Mesenteric approach during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

Abstract

Mesenteric approach is an artery-first approach during pancreaticoduodenectomy (PD). In the present study, we evaluated clinical and oncological benefits of this procedure for pancreatic ductal adenocarcinoma (PDAC) of the pancreas head. Between 2000 and 2015, 237 consecutive PDAC patients underwent PD. Among them, 72 experienced the mesenteric approach (mesenteric group) and 165 the conventional approach (conventional group). A matched-pairs group consisted of 116 patients (58 patients in each group) matched for age, gender, resectability status, and neoadjuvant therapy. Surgical and oncological outcomes were compared between the two groups in unmatched- and matched-pair analyses. Intraoperative blood loss was lower in the mesenteric group than in the conventional group in both resectable PDAC (R-PDAC) and borderline resectable PDAC (BR-PDAC) on unmatched- and matched-pairs analyses (R-PDAC, unmatched: 312.5 vs 510 mL, P=.008; matched: 312.5 vs 501.5 mL, P=.023; BR-PDAC, unmatched: 507.5 vs 935 mL, P<.001; matched: 507.5 vs 920 mL, P=.003). Negative surgical margins (R0) and overall survival (OS) rates in the mesenteric group were better in R-PDAC patients (R0 rates, unmatched: 100% vs 87.7%, P=.044; matched: 100% vs 86.7%, P=.045; OS, unmatched: P=.008, matched: P=.021), although there were no significant differences in BR-PDAC patients. Mesenteric approach might reduce blood loss by early ligation of the vessels to the pancreatic head. Furthermore, it might increase R0 rate, leading to improvement of survival for R-PDAC patients. However, R0 and survival rates could not be improved only by the mesenteric approach for BR-PDAC patients. Therefore, effective multidisciplinary treatment is essential to improve survival in BR-PDAC patients.

Keywords: borderline resectable pancreatic ductal adenocarcinoma (BR‐PDAC); mesenteric approach; pancreatic ductal adenocarcinoma (PDAC); resectable PDAC (R‐PDAC).

Figure 1

(A) Inferior pancreaticoduodenal artery (IPDA) anatomy was evaluated based on three‐dimensional computed tomography (3D‐CT) angiography. In this case, the common trunk was composed of IPDA and the first jejunal artery (J1 artery) arose from the superior mesenteric artery (SMA). In this case, the distance from the root of the middle colic artery (MCA) to the root of the common trunk of IPDA and J1 artery was approximately 25 mm based on 3D‐CT. (B) During dissection of the connective tissue around the SMA, the root of the common trunk of IPDA and J1 artery was identified; it was then ligated and divided. (C) Completion of dissection of the connective tissue around the SMA and superior mesenteric vein (SMV).

Figure 2

Recurrence rates of resectable pancreatic ductal adenocarcinoma (R‐PDAC) and borderline resectable PDAC (BR‐PDAC) patients in unmatched‐ and matched‐pairs analyses. All recurrence rates and local recurrence rates were significantly lower in the mesenteric group than in the conventional group in unmatched‐pairs analysis only (*all recurrence: 53.3% vs 77.8%, P=.012; **local recurrence: 16.7% vs 38.3%, P=.031).

Figure 3

(A) Overall survival (OS) for resectable pancreatic ductal adenocarcinoma (R‐PDAC) patients in unmatched‐pairs analysis was longer in the mesenteric group than in the conventional group (P=.008), although the disease‐free survival (DFS) was similar in the two groups. (B) OS for R‐PDAC patients in matched‐pairs analysis was also longer in the mesenteric group than in the conventional group (P=.021), although there was no significant difference of DFS. (C) There were no significant differences of both OS and DFS in borderline resectable PDAC (BR‐PDAC) patients in unmatched‐pairs analysis. (D) There were no significant differences of both OS and DFS in BR‐PDAC patients in matched‐pairs analysis.