Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer

Abstract

Background: A superior mesenteric artery (SMA)-first approach has been considered to be an efficient technique in pancreaticoduodenectomy when the SMA is a factor of borderline resectable pancreatic head cancer (BRPHC). However, this excellent procedure has limitations in terms of tumor resection with an intact coverage including the pancreatic tumor and the tumor-draining lymphovascular systems and the ability to achieve a complete regional lymphadenectomy.

Methods: A modified mesenteric plane procedure has been developed that provides improved regional lymphadenectomy and permits adjustment of the surgical approach, which is based on the direction of the tumor infiltration.

Results: Of 55 patients taken to surgery, 19 had peritoneal dissemination and/or liver metastasis at staging laparoscopy, and the procedure revealed tumor infiltration to the SMA and/or hepatic artery (HA) in 4 patients. Finally, 32 patients with BRPHC have undergone the procedure between April 2009 and June 2015. Twenty-four of 32 patients (75.0%) had negative resection margins, and the median number of lymph nodes harvested was 34. Lymph nodes around the SMA tested positive for metastasis in 13 patients (40.6%), and those around the HA tested positive for metastasis in 7 patients (21.9%). Complications occurred in 14 patients (43.7%), with no perioperative mortality. Overall survival rates were 65.3% at 1 year and 35.2% at 3 years.

Conclusions: Short-term results with the procedure may encourage surgical management for BRPHC.

Keywords: Artery-first approach; Borderline resectable pancreatic cancer; Meso-pancreatoduodenum; Mesopancreatic plane surgery; Pancreaticoduodenectomy.