Conventional Pancreaticoduodenectomy Research Articles

Utility of modified pancreaticoduodenectomy (Hi-cut PD) for middle-third cholangiocarcinoma: an alternative to hepatopancreaticoduodenectomy

BackgroundThe standard procedure for middle-third cholangiocarcinoma (MCC) is pancreaticoduodenectomy (PD); hepatopancreaticoduodenectomy (HPD) is often performed despite its high risk. There is no clear selection guidance for these procedures. MethodsPatients with MCC who underwent HPD or PD were retrospectively evaluated. The conventional PD was modified (mPD) to transect the bile duct beyond or close to the cranial level of the portal bifurcation. ResultsThe mPD group (n = 55) was characterized by older age, shorter operation time, less blood loss, and less frequent complications than were observed in the HPD group (n = 34). The median grossly tumor-free margin of the proximal bile duct (GM) was 13 mm vs 20 mm (P = 0.006). Overall survival did not differ significantly between groups (48% vs 53% at 5 years, P = 0.399). Multivariate analysis identified positive surgical margin as a sole independent prognostic factor (hazard ratio, 1.89; P = 0.043), which was statistically associated with GM length. Five-year survival for mPD patients with GM ≥15 mm was significantly better than that for those who had GM <15 mm (69% vs 33%, P = 0.011) and comparable to that of HPD patients (53%, P = 0.450). ConclusionThe mPD may be recommended in patients with MCC, provided that GM ≥15 mm is expected from the preoperative radiological imaging. Otherwise, HPD should be considered.

Modified Intestinal Derotation Procedure with Reversed Kocherization to Facilitate Mesopancreas Excision During Pancreaticoduodenectomy.

Although intestinal derotation procedure has advantages of facilitating mesopancreas excision during pancreaticoduodenectomy, the wide mobilization takes time and risks injuring other organs. This article describes a modified intestinal derotation procedure in pancreaticoduodenectomy and its clinical impact on short-term outcomes. The modified procedure comprised the pinpoint mobilization of the proximal jejunum following reversed Kocherization. Among 99 consecutive patients who underwent pancreaticoduodenectomy between 2016 and 2022, the short-term outcomes of pancreaticoduodenectomy with the modified procedure were compared with those of conventional pancreaticoduodenectomy. The feasibility of the modified procedure was investigated based on the vascular anatomy of the mesopancreas. Compared with conventional pancreaticoduodenectomy (n = 55), the modified procedure (n = 44) involved less blood loss and shorter operation time (p < 0.001 and 0.017, respectively). Severe morbidity, clinically relevant postoperative pancreatic fistula, and prolonged hospitalization occurred less often with the modified procedure compared with conventional pancreaticoduodenectomy (p = 0.003, 0.008, and < 0.001, respectively). According to preoperative image findings, most (72%) patients had a single inferior pancreaticoduodenal artery sharing a common trunk with the first jejunal artery. The inferior pancreaticoduodenal vein drained into the jejunal vein in 71% of the patients. The first jejunal vein ran behind the superior mesenteric artery in 77% of the patients. By combining our modified intestinal derotation procedure with preoperative recognition of the vascular anatomy of mesopancreas, mesopancreas excision during pancreaticoduodenectomy can be performed safely and accurately.

Long Term Outcomes of No-Touch Isolation Principles Applied in Pancreaticoduodenectomy for Treatment of Pancreatic Adenocarcinoma: A Multicenter Retrospective Study with Propensity Score Matching.

Background: The recurrence and liver metastasis rates are still high in pancreatic head cancer with curative surgical resection. A no-touch isolation principle in pancreaticoduodenectomy (PD) may improve this situation, however, the exact advantages and efficacy of these principles have not been confirmed. Materials and methods: Among 370 patients who underwent PD, three centers were selected and classified into two groups: the no-touch PD group (n = 70) and the conventional PD group (n = 300). Propensity score matching was used to control for selection bias at a ratio of 1:1. The confounding variables were age, sex, body mass index, adjuvant chemotherapy, carbohydrate antigen 19-9, tumor size and tumor differentiation. Results: Patients in the no-touch PD group had better overall survival (OS) and disease-free survival (DFS) than those in the conventional PD group (OS: 17 vs. 13 months, p = 0.0035, DFS: 15 vs. 12 months, p = 0.087), with lower 1- and 2-year disease-related mortality rates (1-year: 32.9% vs. 47%, p = 0.032; 2-year: 42.5% vs. 82% p = 0.000) and recurrence and liver metastasis rates (1-year: 30.0% vs. 43.3%, p = 0.041; 2-year: 34.3% vs. 48.7%, p = 0.030). Compared with the matched conventional PD group, the no-touch PD group also had a better OS (17 vs. 12 months, p = 0.032). Conclusions: Our study showed the no-touch isolation principle may be a better choice to improve long-term survival for pancreatic cancer patients.

Subtotal gastrectomy pancreaticoduodenectomy versus conventional pancreaticoduodenectomy in the incidence of delayed gastric emptying: single-center retrospective cohort study

BackgroundDelayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). There is currently no widely accepted procedure for PD to reduce the incidence of DGE. Our institution attempts to perform subtotal gastrectomy in patients undergoing PD to reduce DGE. Here we aimed to evaluate the effectiveness and safety of PD with subtotal gastric resection.MethodsPatients who underwent PD between January 2014 and December 2021 were reviewed. They were stratified by extent of gastrectomy into a conventional PD group (PD that resected approximately 1/3 of the distal stomach) and a subtotal gastrectomy PD group (PD that resected approximately 3/4 of the distal stomach), which were compared in terms of intraoperative and postoperative parameters.ResultFrom January 2014 to December 2021, a total of 512 patients underwent PD in the Department of Hepatobiliary Surgery, Peking University People’s Hospital. Nineteen patients were excluded from this study due to benign disease. A total of 493 patients were included, with 378 in the conventional PD group and 115 in the subtotal gastrectomy PD group. Compared with the conventional PD group, the subtotal gastrectomy PD group had a lower incidence of DGE (8.7% vs. 17.7%, p = 0.019), and a shorter hospital stay. Multivariate analysis showed that conventional PD and higher body mass index were independent risk factors for grade B/C DGE.ConclusionThis study showed that, compared with conventional PD, subtotal gastrectomy PD can reduce the incidence of DGE and shorten the length of hospital stay. At the same time, subtotal gastrectomy PD is comparable to conventional PD in terms of surgical safety. Furthermore, high BMI is an independent risk factor for postoperative DGE.

Various types of reconstruction after pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: a single-enter experience.

PurposeThe incidence of patients requiring pancreaticoduodenectomy (PD) following any type of gastrectomy is increasing as the population of elderly patients is increasing, especially in endemic areas of gastric cancer such as Korea. All types of gastrectomy can be categorized as subtotal gastrectomy with Billroth I (BI), Billroth II (BII), and total gastrectomy with Roux-en-Y anastomosis. In this paper, we reviewed our experiences of PD for patients who previously underwent gastrectomy.MethodsWe reviewed the medical records of the patients who underwent PD following any type of gastrectomy among 505 consecutive patients who underwent PD in a single institution between 2011 and 2020 retrospectively.ResultsThere were 13 patients who had undergone gastrectomy including 7 patients of BI, 1 patient of BII, and 5 patients of total gastrectomy. For all 7 patients of BI, the reconstruction was not different from conventional PD. For the 1 patient of BII, previous gastrojejunal anastomosis was preserved and reconstruction was performed in Roux-en-Y method. For the 5 patients with total gastrectomy, 2 different types of reconstruction were performed. In one patient, we removed the remaining jejunum with the specimen, and reconstruction was performed. For the other 4 patients, the remaining jejunum, distal to the Treitz ligament, was preserved and was utilized for anastomosis. Surgeries for all patients were uneventful.ConclusionPD following any type of gastrectomy can be safe. Especially, if the length of remained jejunum is long enough, its utilization for the reconstruction can be an appropriate option.

Surgical Outcomes and Comparative Analysis of Transduodenal Ampullectomy and Pancreaticoduodenectomy: A Single-Center Study

BackgroundTransduodenal ampullectomy (TDA) is performed for adenoma or early cancer of the ampulla of Vater (AoV). This study aimed to analyze the short- and long-term outcomes of TDA (TDA group) when compared with conventional pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PD group).MethodsPatients who underwent TDA between January 2006 and December 2019, and PD cases performed for AoV malignancy with carcinoma in-situ (Tis) (high-grade dysplasia, HGD) and T1 and T2 stage from January 2010 to December 2019 were reviewed.ResultsForty-six patients underwent TDA; 21 had a benign tumor, and 25 cases with malignant tumors were compared with PD cases (n = 133). Operation time (p < 0.001), estimated blood loss (p < 0.001), length of hospital stays (p = 0.003), and overall complication rate (p < 0.001) were lower in the TDA group than in the PD group. Lymph node metastasis rates were 14.6% in pT1 and 28.9% in pT2 patients. The 5-year disease-free survival and 5-year overall survival rates for HGD/Tis and T1 tumor between the two groups were similar (TDA group vs PD group, 72.2% vs 77.7%, p = 0.550; 85.6% vs 79.2%, p = 0.816, respectively).ConclusionTDA accompanied with lymph node dissection is advisable in HGD/Tis and T1 AoV cancers in view of superior perioperative outcomes and similar long-term survival rates compared with PD.

Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery.

The aim of the current study was to investigate whether the artery-first approach (AFA) improved surgical outcomes of pancreaticoduodenectomy (PD) at our non-high-volume center. We retrospectively reviewed data on 121 consecutive patients who underwent PD between January 2009 and December 2018. The perioperative data of 49 patients who underwent conventional PD (conventional group) and 72 patients who underwent PD via artery-first approach were analyzed and compared to assess the effectiveness of the AFA. Although no significant difference was observed between the two groups overall, in those with pancreatic cancer, the duration of surgery, intraoperative blood loss and transfusion rate in the AFA group (n=33) were significantly lower than those for the conventional group (n=11) (p=0.011, p=0.021 and p=0.038 respectively). AFA can be used to reduce the operative time, intraoperative blood loss, and transfusion rate in patients with pancreatic cancer.

Hepatic artery resection without reconstruction in pancreatoduodenectomy.

It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD. All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015. There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group. We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected.

Surgical management of choledochal cysts in adults; Our experience

Choledochal cysts are the name given to the congenital cystic dilatation of the intrahepatic and/or extrahepatic bile ducts. It is most commonly observed in childhood ages but there are cases diagnosed in adult-hood. They are precancerous lesions and should be resected when diagnosed. The aim of this study is to present the results of the patients who underwent surgical therapy due to choledochal cyst. This study retrospectively included adult patients who were diagnosed with choledochal cyst between January 2015 and December 2019. In addition to demographic data such as age and gender, the operative and postoperative morbidity and mortality rates were documented. The study included nine patients who underwent surgery due to a choledochal cyst. Of nine patients, three (33%) were male and six (66%) were female. The general mean age of the patients was 42.4 while the mean age of male patients was 56.5 and female patients was 35.5. The complaints were jaundice in three pati-ents (33%), acute pancreatitis in two patients (22%), biliary colic abdominal pain in two patients (22%), sepsis in one patient (11%), and suspected malignity in one patient (11%). Type 1 choledochal cyst was detected in all cases. In all patients included in the study, the external bile ducts including the intrapancreatic part were resected by incising the choledochal dilatation from the endpoint. The surgical procedure was performed laparoscopi-cally in two cases (22%). A biliary fistula that regressed with medical treatment was detected in postoperative one patient (11%). A postoperative pancreas fistula was not detected in any patient. Margin positive adenocar-cinoma was observed in the choledochal incisions of one patient who underwent laparoscopic surgery. The pati-ent was taken to re-exploration and conventional pancreaticoduodenectomy was performed. Choledochal cysts detected in older ages and male patients have a greater risk of malignity. Therefore, complete resection of bile ducts is necessary. The intraoperative frozen examination should be kept in mind as it protects patients from the second operation.

Survival outcomes of pancreaticoduodenectomy versus extended pancreaticoduodenectomy procedure for pancreatic head carcinoma: a propensity score matching study.

BackgroundIt is unclear if the modified extended pancreaticoduodenectomy (PD) has better outcome superior the conventional PD for patients with pancreatic head carcinoma (PHC). The objective of this study is to compare the survival outcomes of the classic PD procedure and the modified extended PD procedure for PHC.MethodsA total of 7,084 resected PHC patients with PD and extended PD procedure from the SEER database from 2004 to 2014 were stratified. With the utilization of propensity score matching (PSM), patient baseline characteristics were balanced to decrease the bias. Overall survival (OS) and cancer-specific survival (CSS) were analyzed in both groups.ResultsOf the 7,084 patients, 6,541 (92.3%) and 543 (7.7%) patients received PD and extended PD surgical procedures, respectively. After 2:1 ratio of PSM, 543 patients with extended PD procedure and 1,084 patients with PD procedure were completely matched. The median CSS and OS for PD and extended PD group were 20.0 and 19.0 months, and 19.0 and 18.0 months, respectively. The 5-year CSS and OS rates for PD and extended PD group were 17.5% and 16.1%, and 13.9% and 13.1%, respectively.ConclusionsThere is no distinct difference in survival outcomes between PD and extended PD procedure in patients with PHC.

Left-sided Portal Hypertension After Pancreaticoduodenectomy With Resection of the Portal Vein/Superior Mesenteric Vein Confluence in Patients With Pancreatic Cancer: A Project Study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery.

The aim of this study was to evaluate how often left-sided portal hypertension (LPH) develops and how LPH affects the long-term outcomes of patients with pancreatic cancer treated with pancreaticoduodenectomy (PD) and resection of the portal vein (PV)/superior mesenteric vein (SMV) confluence. Little is known about LPH after PD with resection of the PV/SMV confluence. Overall, 536 patients who underwent PD with PV/SMV resection were enrolled. Among them, we mainly compared the SVp group [n=285; the splenic vein (SV) was preserved] and the SVr group (n = 227; the SV was divided and not reconstructed). The incidence of variceal formation in the SVr group increased until 3 years after PD compared with that in the SVp group (38.7% vs 8.3%, P < 0.001). Variceal bleeding occurred in the SVr group (n = 9: 4.0%) but not in the SVp group (P < 0.001). In the multivariate analysis, the risk factors for variceal formation were liver disease, N factor, conventional PD, middle colic artery resection, and SV division. The only risk factor for variceal bleeding was SV division. The platelet count ratio at 6 months after PD was significantly lower in the SVr group than in the SVp group (0.97 vs 0.82, P < 0.001), and the spleen-volume ratios at 6 and 12 months were significantly higher in the SVr group than in the SVp group (1.38 vs 1.00 and 1.54 vs 1.09; P < 0.001 and P < 0.001, respectively). PD with SV division causes variceal formation, bleeding, and thrombocytopenia.

Risk Factors of Postoperative Pancreatic Fistula after Pancreaticoduodenectomy: A Multicenter Cohort Study

Introduction: This study was designed to analyze the risk factors associated with postoperative pancreatic fistula (PF) using a large cohort registered in the Korean Tumor Registry System: Biliary-Pancreas (KOTUS-BP). Method: Sixty-two surgeons from 18 tertiary hospitals participated in the KOTUS-BP cohort. Patients who underwent pancreaticoduodenectomy for periampullary neoplasia were identified in the database. We analyzed the patients’ characteristics, preoperative data, operation method, and postoperative outcomes including PF. Result: Of the 4,846 patients, 179 patients with missing records of PF were excluded. A total of 4,667 patients were enrolled in this study. Postoperatively, 298 patients (6.4%) had experienced clinically relevant pancreatic fistula (CR-PF). In multivariate analysis, female sex, pancreatic cancer, and lymphovascular invasion were statistically significantly protective factor of CR-PF (p = 0.006, p < 0.001, p = 0.039, respectively). However, pylorus preservation was associated with CR-PF (p <0.001). Conclusion: The analysis of large-scale multicenter cohort data showed that female gender, pancreatic cancer, conventional pancreaticoduodenectomy, and lymphovascular invasion were associated with decreased CR-PF incidence.

Evaluation of Clinicopathological findings in Resected Serous Cystic Neoplasm

Introduction: Serous Cystic Neoplasm (SCN) are relatively rare pancreatic tumors. Close observation is usually recommended. However, surgical resection should be considered with suspicious malignant tumor, and/or with symptom. Method: From October 1994 to October 2018, 12 patients underwent the surgical resection in our institute. We evaluated clinicopathological findings and surgical indications, retrospectively. Result: 1) Patients and tumor characteristics: The mean age was 58.5 years old(34-83y.o), 3 were male, and 9 cases were female. The tumor locations were head of pancreas in 2, body and tail in each 5 cases. The median tumor size was 3.9 cm(1.0-8.0cm) in a diameter. 2) Symptom: Nine cases were asymptomatic, and 3 cases were symptomatic. Asymptomatic cases were all found incidentally. In symptomatic cases, 2 patients had liver dysfunction and one had acid reflex caused by the tumor compression toward the common bile duct, and the stomach. 3) Surgical indications: Surgical indication was the suspicious malignant in 9 cases and 3 cases with symptom, located in head in 2 cases, and in tail in 1 case. In one case, he was diagnosed 16 years ago, tumor gradually increased, finally come down with the liver dysfunction. 4) Surgical procedure: Distal pancreatectomy was performed in 9 cases, and conventional pancreaticoduodenectomy, duodenum preserving pancreatic head resection, segmental pancreatectomy in each 1 case. 5) Histopathological findings: Patients were pathologically diagnosed as macrocystic type in 7, microcystic type in 4 cases, and solid type in 1 case. There was no mixed type in macroscopic. In all cases, final diagnosis was serous cystadenoma and no findings on malignancy. 6) Prognosis: All cases survive with no recurrence (postoperative 2 month-24 years). Conclusion: Surgical indications regarding tumor size and growth rate were still unclear and not established. However, the aggressive surgical resection should be considered in symptomatic patients and rapid tumor growth.

AB059. P031. Outcomes of pylorus-preserving versus conventional pancreaticoduodenectomy in the era of enhanced recovery: a single-institution experience

Background: Recent randomized trials and meta-analysis have demonstrated an increased incidence of delayed gastric emptying (DGE) with pylorus preserving pancreaticoduodenectomy (PP) compared to conventional Whipple (CW). At our high-volume referral center, both techniques are performed according to individual surgeon preference, with perioperative care standardized by an enhanced recovery [Electronic Residency Application Service (ERAS)] protocol—a setup akin to an expertise-based trial. We therefore set out to compare the morbidity experience of patients undergoing PP and CW at our institution.

[Diagnosis and treatment of pancreatic head cancer followed by mesenteric-portal vein invasion].

To evaluate the outcomes of pancreaticoduodenectomy with mesenteric-portal vein resection for pancreatic head cancer. Retrospective analysis included 124 patients with pancreatic head cancer for the period 2010-2017. Mesenteric-portal vein (MPV) invasion was diagnosed in 37 (29.8%) patients, tumor contact with superior mesenteric artery as a borderline resectable state was noted in 11 cases. All patients underwent pancreaticoduodenectomy with mesenteric-portal vein resection. Vein invasion was histologically confirmed in 19 (51.3%) out of 37 patients. At the same time, arterial invasion was absent in 11 patients with a borderline resectable tumor. CT-associated overdiagnosis of venous wall invasion was 6.4%, intraoperative overdiagnosis - 87.5%. R0-resection was achieved in 88.5% after conventional pancreaticoduodenectomy and in 78.4% after pancreaticoduodenectomy followed by MPV resection. Median survival was 17 months, 2-year survival - 41%. Among 11 patients with a borderline resectable tumor median survival was 11 months. Pancreaticoduodenectomy without vein resection was followed by 2-year survival near 68.1%. Differences were significant (p=0.02). Pancreaticoduodenectomy followed by MPV resection as the first stage of combined treatment of pancreatic head cancer is absolutely justified if circumferential involvement of the vein and contact with superior mesenteric artery or celiac trunk do not exceed 50%. Vein resection can provide R0-surgery in these cases.

The “Colonial Wig” pancreaticojejunostomy: zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) remains common and morbid after pancreaticoduodenectomy (PD). A major advance in the study of POPF is the fistula risk score (FRS). We analyzed 48 consecutive patients undergoing PD. The "Colonial Wig" pancreaticojejunostomy (CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs. Postoperative morbidity was 49% (27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF (CR-POPF) rate was 15%, similar to the FRS-predicted rate (14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups (14% vs 13%), the CR-POPF rate in the CWPJ group was 0 (P=0.052). Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.

[Anatomic study and clinical practice of mesopancreas and total mesopancreatic excision].

Objective: To explore the anatomical characteristics of the mesopancreas, to define the range of the total mesopancreas excision and to evaluate the feasibility, safety and effectiveness in the treatment of pancreatic cancer. Methods: A regional anatomical and pathological study was performed on 14 cadavers with large slices and paraffin sections. The clinical and pathological data of 58 consecutive patients underwent total mesopancreas excision for pancreatic head carcinoma from January 2013 to December 2015 were prospectively collected and analysed. The perioperative morbidity, mortality and clinical outcomes of patients underwent total mesopancreas excision were compared with the patients underwent conventional pancreaticoduodenectomy from January 2010 to December 2012. Results: The mesopancreas located in the retropancreatic area, extending from the head, neck, and uncinated process of pancreas to the aorto-caval groove, in which there were loose areolar tissue, adipose tissue, nerve plexus, lymphatic and capillaries. Although no fibrous sheath or fascia like mesocolorectum was found around the structures, a relatively fixed extent could be defined according to its embryologic and anatomic characters. In clinical practice, total mesopancreas excision was classified into two levels according to the extent of resection in this series: level Ⅰ was a"standard total mesopancreas excision" or"total mesopancreas excision in a narrow sense" , which was similar to the extent of standard resection from consensus statement of ISGPS. Level Ⅱ was defined as any procedure extending the range of level Ⅰ, called the"extended total mesopancreas excision" or"total mesopancreas excision in a broad sense". In TMpE group, the intraoperative blood loss( (461.4±184.5)ml vs. (532.2±319.8)ml, P=0.301), operation time( (368.6±92.5)minutes vs. (397.1±112.7)minutes, P=0.559), total complication rate (39.7% vs. 51.2%, P=0.250), fistula mortality (25.9% vs. 30.2%, P=0.628) were all reduced. There were significantly higher R0 rate (91.4% vs.76.7%, P=0.041) and more harvested lymph nodes (16.2 vs. 11.4, P=0.000) and lower total and local recurrence: rate (half-year local recurrence rate: 7.8% vs. 23.7%, P=0.036; one-year local recurrence rate: 18.2% vs. 39.5%, P=0.018) and longer disease-free survival (16.9 months vs. 13.4 months, P=0.044) and overall survival(22.5 months vs. 19.9 months, P>0.05) were also found in the study group. Conclusions: Mesopancreas is different from mesorectum since it has no fascial envelop, which should be regarded as a surgical concept, rather than an anatomical structure. Total mesopancreas excision is safe and feasible for pancreatic head cancer and probably helps to increase the R0 resection rate and improve the clinical outcomes.

Outcomes of pylorus-preserving versus conventional pancreatico-duodenectomy: a single-institution experience

Outcomes of pylorus-preserving versus conventional pancreatico-duodenectomy: a single-institution experience

Total mesopancreas excision for the treatment of pancreatic head cancer.

Mesopancreas is a controversial structure. This study aimed to explore the anatomical characteristics of the mesopancreas, define the range of the total mesopancreas excision (TMpE), and evaluate the feasibility, safety and effectivity of TMpE in the treatment of pancreatic head cancer. The clinical and pathological data of 58 consecutive patients undergoing TMpE for pancreatic head carcinoma from January 2013 to December 2015 were analyzed prospectively. The perioperative morbidity, mortality and clinical outcomes of patients undergoing TMpE were compared with the patients undergoing conventional pancreaticoduodenectomy. The mesopancreas was located in the retropancreatic area, extending from the head, neck, and uncinated process of pancreas to the aorto-caval groove, in which there were loose areolar tissue, adipose tissue, nerve plexus, lymphatic and capillaries. We observed significantly higher R0 rate (94.8% vs. 81.4%, P=0.035), more lymph nodes (16.2 vs. 11.4, P=0.000), lower total and local recurrence rate (half-year local recurrence rate 7.8% vs. 23.7%, P=0.036, one-year 18.2% vs. 39.5%, P=0.018) and longer disease-free survival (16.9 vs. 13.4 months, P=0.044) in TMpE group than in control group. In conclusion, mesopancreas is different from mesorectum because there is no fascial envelop or anatomical boundary in this area. TMpE could be safely and feasibly performed for the treatment of pancreatic head cancer to increase the R0 resection rate and improve the clinical outcomes.

Total meso-pancreatoduodenum excision with pancreaticoduodenectomy in lower biliary tract cancer.

Incomplete tumor resection with insufficient lymphadenectomy following a pancreaticoduodenectomy (PD) for lower biliary tract cancer results in a dismal outcome. This study aimed to compare the short-term outcomes of PD between total meso-pancreatoduodenum excision (tMPDe) and the conventional procedure for lower biliary tract cancer. Patients who underwent PD for lower biliary tract cancer between May 2003 and March 2015 were included in this study. We have devised a new surgical technique, tMPDe, as a mesenteric plane surgery with an artery-first approach, for achieving complete clearance of the peripancreatic retroperitoneal tissue and lymph nodes. Perioperative data, including complications and short-term survival, were evaluated. A total of 74 consecutive patients underwent a PD: 41 patients underwent conventional PD (cPD), and 33 underwent tMPDe. The tumor stages were similar in the two study groups. R0 was achieved in 32 patients (78.0%) with cPD and in 31 patients (93.9%) with tMPDe (p = 0.046). The survival rates at 1 and 3years after surgery were 82.5 and 64.0% for the cPD group, with a median follow-up period of 44.6months, and 92.8 and 84.4% for the tMPDe group, with a median follow-up period of 28.6months, respectively. The tMPDe technique significantly increased R0 resection and contributed to better oncological outcomes in lower biliary tract cancer.