Abstract
Background. Pancreaticoduodenectomy is the potentially curative treatment for malignant and several benign conditions of the pancreatic head and periampullary region. While performing pancreaticoduodenectomy, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels, intraductal papillary mucinous neoplasm, and pancreatic head bleeding pseudoaneurysm. Our work aims to highlight a particular hind right approach pancreaticoduodenectomy in selected indications and assess the preliminary results. Methods. We describe our early hind right approach to the retropancreatic vasculature during pancreaticoduodenectomy by mesopancreas dissection before any pancreatic or digestive transection. Results. We used this approach in 52 patients. Thirty-two had hepatic artery anatomic variant and 2 had bleeding pancreatic head pseudoaneurysm. The hepatic artery variant was preserved in all cases out of 2 in which arterial reconstruction was performed. In nine patients with intraductal papillary mucinous neoplasms the pancreaticoduodenectomy was extended to the body in 6 and totalized in 3 patients. Seven patients with adenocarcinoma involving the portomesenteric axis required venous resection and reconstruction. Conclusions. Early hind right approach is advocated in selected cases of pancreaticoduodenectomy to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement.
Highlights
Pancreaticoduodenectomy (PD) is the treatment of choice for malignant and several benign conditions of the pancreatic head and periampullary region [1,2,3,4]
A replaced common HA (RCHA) originating from the superior mesenteric artery (SMA) was involved by an enlarged lymph nodes mass behind the pancreatic head in 2 patients, so a segmental resection of the involved RCHA had to be performed with arterial reconstruction, using the reversed splenic artery in both cases
Seven patients with borderline resectable ductal adenocarcinoma involving the portomesenteric confluence required en bloc resection, mobilization of the right colon, and mesentery root followed by mesentericoportal venovenous suture
Summary
Pancreaticoduodenectomy (PD) is the treatment of choice for malignant and several benign conditions of the pancreatic head and periampullary region [1,2,3,4]. The extended indications of PD in case of tumors associating hepatic artery (HA) variants or invading the mesentericoportal axis (borderline resectable pancreatic head adenocarcinomas) [11], as well as the importance to achieve R0 posteromedial resection margins (in adenocarcinomas and main duct-intraductal papillary mucinous neoplasms-MD-IPMN) [12], led to the development of so called “artery first” approaches [13]. Notable amongst these is an early right posterior approach to the superior mesenteric vessels, with mesopancreas (MP) dissection close to the origin of the SMA. Hind right approach is advocated in selected cases of pancreaticoduodenectomy to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement
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