Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space

Gockel, Ines; Domeyer, Mario; Wolloscheck, Tanja; Konerding, Moritz A.; Junginger, Theodor

doi:10.1186/1477-7819-5-44

Cited by 135 publications

(101 citation statements)

References 29 publications

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“…A randomized study from a center of repute showed a trend towards increasing survival in pancreatic cancer patients who had extended resection and this was attributed mainly due to higher incidence of negative resection margin in this sub-group [3]. In this respect the retroperitoneal resection margin, often termed as mesopancreas, is finding increasing prominence in the recent literature [4]. This structure extends from the posterior surface of the pancreatic head to behind the mesenteric vessels.…”

Section: Dear Sirmentioning

confidence: 99%

Extended pancreatectomy for pancreatic cancers

Sadhu

Roy

2010

Indian J Surg

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Dear Sir,We read with interest the excellent article by Shukla et al.(Extended pancreatectomy for pancreatic cancers. IJS 2009; 71:2-5). It is a ready-reckoner for the surgeon who is keen to update on the contextual importance of extended pancreatic resection. That extended lymphadenectomy doesn't confer survival advantage, is well proven in randomised trials and meta-analysis [1]. But what constitutes a R0 (complete resection) is still mired in confusion mainly because of lack of unanimity amongst pathologist on a standardized technique of histopathological examination [2]. Achieving negative resection margin is not only a surgical triumph, but could potentially increase survival. A randomized study from a center of repute showed a trend towards increasing survival in pancreatic cancer patients who had extended resection and this was attributed mainly due to higher incidence of negative resection margin in this sub-group [3]. In this respect the retroperitoneal resection margin, often termed as mesopancreas, is finding increasing prominence in the recent literature [4]. This structure extends from the posterior surface of the pancreatic head to behind the mesenteric vessels. In order to excise this tissue en masse the recently described hanging technique is an elegant operative innovation [5]. Briefly, the duodenum is widely Kocherized beyond the medial border of aorta and the origin of superior mesenteric artery (SMA) is identified. A tunnel is dissected between the mesopancreas and the SMA and a tape is passed through. Sustained traction on this tape stretches the retroperitoneal margin, which is then excised in a controlled manner.To some extent, the traditional nihilism surrounding portal vein invasion by pancreatic malignancy has been partially annulled by finding survival equivalence between patients who were operable vis-vis those who required portal vein excision for complete clearance. However, this benefit is limited to patients with superficial invasion into the tunica adventitia [6]. With deeper portal vein wall invasion into the tunica media or intima, the survival is similar to those with non-curative surgery. The depth of portal vein invasion appears to correlate with preoperative CT portogram type C and D and a tumor diameter more than 45 mm [6].Although autologous venous and polytetrafluoroethylene grafts are conduits of choice for portal vein reconstruction, a generous Cattell-Braasch manoeuvre, wherein the ligament of Treitz is incised and hepatic flexure dissected liberally, serves to mobilise the root of mesentery and helps in moving it cranially. Mobilising the liver by incising the falciform, coronary and triangular ligaments causes a caudal displacement of the liver. These two steps in tandem approximate the transected ends of the portal vein and a defect as long as 5 cm could be primarily anastomosed in a tension free manner, thereby obviating the need for a graft [7].

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Section: Dear Sirmentioning

confidence: 99%

Extended pancreatectomy for pancreatic cancers

Sadhu

Roy

2010

Indian J Surg

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“…The term mesopancreas was first proposed by Gockel et al in the year 2007 in analogy to total mesorectal excision in rectal cancer [13]. They emphasized the need of new surgical classification involving mesopancreas.…”

Section: Review Of Literaturementioning

confidence: 99%

“…Pancreatic cancer of head hence follows these arteries, veins, nerves and spread horizontally towards the SMA or celiac axis rather than posteriorly towards inferior vena cava (IVC). This soft tissue between the pancreatic head and SMA includes nerves, vessels, lymphatics and nodes which is called as the mesopancreas [13] (Fig. 3).…”

Section: Anatomymentioning

confidence: 99%

“…This concept of applied embryology and anatomy was introduced to various organs to increase rate of negative margins of resection. Mesopancreas, mesogastrium, mesoesophagus, mesohepatectomy and mesometria were described based on postulates in analogy with mesorectum [13][14][15][16][17]. Whether these descriptions and further refinement in surgical technique based on these postulates will give better results or not is not yet known.…”

Section: Introductionmentioning

confidence: 99%

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Mesopancreas in Pancreatic Cancer: Where do We Stand – Review of Literature

Ramachandra

Challa

2014

Indian J Surg Oncol

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Pancreatic cancer is associated with poor prognosis and surgery remains the main modality of treatment. Negative resection margin is an important prognostic factor for survival. Retropancreatic margin or the medial margin is the most common site of positive resection margin. Mesopancreas was proposed in analogy with mesorectum, which is considered as a fusion fascia formed embryologically during the development of pancreas. This mesopancreas lies posterior to the pancreas and contains pancreaticoduodenal vessels, lymphatics, nerve plexus and loose areolar tissue. Various technical modifications were proposed for better dissection of mesopancreas like posterior approach and artery first approach. There is an increased rate of R0 resection by these technical modifications but whether this will turn to increase in survival rates is yet to be established.

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“…First described in 2007, the mesopancreas (54) includes the dorsal pancreatic nerve and the lymph tissue layer. Total mesopancreas excision (TMpE) is based on the principle of total mesorectal excision (TME) and includes the peripancreatic lymphatic and adipose tissue layers in an en bloc resection (55).…”

Section: Treatment Of Retroperitoneal Nerve Dissection and Vascular Smentioning

confidence: 99%

The concept and controversy of retroperitoneal nerve dissection in pancreatic head carcinoma (Review)

Wang

Zhang

Wang

et al. 2015

International Journal of Oncology

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Abstract. Pancreatic head cancer is a common but the most lethal cancer of the human digestive system. It is invasive, resulting in early infiltration of adjacent structures and lymph node and distant metastases. Its biological characteristics of neurotropic growth lead to early neural invasion (NI) which is an independent prognostic factor of survival for pancreatic cancer. Radical surgical resection remains the only form of curative treatment. The extent of surgical resection and whether extended resection results in better long-term survival have been controversial. Studies have reported that peripancreatic plexus invasion is a frequent cause of pancreatic cancer recurrence and death. The relationship between cancer microenvironment and nerve cells, and whether the peripancreatic nerve plexus nearby needs to be resected require further studies. The present review aims to discuss the role of peripancreatic nerve and its implications in pancreatic head cancer resection.

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Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space

Cited by 135 publications

References 29 publications

Extended pancreatectomy for pancreatic cancers

Extended pancreatectomy for pancreatic cancers

Mesopancreas in Pancreatic Cancer: Where do We Stand – Review of Literature

The concept and controversy of retroperitoneal nerve dissection in pancreatic head carcinoma (Review)

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