Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer

Abstract

BackgroundThe aim of the present study was to investigate the feasibility of resection based on the nerve and fibrous tissue (NFT) structures around the superior mesenteric artery (SMA) for resectable pancreatic adenocarcinoma (R‐PDAC) patients.MethodsNFTs around the SMA were classified into four “intensive NTFs area” with spreading the NFTs around the SMA and three SMA nerve plexus regions without branching nerves according to autopsy findings. Complete dissection of four “intensive NTFs areas” was performed by pre‐exposing three SMA nerve plexus regions without branching nerves as “dissection‐guiding points” with SMA nerve plexus preservation (NFT‐based resection). Among 157 R‐PDAC patients undergoing pancreaticoduodenectomy, surgical outcomes of 78 patients with NFT‐based resection were compared with 59 patients with half‐SMA nerve plexus dissection and 20 patients without NFTs dissection.ResultsIn the NFT‐based resection group, 76.5% had tumor involvement and metastasis in each intensive NTFs area. Operative time, blood loss, and postoperative diarrhea rate were significantly lower in NFT‐based resection than in half‐SMA nerve plexus group (321 vs 390 min; P < .01, 228 vs 550 mL; P < .01, 5.1% vs 15.3%; P = .04, respectively). R0 rate and median overall survival significantly improved in NFT‐based resection than in non‐NFT dissection group (93.6% vs 65.0%; P < .01, 49.6 vs 23.6 months, P = .01).ConclusionNFT‐based resection may become a novel method for R‐PDAC patients.

Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer

“…This procedure may well be complemented by the approach of Nagakawa et al, and a better understanding of the concept of NFT around the SMA would improve surgical and oncological safety, especially in R-PDAC close to the SMV and borderline resectable PDAC with SMV involvement. Overall, I greatly appreciate this work by Nagakawa et al 1 and agree that dissection-guiding points provide useful landmarks to determine appropriate dissection ranges in PD for R-PDAC. Several approaches might provide better access to Areas C and D around the SMA and should be discussed in the future.…”

“…Direct tumor infiltration and lymph node metastasis in each area were frequently observed during pathological examinations, even in resectable pancreatic ductal adenocarcinoma (R-PDAC). 1 The authors also demonstrated dissection procedures in high-quality videos. They first exposed SMA III by isolating Area D and the proximal jejunal vein, then Area D was dissected at approximately 3 cm from the third portion of the duodenum.…”

“…I read with great interest the recent report on "Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer" by Nagakawa et al 1 The article provided useful information for pancreatic cancer surgeons on the concepts of nerve and fibrous tissue structures (NFTs) around the superior mesenteric artery (SMA)-based resection during pancreatoduodenectomy (PD). The authors shared the precise anatomy for connective tissue dissection around the SMA, in Areas A-D. Area C and D fix the uncinate process to the jejunal mesentery, comprising the mesentery of the third portion of the duodenum and oral jejunum.…”

“…2 However, even in R-PDAC, the root of the proximal dorsal jejunal vein (PDJV) is sometimes adherent to or involved by tumor or peri-pancreatic inflammation, as the authors suggested. 1 Approaches with a first aim of identifying the PDJV and proximal jejunal vein carry a risk of exposing tumor F I G U R E 1 Anterior and posterior views of Areas C and D. (A) Left anterior view of the proximal jejunum and SMA. (B) Posterior view (from a posterior pedicle approach) of the proximal and distal jejunum mesentery separated from the SMA.…”

Neoadjuvant gemcitabine and nab‐paclitaxel for borderline resectable pancreatic cancers: Intention‐to‐treat analysis compared with upfront surgery

“…Indeed, many surgeons have struggled to improve the R0-resection rate by surgical techniques or preoperative therapies. [24][25][26] We have previously reported techniques to balance radical surgery and safety in pancreaticoduodenectomy and distal pancreatectomy for PCs; 14,15 however, the R0-resection rate of UPS for BR cases remained unsatisfactory. In the UPS group in this series, the most common site for a positive margin was the SMA margin, which is reported to be the most difficult site for obtaining a cancer-free margin.…”