"Mesopancreas-first" radical resection of pancreatic head cancer following the Cattell-Braasch-Valdoni maneuver: Appreciating the legacy of pioneers in visceral surgery

Validating the Cattell-Braasch maneuver with a case of inherent atypical malrotation of the bowel: a case report

BACKGROUND

Malrotation of the bowel due to imperfect embryologic development is a rare condition with a wide spectrum of resulting anatomical variations. Similar conditions are achieved in the adult by derotating the bowel via the Cattell-Braasch maneuver. However, possible preparational bias might compromise the resulting topography.

CASE PRESENTATION

We present a case of atypical malrotation of the bowel in a cadaver study using a 96-year-old Caucasian male specimen with incidental finding of the pathology post mortem with no known surgical intervention in the abdomen during his lifetime. We compare the topography and abdominal layers with the anatomy of a 98-year-old Caucasian female specimen where the Cattell-Braasch maneuver was used to revert the embryologic development.

CONCLUSIONS

Reverting the embryologic development in the adult via Cattell-Braasch maneuver enables to mirror inherent malrotation and reestablishes the position of the bowel prior to its rotation. The Cattell-Braasch maneuver is further validated in this study by showing that it is able to demonstrate essential layers for surgical interventions without damaging their integrity. Atypical malrotation unmasks those fascial border-like layers, which are often hidden due to adhesions and fusing of tissue during the usual embryologic development. Developmental defects present a chance to explore essential surgical layers that are otherwise masked by artifacts due to fusion of layers of connective tissue.

A more radical perspective on surgical approach and outcomes in pancreatic cancer-a narrative review

Background and Objective

Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical aspects for pancreaticoduodenectomy (PD), distal and total pancreatectomy (TP), incorporating lessons from both the western and eastern visions in treating pancreatic cancer.

Methods

We conducted an extensive literature review through PubMed, prioritizing papers published in the last 5 years, but older emblematic papers were also included. We included articles that explored the treatment of pancreatic adenocarcinoma, with focus on the surgical aspect and strategies to improve outcomes. References of selected articles were also reviewed to identify any missed studies. Only papers in English were included.

Key Content and Findings

As evidence continues to build, it is clear that both systemic and surgical therapies have a fundamental and complementary role. State of art surgical treatment encompasses complete mesopancreas excision for radical lymphadenectomy. Preoperative planning of dissection planes, extensive knowledge of vascular anatomic variations, oncological principles and expertise for vascular resections are mandatory to perform a more radical operation, in pursuit of improved outcomes.

Conclusions

Based on current data, patient selection remains key and a more radical surgical approach brings more accomplishing results bringing as to believe that more is better.

Superior Mesenteric Artery First Approach for Minimally Invasive Pancreaticoduodenectomy: A Step-By-Step Surgical Technique Video

INTRODUCTION

In the past decade, minimally invasive pancreaticoduodenectomy has been gaining interest. However, minimally invasive pancreaticoduodenectomy remains technically challenging and is associated with a steep learning curve. Additionally, the operating surgeon should be cognizant of replicating the same oncological steps as observed in the typical open approach. In view of this, there exist various maneuvers that are designed to achieve negative margins and a safer mesopancreatic dissection. One of these techniques is the superior mesenteric artery first approach, which is garnering interest among pancreatic surgeons.

MATERIAL AND METHODS

According to existing literature, there are several superior mesenteric artery dissections approaches. We describes 5 different minimally invasive approaches.

RESULTS

This multimedia manuscript provide, for the first time in literature, a comprehensive step-by-step overview of the superior mesenteric artery first approach for minimally invasive pancreaticoduodenectomy by a team of expert surgeons from various international institutions.

CONCLUSIONS

Through the tips and indications presented in this article, we aim to guide the choice of this approach according to tumor location, type of minimally invasive approach and the operating surgeon's experience and increase familiarity with such a complex procedure.

First jejunal vein, jejunal trunk, and pancreatico-duodenectomy: resolving the literature conundrum

A detailed knowledge of the surgical anatomy of tributaries of the superior mesenteric vein, especially proximal jejunal venous anatomy (first jejunal vein and jejunal trunk), is a key prerequisite for performing a safe pancreatico-duodenectomy. However, the available literature on the anatomical course and surgical relevance of these vessels is scarce, the nomenclature across the articles is heterogeneous, and the resulting evidence is confusing to interpret. Standardized terminology and an in-depth review of these vessels with regard to their course, termination, vascular relations, and variations will help the surgeons in planning and performing this complex surgery safely, especially when a venous resection and reconstruction is planned in cases of borderline resectable pancreatic cancer. A uniform nomenclature and a unifying classification are proposed in this review for these two tributaries to help resolve the literature conundrum. This standardized terminology and anatomical description will assist the radiologists in reporting pancreatic protocol-computed tomography scans and surgeons in selecting the appropriate steps for the different anatomical orientations of these tributaries for the performance of safe pancreatic surgery. This will also help future researchers communicate in well-defined terms in reference to these tributaries so as to avoid confusion in future studies.