Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer

Non-curative resection for surgical T4b esophageal cancer: esophagectomy or non-esophagectomy?

BACKGROUND

Recently, with the development of multidisciplinary treatment, the treatment outcomes of esophageal cancer (EC) have improved. However, despite advances in diagnostic imaging modalities, preoperative diagnosis of T4 EC is still difficult, and the prognosis of T4 EC remains very poor. In addition, the prognosis of surgical T4b EC (sT4b EC) after surgery remains unclear. In this study, we retrospectively reviewed sT4b EC.

METHODS

We evaluated the clinical course of sT4b EC and compared palliative esophagectomy with R2 resection (PE group) with other procedures without esophagectomy (NE group) (e.g., only esophagostomy) for sT4b EC.

RESULTS

Forty-seven patients with thoracic EC underwent R2 resection at our institution between January 2009 and December 2020. Thirty-four patients were in the PE group, and 13 patients were in the NE group. The 2-year overall survival rate was 0% in the PE group and 20.2% in the NE group (p = 0.882). There was one case of long-term survival in the NE group that underwent surgery followed by definitive chemoradiation. Postoperative complications (Clavien-Dindo grade ≥ 3) were observed in 25 patients (73.5%) in the PE group and in three patients (23.1%) in the NE group (p = 0.031). The median time to the initiation of postoperative treatment was 68.1 days in the PE group and 18.6 days in the NE group (p = 0191).

CONCLUSIONS

If EC is diagnosed as sT4b, palliative esophagectomy should be avoided because of the high complication rate and the lack of long-term survival.

Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of "art" and "science"

Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long-term survival outcomes, and various challenges in obtaining high-level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long-term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high-level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico-enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called "art" when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered "surgical artists," "surgical scientists," and "surgical practitioners." We look forward to more "surgical artists" educating future "surgical artists and scientists" to create a richer "spirit of innovation," leading to a more beautiful integration of art and science in the field of pancreatic surgery.

Anatomical Study of the Duodenojejunal Uncinate Process Vein: A Key Landmark for Mesopancreatoduodenal Resection During Pancreaticoduodenectomy

Background

The mesopancreas or mesopancreatoduodenum is an important anatomical concept during pancreaticoduodenectomy (PD) in patients with periampullary carcinoma. This study investigated whether the duodenojejunal uncinate process vein (DJUV), which is defined as the vein draining from the upper jejunum to the superior mesenteric vein adjacent to the uncinate process, is a useful anatomical landmark for the caudal border of mesopancreatoduodenum resection during PD.

Methods

This study enrolled 100 adult patients with hepatobiliary pancreatic disease who underwent preoperative multidetector‐computed tomography (CT). The anatomy of the key blood vessels involved during PD, and the relationship between these vessels and the DJUV, were analyzed by preoperative CT.

Results

The first jejunal vein was the DJUV in 85 cases, whereas the second jejunal vein was the DJUV in 15 cases. Furthermore, the DJUV was classified into two subtypes depending on its positional relationship with the superior mesenteric artery (SMA). The inferior pancreaticoduodenal artery and vein were located on the cranial side of the DJUV in all cases. The distance between the middle colonic artery, used as a guide for regional lymph nodes, and the point where the DJUV intersected the SMA was within 10 mm in 80% of cases. These results imply that using the DJUV as a landmark for the caudal border of the mesopancreatoduodenum provides a safe approach and enables sufficient dissection of regional lymph nodes and tissues around the SMA.

Conclusion

The DJUV may be a useful anatomical landmark for the caudal border of the mesopancreatoduodenum resection during PD.

The role of mesopancreas excision for ampullary carcinomas: a single center propensity-score matched analysis

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.

Borderline resectable pancreatic cancer and vascular resections in the era of neoadjuvant therapy

While pancreatic cancer is still characterized by early systemic spread and poor outcomes, the treatment of this disease has changed significantly in recent years due to major advancements in systemic therapy and advanced surgical techniques. Broader use of effective neoadjuvant approaches combined with aggressive surgical operations within a multidisciplinary setting has improved outcomes. Borderline resectable pancreatic cancer is characterized by tumor vascular invasion, and is a setting where the combination of potent neoadjuvant chemotherapy and aggressive surgical methods, including vascular resections and reconstructions, shows its full potential. Hopefully, this will lead to improved local control and curative treatment in a number of patients with this aggressive malignancy.

What do surgeons need to know about the mesopancreas

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.

Technical details of a left-side approach to the superior mesenteric artery during pancreaticoduodenectomy

BACKGROUND AND PURPOSE

To describe the procedure for a left-side approach to the superior mesenteric artery (SMA) during pancreaticoduodenectomy (PD) in a cadaveric study.

OPERATIVE PROCEDURE

After dividing the upper jejunum, the jejunal artery (JA) is followed to its origin. At the cranial side of the JA, the mesojejunum to be dissected is detached from the ventral to the dorsal side and from the peripheral to the origin side of the SMA. The inferior pancreatoduodenal artery (IPDA), which is usually the common trunk of the IPDA and the first JA, is able to be visualized at the cranio-dorsal side of the origin of the JA. After cutting the IPDA, the mesojejunum can be detached from the SMA from the dorsal aspect to the right side. Subsequently, the pancreas head is dissected easily from the right aspect of the SMA.

CONCLUSION

This left-side approach to the SMA may become a standard procedure.

En bloc proximal peri-mesenteric clearance for pancreatic head cancer surgery

The superior mesenteric artery (SMA) first approach and meso-pancreas excision (MPE) during pancreatoduodenectomy (PD) for pancreatic head cancer have been suggested for complete local tumor control, less operative blood loss, and early determination of resectability. However, SMA-first approach is merely a mode of approach and the concept of MPE has been challenged due to its anatomical obscurity. Dissection around proximal mesenteric vessels, superior mesenteric vein and SMA, is a critical procedure point for local tumor control as tumor infiltration is frequently observed both at the time of initial diagnosis and recurrence. The meso-pancreas, which encompasses the soft tissue between the uncinated process and SMA, does not include all the aforementioned points of proximal mesenteric areas. Therefore, the authors propose a new terminology named, “en bloc proximal peri-mesenteric clearance (PPMC)”, to describe the removal of all the lymph nodes including soft tissue around proximal mesenteric vessels, especially the SMA, to ensure complete local tumor control of pancreatic head cancer. The SMA-first approach applied either by the mesenteric approach or supra-colic approach can make this procedure more feasible. The extent of the circumferential dissection of the peri-SMA nerve plexus can be adjusted according to the primary disease. PPMC including the removal of all lymph nodes around the proximal SMA may be considered as a standard extent of PD for pancreatic head cancer.

Periarterial divestment in pancreatic cancer surgery

BACKGROUND

Modern pancreatic cancer surgery changed with the introduction of effective neoadjuvant therapies. Complete tumor resection is the mainstay for long-term, disease-free, and overall survival and has been a prerequisite for decreasing local recurrence. The medial resection margin in the area of the superior mesenteric vessels limits the radicalness of the resection, especially in borderline and locally advanced cases. Therefore, the periarterial soft tissue around the peripancreatic visceral arteries must be completely cleared. This procedure, namely periarterial divestment, is technically demanding but often represents an alternative to arterial resection.

OBJECTIVE

Here we describe the technique and our initial experience with periarterial divestment along the peripancreatic visceral arteries during pancreatic surgery. This technique, in combination with previously published resection strategies, such as artery first maneuver and mesenterico-portal venous bypass first, enables tumor resection in locally advanced pancreatic cancer.

CONCLUSION

Periarterial divestment can prevent the need for arterial resection in borderline and locally advanced pancreatic cancer, especially after neoadjuvant therapy. The feasibility, improved safety, and oncologic equivalence of arterial divestment versus arterial resection for pancreatic cancer surgery must be evaluated by clinical trials.

Laparoscopic versus open radical antegrade modular pancreatosplenectomy with artery-first approach in pancreatic cancer

BACKGROUND

An artery-first approach for pancreatic cancer (PC) is challenging to perform laparoscopically and is mainly performed using an open approach. The aims of this study were to assess the safety and feasibility of laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) with an artery-first approach (L-aRAMPS) as compared with open aRAMPS (O-aRAMPS) in resectable PC using matched-pair analysis.

METHODS

Artery-first approach is an early dissection of the superior mesenteric artery (SMA) from behind the pancreas body as the first surgical step. Data on L-aRAMPS and O-aRAMPS, performed between July 2013 and November 2019, were collected retrospectively. Additionally, the spatial characteristics of the splenic artery were analyzed using computed tomography.

RESULTS

Thirty L-aRAMPS and 33 O-aRAMPS for resectable PC were included. After matching, 15 L-aRAMPS were compared with 15 O-aRAMPS. Median intraoperative blood loss and hospital stay were significantly improved in L-aRAMPS compared to O-aRAMPS (30 vs. 220 g, p < 0.001; 12 vs. 16 days, p = 0.049). The overall morbidity was similar in both study groups. The total number of lymph nodes dissected and those harvested from around the SMA and R0 resection was similar in both study groups. We classified the width of the cross section of the pancreas body into three equal parts: the upper, middle, and lower parts of the pancreas; 63% of the splenic artery origin was located in middle and lower parts of the pancreas body.

CONCLUSION

L-aRAMPS is technically safe and oncologically feasible to secure favorable surgical outcomes for resectable PC patients.

Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes

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.

Clinical evaluation of modified invaginated pancreaticojejunostomy for pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy (PD) remains the major curative operation for malignant neoplasm of pancreas or cancerous tumors near the pancreas. Despite advancements in recent years, the postoperative recurrence rate of these neoplasms and tumors remains high. Moreover, overall morbidity remains high due to clinically relevant postoperative pancreatic fistula (POPF).

METHODS

To compare the clinical outcomes of modified invaginated anastomosis and mucosa-to-mucosa anastomosis, this retrospective study included 343 patients who underwent PD from January 2008 to January 2019 at Beijing Friendship Hospital, Capital Medical University. The patients' general conditions and disease status were preoperatively evaluated. The surgical procedure was recorded, and operative management was appropriately performed.

RESULTS

Compared with mucosa-to-mucosa anastomosis, modified invaginated anastomosis resulted in a higher intraoperative blood transfusion rate (P < 0.001) and lower hospitalization expenses (P = 0.049). However, no significant differences were found in operation time (P = 0.790), intraoperative bleeding (P = 0.428), postoperative recovery exhaust time (P = 0.442), time to normal flow of food (P = 0.163), and hospitalization time (P = 0.567). Operation time was a risk factor for POPF (odds ratio 1.010; 95% confidence interval 1.003-1.016; P = 0.003). The incidence of pancreatic fistula (grades B and C) was lower in the patients who underwent modified invaginated anastomosis (14.1%) than in those who underwent mucosa-to-mucosa anastomosis (15.3%). The operation time was greater in the POPF group than in the non POPF group among the patients who received modified invaginated anastomosis (P = 0.003) and mucosa-to-mucosa anastomosis (P = 0.002).

CONCLUSION

Modified invaginated pancreaticojejunostomy for PD resulted in a decreased incidence of POPF; it may serve as a new approach for PD while managing patients who have undergone PD.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).

Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.

Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).

Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: A meta-analysis

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.

Systematic review of the mesopancreas: concept and clinical implications

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.