Anterior Approach to the Superior Mesenteric Artery by Using Nerve Plexus Hanging Maneuver for Borderline Resectable Pancreatic Head Carcinoma

Abstract

To achieve R0 resection for pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head, complete resection of the retropancreatic nerve plexus around the superior mesenteric artery (SMA) is thought to be required. Twenty-five patients with borderline resectable right-sided PDAC were divided into two groups after neoadjuvant chemoradiotherapy: those with portal vein (PV) invasion alone (n = 12), and those with invasion of both PV and SMA (n = 13). A tape for guidance was passed in a space ventral to the SMA and behind the pancreatic parenchyma, followed by resection of the pancreatic parenchyma with the splenic vein. Another tape was passed behind the nerve plexus lateral to the hepatic artery and the SMA ventral to the inferior vena cava and the nerve plexus was dissected, resulting in complete resection of the nerve plexus around the SMA. Pathological findings revealed that the rates of R0, R01 (a margin less than 1 mm) and R1 were 58.3 %, 41.7 % and 0 % in PV group, and 53.8 %, 30.8 % and 15.4 % in PV/A group, respectively. The median survival time was 23.3 and 22.8 months in PV and PV/A groups, respectively. The plexus hanging maneuver for PDAC of the pancreatic head achieved complete resection of the retropancreatic nerve plexus around the SMA, helping to secure a negative surgical margin.

Mesenteric approach during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

“…The dissected margin of plPh‐II is reported to be the most favorable positive margin site for PDAC of the pancreatic head 3, 4, 5, 6. Therefore, complete clearance of the connective tissue around the SMA during PD is considered to increase R0 rate and improve the survival rate of patients with PDAC located in the pancreatic head 8, 9, 10, 12, 13, 21, 22, 23, 25. Furthermore, the artery‐first approach aims to assess resectability status before irreversible steps in the operation and reduce blood loss as a result of early ligation of the vessels to the pancreatic head.…”

Superiority of stapled side-to-side gastrojejunostomy over conventional hand-sewn end-to-side gastrojejunostomy for reducing the risk of primary delayed gastric emptying after subtotal stomach-preserving pancreaticoduodenectomy

“…For patients with malignancy, lymphadenectomy was performed, including dissection of the hepatoduodenal ligament, the common hepatic artery, portal vein, superior mesenteric vein, celiac trunk, and the superior mesenteric artery. For patients with pancreatic adenocarcinoma, the nerve plexus was dissected around the superior mesenteric artery (SMA) as described previously [24]. Other organs were resected for the portal vein/superior mesenteric vein in 63 patients, for the hepatic artery in five patients, for the splenic artery in eight patients, and for the colon in 12 patients.…”

Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection

“…SMA-first dissection12 and periadventitial dissection of the SMA24 are recommended in order to improve the likelihood of R0 resections along this margin, without clear evidence to support 25. The other commonly involved margin is the pancreatic transection margin (27% in the present series) especially in patients with tumor overlying the splenopancreatic junction 26.…”