Approach In Pancreaticoduodenectomy Research Articles

Artery first approach pancreaticoduodenectomy with segmental resection and reconstruction of SMV for borderline resectable PDAC after neoadjuvant chemotherapy

Artery first approach pancreaticoduodenectomy with segmental resection and reconstruction of SMV for borderline resectable PDAC after neoadjuvant chemotherapy

Mesopancreas Level 3 Dissection in Robotic Pancreaticoduodenectomy

Introduction: There is no study regarding mesopancreas dissections using the robotic approach in pancreaticoduodenectomy in the literature. This study is to evaluate the feasibility and justification of mesopancreas level 3 dissection in robotic pancreaticoduodenectomy (RPD). Method: Surgical outcomes after RPD and open pancreaticoduodenectomy (OPD) were evaluated and compared. Results: There were 289 RPD and 162 OPD patients. Postoperative diarrhea occurred in 34.5% by mesopancreas level 3 dissection, higher than those for level 2 and 1. Blood loss in the RPD group was higher by mesopancreas level 3 dissection, with a median of 263 ml. The rate of R0 resection with margin >1 mm by mesopancreas level 3 dissection was 93.8%, higher than 72.2% by level 2 dissection. Lymph node yield by mesopancreas level 3 dissection in RPD was higher, with a median of 21, vs. 18 by level 2 and 14 by level 1. Compared with mesopancreas level 1 and 2 dissections in RPD groups, level 3 dissection did not increase in surgical mortality, postoperative complications including postoperative pancreatic fistula, delayed gastric emptying (DGE), postpancreatectomy hemorrhage, chyle leakage, bile leakage, and wound infection. Compared with OPD, mesopancreas level 3 dissection in RPD was associated with less blood loss, no DGE, and lower chyle leakage. Conclusion: Mesopancreas level 3 dissection in RPD is not only justified with increasing oncological radicality but also feasible without compromising the surgical risks. Therefore, RPD can be recommended as a safe alternative to OPD for mesopancreas level 3 dissection.

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

The “artery-first” approach pancreaticoduodenectomy, with maximal mesopancreas excision and central vascular ligation, represents the current principal determinants of radicality in pancreatic head cancer resection. However, these modifications at the resection stage of pancreaticoduodenectomy constitute extremely demanding and technically complicated procedures. Among the most critical contributing factors in the difficulty of artery-first approaches is the spiral configuration of the mesoduodenum and proximal mesojejunum around the superior mesenteric artery axis. This creates complicated tridimensional anatomy, making surgical dissection in the inferior peripancreatic anatomic area extremely challenging and demanding. The Cattell–Braasch–Valdoni maneuver (right-sided medial visceral mobilization and intestinal derotation maneuver) restores the embryological twist of the duodenojejunal junction, which demystifies the distorted peripancreatic vascular anatomy and facilitates a safe and radical “mesopancreas-first” pancreatic head cancer resection. The aim of this paper was to present the advantages, efficacy, and safety of the Cattell–Braasch–Valdoni maneuver in artery-first approach radical pancreaticoduodenectomy and provide a detailed description of its surgical technique.

Application of left-sided uncinate process first approach in pancreaticoduodenectomy

Objective: To evaluate the value of left-sided uncinate process first approach in pancreaticoduodenectomy. Methods: The clinical data of 152 patients who underwent the left-sided uncinate process first approach during pancreaticoduodenectomy at Pancreas Center, the First Affiliated Hospital of Nanjing Medical University from January 2020 to December 2020 were analyzed retrospectively. There were 64 females and 88 males,with age(M(QR)) of 62.0(14.7)years(range:16.0 to 84.0 years). The clinical date of 117 patients who underwent pancreaticoduodenectomy without using left-sided uncinate process first approach in the same period was selected as the control group,including 65 females and 52 males,with age of 64.0(13.0) years(range:13.0 to 84.0 years). Fisher exact probability method and t test were used to compare the data between the two groups,rank sum test was used for comparison of continuous variables between the two groups. Results: Pancreaticoduodenectomy was successfully performed in 152 patients in left-sided uncinate process first approach group. The operation time was 222.5(77.0) minutes(range:117.0 to 480.0 minutes),the time of uncinate process resection from left-side(the time from jejunum dissection to complete dissociation of the uncinate process) was 11.0(4.5) minutes(range:7.5 to 20.0 minutes),the time of pancreatic head resection (the time from jejunum dissection to pancreaticoduodenal specimen removal) was 26.0(8.5) minutes(range:20.0 to 41.0 minutes),the intraoperative blood loss was 200(150) ml(range:50 to 800 ml),and the intraoperative blood transfusion rate was 9.2% (14/152). Postoperative conditions:The postoperative hospital stay was 12 (9) d(range:6 to 55 d),the overall incidence of postoperative complications was 59.9%(91/152),and there was no perioperative death. Pathological results:The R0 resection rate of periampullary malignant tumor was 64.3%(77/112),with negative rate of uncinate process margin was 91.1%(102/112). The R0 resection rate of pancreatic ductal adenocarcinoma was 46.9%,with negative rate of uncinate process margin was 89.1%(57/64). Compared with the non-left-sided uncinate process first approach group(222.5(77.0) minutes, 9.2%(14/152)),the left-sided uncinate process first approach group had shorter operation time(246.0(94.0) minutes) (Z=3.964,P<0.01),less intraoperative blood loss (18.8%(22/117))(Z=4.843,P<0.01),and lower intraoperative blood transfusion rate(χ²=5.248,P=0.029). However,there were no significant differences between two groups in postoperative hospital stay(Z=1.682,P=0.093),postoperative overall complications(P=0.549),R0 resection rate of periampullary malignant tumor(χ²=2.012,P=0.156),and negative rate of uncinate process margin(χ²=2.108,P=0.147). Conclusions: The "left-sided uncinate process first approach" could completely resect uncinate process under a direct vision,especially when the uncinate process was behind the superior mesenteric artery or beyond the left lateral margin of the superior mesenteric artery. The "left-sided uncinate process first approach" might increase the negative rate of uncinate process margin and R0 resection rate for periampullary malignant tumor.

"How I dissect the uncinate process of the superior mesenteric vessels" a robotic assisted approach in pancreaticoduodenectomy

Presenter: Nicole M Nevarez MD | University of Texas Southwestern Medical Center Methods: In this submitted video we detail the four steps utilized in dissecting the uncinate process off the superior mesenteric vessels during a robotic assisted pancreaticoduodenectomy. The four steps we commonly utilize during this segment of the procedure include in order:1.Dissection of superior mesenteric vein from uncinate process2.Cranial dissection of uncinate process for landing zone3.Dissection of 1st jejunal branch of superior mesenteric vein4.Dissection of uncinate process off superior mesenteric artery-caudal to cranial approach

489 – Artery First Approach Pancreaticoduodenectomy with Pvsmv Reswction and Reconstruction for Pancreatic Head Cancer

489 – Artery First Approach Pancreaticoduodenectomy with Pvsmv Reswction and Reconstruction for Pancreatic Head Cancer

Comparisons of different neoadjuvant chemotherapy regimens with or without stereotactic body radiation therapy for borderline resectable pancreatic cancer: study protocol of a prospective, randomized phase II trial (BRPCNCC-1)

BackgroundFew patients with pancreatic cancer may be candidates for immediate surgical resection at the initial diagnosis. Even if patients with borderline resectable pancreatic cancer (BRPC), micrometastases may occur before surgery. Therefore, neoadjuvant therapy is vital for improved survival, which has been confirmed in previous studies that neoadjuvant chemotherapy with or without radiotherapy provides superior overall compared with upfront surgery. However, question of whether the addition of radiotherapy to neoadjuvant chemotherapy can improve prognosis compared with chemotherapy alone is a challenging matter. Moreover, most of previous studies only adopted conventional radiotherapy as the neoadjuvant modality though stereotactic body radiation therapy (SBRT) has been proven effective and commonly employed in pancreatic cancer. Also, no studies have evaluated the efficacy of S-1 as the neoadjuvant chemotherapy regimen for BRPC albeit similar prognosis has been found between S-1 and gemcitabine in advanced pancreatic cancer. Hence, the aim of this study is to investigate whether neoadjuvant chemotherapy plus SBRT results in better outcomes compared with neoadjuvant chemotherapy alone and also compare the efficacy of gemcitabine plus nab-paclitaxel with SBRT and S-1 plus nab-paclitaxel with SBRT.MethodsPatients with biopsy and radiographically confirmed BRPC, no prior treatment and severe morbidities are enrolled. They will be randomly allocated into three groups: neoadjuvant gemcitabine plus nab-paclitaxel, neoadjuvant gemcitabine plus nab-paclitaxel with SBRT and neoadjuvant S-1 plus nab-paclitaxel with SBRT. Standard doses of gemcitabine and nab-paclitaxel are used. The radiation dose of SBRT is 7.5-8Gy/f for 5 fractions. Surgical resection will be performed 3 weeks after SBRT. Artery first approach pancreaticoduodenectomy or radical antegrade modular pancreatosplenectomy will be used for the tumor in the head or body and tail of the pancreas, respectively. The primary endpoint is overall survival. The secondary outcomes are disease free survival, pathological complete response rate, R0 resection rate and incidence of adverse effects.DiscussionIf results show the survival benefits of neoadjuvant chemotherapy plus SBRT and similar outcomes between S-1 and gemcitabine, it may provide evidence of clinical practice of this modality for BRPC.Trial registrationThe study has been registered in ClinicalTrial.gov (NCT03777462).

Pancreatoduodenectomy with artery-first approach.

"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.

Comparative analysis of afferent loop obstruction between laparoscopic and open approach in pancreaticoduodenectomy

Introduction: Afferent loop obstruction (ALO) is a rare mechanical complication of pancreaticoduodenectomy (PD) and is associated with a high rate of morbidity and mortality. Method: Data from patients who underwent PD between May 2007 and July 2017 at a single large-volume center were retrospectively reviewed. Result: Of the 3223 patients who underwent PD, 67 developed ALO. More patients in the LPD group had developed ALO due to internal herniation than did those in the OPD group (46.2 vs. 4.7%, p <0.001). Patients in the LPD group also showed earlier occurrence of ALO (ALO occurrence within 60 days: 76.9 vs. 22.2%, p <0.001) and more frequent requirement for surgical treatment (76.9 vs. 18.9%, p< 0.001) than did those in the OPD group. Conclusion: The characteristics of ALO were significantly different between patients who had received LPD and OPD. The most common cause of ALO in the LPD group was internal herniation occurring in the early postoperative period. Internal herniation following LPD may be prevented by routine closure of mesocolic window and should be treated by emergency surgery if it occurs.

Analysis on the clinical therapeutic effects of arterial first approach pancreatoduodenectomy in the treatment of borderline resectable pancreatic adenocarcinoma

Objective: To compare the clinical therapeutic effects of arterial first approach pancreaticoduodenectomy(AFA-PD) with standard approach pancreaticoduodenectomy(SPD) in the treatment of borderline resectable pancreatic cancer (BRPC). Methods: A retrospective analysis of the clinical data of 113 cases of pancreatic cancer patients from January 2014 to August 2015 at Department of Hepato-Biliary-Pancreatic Surgery, Changhai Hospital, the Second Military Medical University, including 43 cases in AFA-PD group and 70 cases in SPD group.Every patient had gone high-resolusion computed tomography before the surgery, when BRPC was definitely diagnosed by both experienced radiologist and pancreatic surgeon.There were 24 males and 19 females in the AFA-PD group, with average age of (61.6±10.2)years.And in the SPD group, there were 47 males and 23 females, with average age of (62.7±9.4)years. Results: The operation time was (210.7±31.5)minutes in AFA-PD group, (187.9±27.4)minutes in SPD group, and peroperative bleeding volume was (1 007.1±566.3)ml in AFA-PD group, (700.0±390.0)ml in the other group.Those two indicators of AFA-PD group, compared with SPD group, were relatively higher, the difference was statistically significant(all P<0.01). And with regard to postoperative diarrhea(9.3% vs.5.7%), postoperative 1, 3 days of white blood cells(postoperative 1 day: (13.3±1.1)×10(9)/L vs.(12.4±2.4)×10(9)/L; postoperative 3 days: (12.7±1.6)×10(9)/L vs.(11.7±2.5)×10(9)/L), postoperative 1, 3, 5 days of peritoneal drainage fluid volume(postoperative 1 day: (184±42)ml vs.(156±54)ml; postoperative 3 days: (155±48)ml vs.(133±35)ml; postoperative 5 days: (66±20)ml vs.(47±31)ml), the differences between the two groups were statistically significant (all P<0.05). One patient in the SPD group was treated with unplanned secondary surgery for postoperative intraperitoneal hemorrhage, and the patient was cured and discharged.There was no death in the two groups within 30 days after surgical operation and no patient with positive gastric margin, duodenal margin, or anterior margin.The resection rate of superiormesenteric artery(SMA) margin R0 in AFA-PD group was higher than that in SPD group (P=0.019). The two groups were followed up for 14 to 30 months.As for AFA-PD group, the average survival time, progression free survival time and median survival time was respectively (20.4±1.2)months, (21.5±1.4)months and 20 months.There were 3 cases(7.0%) with local recurrence and 8 cases(18.6%) with liver metastasis or distant metastasis.In the SPD group, the average survival time, progression free survival time and median survival time was (17.1±1.1)months, (16.4±1.3)months and 16 months, respectively.There were 13 cases(18.6%) with local recurrence and 25 cases(35.7%) with liver metastasis or distant metastasis.As a result, the AFA-PD group had longer survival time(P=0.001)and progression free survival time(P=0.002). However, the lower local recurrence and distant metastasis rate in AFA-PD group did not reach statistical standard (P>0.05). Conclusion: The arterial first approach pancreaticoduodenectomy is safe and effective in the treatment of borderline resectable pancreatic cancer, which can improve the resection rate of SMA margin R0, and prolong patient survival time.

Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis

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). 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. 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. 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.

SMA first approach Pancreaticoduodenectomy for cancer – should it be standard approach?

Background: pancreaticoduodenectomy (PD) has become the standard treatment for cancer of head of pancrease and periampullary malignancies. Recently superior mesenteric artery (SMA) first approach has shown to have several advantages over the conventional superior mesenteric vein (SMV) first approach. We present our initial experience with SMA first approach for PD.Methods: Thirteen patients undergoing SMA first PD during year 2014-2015 (1 year) were prospectively studied. A posterior approach with “hanging maneuver” was used to identify SMA first and the resectibility was confirmed. Inferior pancreaticoduodenal artery (IPDA) was ligated before the division of pancreatic neck. Duct to mucosa pancreaticojejunostomy followed by hepaticojejunostomy and gastrojejunostomy was performed.Results: patients with mean age of 53 years presented with abdominal pain and jaundice (100%). Tumors were of periampullary region in 10 cases and of head of pancrease in three cases. Two patients required partial SMV wall resection with tangential repair. Mean operating time, blood loss and postoperative stay was 304 minutes, 380 ml and 14 days, respectively. Replaced/ aberrant right hepatic artery from SMA was observed in 38% cases. Mean number of dissected nodes was 16. R0 resection was achieved in 100% cases. There was one postoperative mortality (7.7%) and minor complications were noted in 46% cases.Conclusion: SMA first PD helps to properly identify and control anomalous or accessory right hepatic artery arising from SMA, minimizes intraoperative bleeding due to proper control.

Posterior superior mesenteric artery first dissection versus classical approach in pancreaticoduodenectomy: outcomes of a case-matched study

Posterior superior mesenteric artery first dissection versus classical approach in pancreaticoduodenectomy: outcomes of a case-matched study

Operative procedure and clinical features of left posterior approach pancreaticoduodenectomy with total mesopancreas excision for pancreatic head carcinoma

Operative procedure and clinical features of left posterior approach pancreaticoduodenectomy with total mesopancreas excision for pancreatic head carcinoma

Hind right approach pancreaticoduodenectomy: from skill to indications.

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.

Left Posterior Approach Pancreaticoduodenectomy with Total Mesopancreas Excision and Circumferential Lymphadenectomy Around the Superior Mesenteric Artery for Pancreatic Head Carcinoma

In most cases of pancreatic head cancer, surgery often results in noncurative resection, which is frequently related to inadequate clearance of the mesopancreas. The aim of this report is to introduce the surgical technique of left posterior approach pancreaticoduodenectomy (PD) with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery (SMA) (LPA-PD) and to examine whether this procedure increases the rate of true curative resection and decreases the rate of locoregional recurrence. Nineteen patients underwent standard PD, and 19 patients underwent LPA-PD. The demographic characteristics, intraoperative outcomes (mean operative time and mean blood loss), postoperative outcomes (complications, type of recurrence and survival), and pathological findings (R number, number of removed regional lymph nodes and positive resection margins) were evaluated. The patient characteristics did not differ significantly between the groups. The mean blood loss in the LPA-PD group was significantly less than that in the standard PD group (p<0.05). The incidence rate of postoperative complications did not differ between the groups. No surgery-related deaths occurred in either group. The number of removed regional lymph nodes around the superior mesenteric artery in the LPA-PD group was significantly greater than that in the standard PD group (p<0.01). The R0 resection rate in the LPA-PD group was higher, although not significantly so, than that in the standard PD group. The resection margin of the mesopancreas was negative in all patients of the LPA-PD group. The rate of locoregional recurrence in the LPA-PD group was significantly lower than that in the standard PD group (p<0.01). The postoperative survival rate did not differ significantly between the groups. Our method of LPA-PD helps secure the negative margin of the mesopancreas and enables complete circumferential lymphadenectomy around the SMA. Therefore, LPA-PD may increase the true curative resection rate and decrease the locoregional recurrence rate compared with standard PD.