD for adenocarcinoma have been published demonstrating the feasibility of this technique. In pancreatic cancer, the advantage of superior mesenteric artery "first approach" is already known to achieve an oncological resection. The purpose of this video is to describe the different technical aspects of the laparoscopic superior mesenteric artery first approach in the right posterior fashion.
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Affiliation(s)
| | - Santiago Sànchez-Cabùs
- HPB Surgery and Transplantation Department, Institut Clinic de Malalties Digestives i Metaboliques, Hospital Clınic de Barcelona, Barcelona, Spain
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18
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Fu SJ, Shen SL, Li SQ, Hu WJ, Hua YP, Kuang M, Liang LJ, Peng BG. Risk factors and outcomes of postoperative pancreatic fistula after pancreatico-duodenectomy: an audit of 532 consecutive cases. BMC Surg 2015; 15:34. [PMID: 25887526 PMCID: PMC4377181 DOI: 10.1186/s12893-015-0011-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 02/13/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pancreatic fistula (PF) remains the most challenging complication after pancreaticoduodenectomy (PD). The purpose of this study was to identify the risk factors of PF and delineate its impact on patient outcomes. METHODS We retrospectively reviewed clinical data of 532 patients who underwent PD and divided them into PF group and no PF group. Risk factors and outcomes of PF following PD were examined. RESULTS PF was found in 65 (12.2%) cases, of whom 11 were classified into ISGPF grade A, 42 grade B, and 12 grade C. Clinically serious postoperative complications in the PF versus no PF group were mortality, abdominal bleeding, bile leak, intra-abdominal abscess and pneumonia. Univariate and multivariate analysis showed that blood loss ≥ 500 ml, pancreatic duct diameter ≤ 3 mm and pancreaticojejunostomy type were independent risk factors of PF after PD. CONCLUSIONS Blood loss ≥ 500 ml, pancreatic duct diameter ≤ 3 mm and pancreatico-jejunostomy type were independent risk factors of PF after PD. PF was related with higher mortality rate, longer hospital stay, and other complications.
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Affiliation(s)
- Shun-Jun Fu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China.,Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of TCM), Guangzhou, 510120, P.R. China
| | - Shun-Li Shen
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China
| | - Shao-Qiang Li
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China
| | - Wen-Jie Hu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China
| | - Yun-Peng Hua
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China
| | - Ming Kuang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China
| | - Li-Jian Liang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China
| | - Bao-Gang Peng
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, P.R. China.
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19
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Sato G, Ishizaki Y, Yoshimoto J, Sugo H, Imamura H, Kawasaki S. Factors influencing clinically significant delayed gastric emptying after subtotal stomach-preserving pancreatoduodenectomy. World J Surg 2014; 38:968-75. [PMID: 24136719 DOI: 10.1007/s00268-013-2288-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD. METHODS Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively. RESULTS Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86-15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE). CONCLUSIONS DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.
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Affiliation(s)
- Go Sato
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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20
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Ishizaki Y, Yoshimoto J, Sugo H, Imamura H, Kawasaki S. Validation of Mucosal Sutureless Pancreatojejunostomy after Pancreatoduodenectomy. Am Surg 2014. [DOI: 10.1177/000313481408000222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although duct-to-mucosa pancreatojejunostomy has been considered safer than other techniques, this procedure is particularly difficult when the pancreatic duct is small. It has therefore become increasingly necessary to develop a simple mucosal sutureless pancreatojejunostomy technique to replace the conventional hand-sewing one. Two hundred fourteen patients who underwent mucosal sutureless pancreatojejunostomy were classified into two groups: those with a normal pancreatic duct diameter (less than 3 mm, n = 97) and those with a dilated pancreatic duct (3 mm or greater, n = 117). The rate of clinically significant pancreatic fistula (Grade B or C by the International Study Group on Pancreatic Fistula definition) among the patients as a whole was 8 per cent. The overall incidence of pancreatic fistula was significantly higher in the patients with a pancreatic duct diameter of less than 3 mm than in those with a pancreatic duct diameter of 3 mm or greater. However, the incidence of clinically significant pancreatic fistula did not differ between the groups (less than 3 mm, 11%; 3 mm or greater, 5%; P = 0.09). Grade C pancreatic fistula developed in one patient with a pancreatic duct diameter of less than 3 mm and in two with a pancreatic duct diameter 3 mm or greater. Although two patients required reoperation, all of the fistulas were cured and the postoperative mortality rate related to pancreatoduodenectomy was zero. Mucosal sutureless pancreatojejunostomy combined with pancreatic duct stenting is associated with a low rate of clinically significant pancreatic fistula even in patients with a small pancreatic duct diameter less than 3 mm.
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Affiliation(s)
- Yoichi Ishizaki
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Jiro Yoshimoto
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Sugo
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Seiji Kawasaki
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
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21
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Cho A, Yamamoto H, Kainuma O. Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:E19-21. [PMID: 24307512 DOI: 10.1002/jhbp.54] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In previous reports of laparoscopic pancreaticoduodenectomy, the Kocher maneuver with a wide mobilization of the right colonic flexure is carried out in the early phase, and dissection of the superior mesenteric artery is performed in the last phase of resection. This report describes laparoscopic superior mesenteric artery first approach, in which the superior mesenteric artery is dissected in the early phase of resection. Through the ligament of Treitz, the retroperitoneum is widely opened and the superior mesenteric artery is isolated just superior to the left renal vein. The periarterial connective tissue and nerve plexuses surrounding the superior mesenteric artery are dissected longitudinally to identify the inferior pancreaticoduodenal artery, which is then tied and divided. The superior mesenteric artery first approach and early ligation of the inferior pancreaticoduodenal artery is considered to be a feasible, safe, and effective method for performing pure laparoscopic pancreaticoduodenectomy.
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Affiliation(s)
- Akihiro Cho
- Division of Gastroenterological Surgery, Chiba Cancer Center Hospital, 666-2 Nitonachou, Chuouku, Chiba, 260-8717, Japan.
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Onda S, Okamoto T, Kanehira M, Suzuki F, Ito R, Fujioka S, Suzuki N, Hattori A, Yanaga K. Identification of inferior pancreaticoduodenal artery during pancreaticoduodenectomy using augmented reality-based navigation system. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:281-7. [PMID: 23970384 DOI: 10.1002/jhbp.25] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In pancreaticoduodenectomy (PD), early ligation of the inferior pancreaticoduodenal artery (IPDA) before efferent veins has been advocated to decrease blood loss by congestion of the pancreatic head to be resected. In this study, we herein report the utility of early identification of the IPDA using an augmented reality (AR)-based navigation system (NS). METHODS Seven nonconsecutive patients underwent PD using AR-based NS. After paired-point matching registration, the reconstructed image obtained by preoperative computed tomography (CT) was fused with a real-time operative field image and displayed on 3D monitors. The vascular reconstructed images, including the superior mesenteric artery, jejunal artery, and IPDA were visualized to facilitate image-guided surgical procedures. We compared operating time and intraoperative blood loss of six patients who successfully underwent identification of IPDA using AR-based NS (group A) with nine patients who underwent early ligation of IPDA without using AR (group B) and 18 patients who underwent a conventional PD (group C). RESULTS The IPDA or the jejunal artery was rapidly identified and ligated in six patients. The mean operating time and intraoperative blood loss in group A was 415 min and 901 ml, respectively. There was no significant difference in operating time and intraoperative blood loss among the groups. CONCLUSIONS The AR-based NS provided precise anatomical information, which allowed the surgeons to rapidly identify and perform early ligation of IPDA in PD.
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Affiliation(s)
- Shinji Onda
- Division of Digestive Surgery, The Jikei University Graduate School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
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Gundara JS, Wang F, Alvarado-Bachmann R, Williams N, Choi J, Gananadha S, Gill AJ, Hugh TJ, Samra JS. The clinical impact of early complete pancreatic head devascularisation during pancreatoduodenectomy. Am J Surg 2013; 206:518-25. [PMID: 23809671 DOI: 10.1016/j.amjsurg.2013.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/22/2012] [Accepted: 01/23/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Early inferior pancreaticoduodenal artery (IPDA) ligation reduces intraoperative blood loss during pancreatoduodenectomy, but the impact on oncologic and long-term outcomes remains unknown. The aim of this study was to review the impact of complete pancreatic head devascularization during pancreatoduodenectomy on blood loss, transfusion rates, and clinicopathologic outcomes. METHODS Clinicopathologic and outcome data were retrieved from a prospective database for all pancreatoduodenectomies performed from April 2004 to November 2010 and compared between early (IPDA+; n = 62) and late (IPDA-; n = 65) IPDA ligation groups. RESULTS Early IPDA ligation was associated with reduced blood loss (394 ± 21 vs 679 ± 24 ml, P < .001) and perioperative transfusion (P = .031). A trend toward improved R0 resection was seen in patients with pancreatic adenocarcinoma (IPDA+ vs IPDA-, 100% vs 82%; P = .059), but this did not translate to improved 2-year (IPDA+ vs IPDA-, 76% vs 65%; P = .426) or overall (P = .82) survival. CONCLUSIONS Early IPDA ligation reduces blood loss and transfusion requirements. Despite overall survival being unchanged, a trend toward improved R0 resection is encouraging and justifies further studies to ascertain the true oncologic significance of this technique.
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Affiliation(s)
- J S Gundara
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, Australia
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Yamaguchi K. Pancreatoduodenectomy for bile duct and ampullary cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:210-5. [PMID: 22170385 PMCID: PMC3311854 DOI: 10.1007/s00534-011-0480-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pylorus-preserving pancreatoduodenectomy has become a standard operation for distal and middle bile duct cancers. Bile duct cancer typically extends longitudinally and invades vertically. It frequently metastasizes to the lymph nodes and infiltrates the perineural spaces. The presence of residual cancer in the bile duct stump and lymph node metastases are significant prognostic factors. Negative surgical margins and D2 lymph node dissection are necessary for curative resection. The clinical course after portal vein resection for bile duct cancer with portal vein invasion is better than that of non-resectable bile duct cancer. Portal vein resection can therefore be useful. The efficacy of prophylactic portal vein resection is unclear. We describe here our methods for performing pylorus-preserving pancreatoduodenectomy for bile duct cancer.
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Affiliation(s)
- Koji Yamaguchi
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
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Pancreatic dissection in the procedure of pancreaticoduodenectomy (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:95-9. [DOI: 10.1007/s00534-011-0476-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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