Mesenteric Approach for Pancreaticoduodenectomy

Abstract

Curative surgical resection with negative surgical margins (R0) is essential to prolong the survival for pancreatic cancer patients. However, obtaining negative surgical margins is sometimes difficult especially for advanced pancreatic cancer with the involvement of the major arteries including the superior mesenteric artery (SMA), celiac artery, and common hepatic artery and/or portal vein/superior mesenteric vein (SMV). The connective tissue around the SMA is one of favorable cancer-positive margin spots during pancreaticoduodenectomy. The surrounding tissues around the SMA include the inferior pancreaticoduodenal artery, first jejunal artery, first jejunal vein, lymph nodes, and nerve plexus toward pancreatic head, and the region is usually called “mesopancreas” or “mesopancreatoduodenum.” Not enough dissection of this region may cause local recurrence and poor survival after surgery. “Artery-first approach” is the term arising from the concept that complete dissection of connective tissues of the SMA is performed for pancreatic head cancer at an early step in operation. The aims of “artery-first approach” are (1) early determination of the resectability, (2) increase of negative surgical margin rates, and (3) reduction of intraoperative blood loss. “Mesenteric approach” during pancreaticoduodenectomy is proposed by Nakao et al. in 1993, and it is one of the “artery-first approach” techniques. This approach starts from complete dissection around the SMA and SMV at the infracolic mesentery during pancreaticoduodenectomy that means no manipulation of the pancreatic head (Kocher’s maneuver) prior to ligating and dividing the arteries supplying the pancreatic head, which is called non-touch isolated method. Recent retrospective reports described the superiority of “artery-first approach” including “mesenteric approach” during pancreaticoduodenectomy; however, further prospective studies are necessary to confirm the superiority.