Pancreatoduodenectomy With Systematic Mesopancreas Dissection Using a Supracolic Anterior Artery-first Approach

Abstract

SMD-PD using an SAA is feasible across PD cases, with acceptable short-term outcomes, and we propose this procedure as a promising option for PD.

Mesenteric approach during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

“…Connective tissue between the pancreatic head and the SMA plexus has been defined as pancreatic head plexus II (plPh‐II), but is also known as ‘mesopancreas’10, 21, 22 or ‘meso‐pancreatoduodenum’ 23. However, from an anatomical point of view, this nomenclature is controversial 24.…”

“…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.…”

“…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. However, a limited case series that reported the feasibility of the artery‐first approach during PD has found little evidence of the availability and/or oncological benefits of this procedure 10, 13, 14, 23, 24. The mesenteric approach, which is one of the artery‐first approaches during PD,8, 9, 12 is considered to be a safer procedure because, in this approach, dissection around the SMA starts from an infracolic noncancerous and/or no inflammatory region toward the root of the SMA.…”

“…The concept of the artery‐first approach is to start from the dissection of the connective tissues around the SMA during PD. The aims of this approach are: (i) early determination of the resectability status before committing an irreversible step during operation; (ii) reduction of intraoperative blood loss by early control of blood inflow into the pancreatic head; and (iii) increase of R0 rates by complete dissection of the connected tissues around the SMA 7, 8, 9, 10, 11, 12, 13…”

Onco-surgical Strategies in Pancreatic Ductal Adenocarcinoma

“…Furthermore, the role of total mesopancreas excision was emphasized to better resect the patients with PDAC (13,23,26). The real benefit of these technical refinements for the long-term survival in patients with pancreatectomies for PDAC remains a matter of debate (27).…”