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Perineural invasion along the nerve (arrow heads), and many tiny lymphatic emboli of afferent lymphatic channels (arrows) were observed in the meso-pancreatoduodenum
Source publication
Background:
Incomplete tumor resection with insufficient lymphadenectomy following a pancreaticoduodenectomy (PD) for lower biliary tract cancer results in a dismal outcome. This study aimed to compare the short-term outcomes of PD between total meso-pancreatoduodenum excision (tMPDe) and the conventional procedure for lower biliary tract cancer....
Citations
... Analysis of the relationship between MCA and J1A showed that: J1A originated at 37.4 mm from the origin of SMA, above MCA and the average distance between MCA and J1A was 19 mm (the smallest distance [14,15]. Meanwhile, Murakami reported a common trunk of IPDA and J1A in 58.9% of cases, independent trunk of IPDA from SMA in 24.2%, and 16.9% with IPDA stemming from both sites, 70.6% of which had IPDA (PIPDA) stemming from the left side of the SMA [16]. ...
Background
SMA-first approach in pancreatoduodenectomy (PD) has been widely applied in open surgery as well as laparoscopy. Finding the superior mesenteric artery (SMA), inferior pancreatoduodenal artery (IPDA), first jejunal artery (J1A) has become a great challenge in laparoscopic PD (LPD). Meanwhile, exposing the midde colic artery (MCA) might be a feasible approach to determine SMA, IPDA, and J1A. Our study aims to find the anatomical correlation between MCA and SMA, IPDA, J1A, especially in SMA-first approach LPD from the left.
Methods
Uncontrolled clinical trial with 33 patients undergoing LPD had preoperative contrast abdominal CT scan to analyze the anatomical relevance between MCA and SMA, J1A, IPDA. The operation was performed starting with exposing MCA in advance to find SMA, J1A and IPDA. The data was analyzed by SPSS 25.0.
Results
90.9% of MCA started at 12–3 o’clock from SMA, the mean distance from the SMA root to the MCA and J1A was 56.4 mm and 37.4 mm, respectively. The distance between SMA and J1A was 19 mm. 72.7% J1A started at 9–12 o’clock, 69.7% J1A and IPDA had a common trunk. 78.8% IPDA started at 3–6 o’clock. 100% of the cases had J1A controlled intraoperatively, 81.8% for IPDA when approached from the left, 3% had MCA injury. The mean time to approach from the left was 98 min, median blood loss was 100 ml.
Conclusion
Exposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of the mesopancreas and lymph nodes.
... As the positive posterior margin after PD in pancreatic head cancer has been reported as frequently as 82% of all cases, it is important to define retroperitoneal and retro-pancreatic soft tissues to achieve an adequate posterior clearance [6]. Gockel et al. [7] first established an anatomical concept named the MP in 2007, which is known in other terms, such as the meso-pancreato-duodenum, to represent the firm, well-vascularized, and peri-neural connective tissue between the posterior area between the pancreatic head and the celiac trunk, as well as the mesenteric vessels [8]. The application of total MP excision (TMpE) in benign, as well as borderline disease, is still discussed and not recommended. ...
... Several recent research reports have revealed that the MP was represented as an anatomical area of 66.6% cases of positive (R1 and R2) resection margins [37,38]. From a pathological aspect, the MP was a retroperitoneal, well-vascularized, and nerve-rich structure surrounding the SMA, including important structures: the first and second nerve plexuses (pl-) of the pancreas head (plPh-I and plPh-II), the IPDAs, the FJAs and FJVs, and LNs [8,19]. Otherwise, until now, there has not been any consensus yet in anatomical landmarks of the MP, though basically, the MP connects the pancreatic head to the SMA and right celiac ganglion [38]. ...
... Then, after transection of the distal stomach, first jejunal loop, and pancreatic gland, the TMpE was conducted based on the MP boundaries that were clearly identified from the right-side (Fig. 5). Moreover, the total number of LNs harvested and metastatic LNs were 27.2 (maximum was 74) and 1.8 (maximum was 16), respectively, which was comparable and quite superior, compared to the results from other studies with the application of TMpE alone (the mean of total number LNs harvested in the studies of Kawabata et al. [8] and Xu et al. [11] were 23 and 16, respectively. With that superior histopathological result, it was necessary to evaluate survival outcomes with long-term follow-up. ...
Backgrounds. Pancreaticoduodenectomy (PD) is the only radical treatment for periampullary malignancies. Superior mesenteric artery (SMA) first approach combined Total meso-pancreas (MP) excision were along conducted to improve the oncological results. There hasn’t been any research of a technique combining SMA first approach and total meso-pancreas excision with describing detailed meso-pancreas macroscopical shape.
Methods. We prospectively assessed 77 patients with for periampullary malignancies between October 2020 and March 2022 (18 months). All patients have undergone PD with SMA first approach combined total meso-pancreas excision. The perioperative indications, clinical data, intra-operative index, R0 resection rate of postoperative pathological specimens especially mesopancreatic margin, postoperative complications and follow-up results were evaluated.
... One of the most impact factors that influence the survival outcomes of resectable pancreatic ductal adenocarcinoma (PDAC) is high frequency of lymph node metastasis, especially the left side of LNs around SMA, due to right-sided soft tissues including LNs usually resected in conventional PD [21,22]. Following the new Japanese LN station system, the LN no. 14 is divided to LN no.14p and 14d, located in the left side of the SMA (left-side LNs of SMA), and located in an anatomicalsurgical layer of the "meso-pancreatoduodenum, " which was along the IPDA and the FJA [23,24]. So, systematic MP dissection does not include left-side SMA LNs. ...
Introduction
Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of the Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “superior mesenteric artery (SMA)-first approach,” “systematic mesopancreas dissection,” and “circumferential lymphadenectomy around SMA” in increasing R0 resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly.
Case presentation
Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10-mm-sized mass in distal bile duct referred to as Vater’s tumor. We used 5 trocars, and the patient was placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, and lymph node groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated as well as the extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, which was 1 of 7 LN no. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative.
Conclusions
This technique was safe and effective to perform precise level 2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.
... One of the most impact factors that in uent the survival outcomes of resectable pancreatic ductal adenocarcinoma (PDAC) is high frequency of lymph node metastasis, especially the left side of LNs around SMA, due to right-sided soft tissues including LNs are usually resected in conventional PD [21,22]. Following new Japanese LN station system, the LN No.14 divided to LN No.14p and 14d, and located in the left side of the SMA (left-side LNs of SMA), and located in an anatomical-surgical layer of the "mesopancreatoduodenum", which was along the IPDA and the FJA [23,24]. So that, systematic MP dissection do not include left-side SMA LNs. ...
Introduction
Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “Superior Mesenteric Artery (SMA)-first approach”, “Systematic mesopanreas dissection” and “Circumferential lymphadenectomy around SMA” in increasing R0-resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly.
Case presentation
Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10mm-sized mass in distal bile duct referred to Vater’s tumor. We use 5 trocars and the patient placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, the lymph nodes groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated and extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, that was 1 of 7 LNs No. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative.
Conclusions
This technique was safe and effective to perform precise level-2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.
... To our knowledge, until now, only a few studies have compared TMpE with traditional PD, and these studies mainly focused on OS and disease-free survival (DFS) [39][40][41]. Kurosaki et al [41] reported similar short-term survival but prolonged 3year survival rates in patients with successful TMpE. Quero et al [43] also reported benefits in terms of DFS for TMpE. ...
... To our knowledge, until now, only a few studies have compared TMpE with traditional PD, and these studies mainly focused on OS and disease-free survival (DFS) [39][40][41]. Kurosaki et al [41] reported similar short-term survival but prolonged 3year survival rates in patients with successful TMpE. Quero et al [43] also reported benefits in terms of DFS for TMpE. ...
Pancreatic head carcinoma (PHC) is one of the common gastrointestinal malignancies with a high morbidity and poor prognosis. At present, radical surgery is still the curative treatment for PHC. However, in clinical practice, the actual R0 resection rate, the local recurrence rate, and the prognosis of PHC are unsatisfactory. Therefore, the concept of total mesopancreas excision (TMpE) is proposed to achieve R0 resection. Although there have various controversies and discussions on the definition, the range of excision, and clinical prognosis of TMpE, the concept of TMpE can effectively increase the R0 resection rate, reduce the local recurrence rate, and improve the prognosis of PHC. Imaging is of importance in preoperative examination for PHC; however, traditional imaging assessment of PHC does not focus on mesopancreas. This review discusses the application of medical imaging in TMpE for PHC, to provide more accurate preoperative evaluation, range of excision, and more valuable postoperative follow-up evaluation for TMpE through imaging. It is believed that with further extensive research and exploratory application of TMpE for PHC, large-sample and multicenter studies will be realized, thus providing reliable evidence for imaging evaluation.
... The mesopancreatoduodenum is the term used by Kawabata et al. [39,48,49] to define a common mesentery located at the back of the SMA, including the mesentery of the third and fourth portions of the duodenum and proximal jejunum, supplied by the IPDA and first jejunal artery. The mesentery consists of a cluster of loose connective tissue along the IPDA and the first jejunal artery. ...
... The authors considered that mesopancreas resection and circumferential lymphadenectomy around the SMA are necessary to achieve locoregional tumor control successfully for pancreatic ductal adenocarcinoma. [39,48,49] Bouassida et al. [33] used the term retroportal lamina as a definite anatomical entity, and the limit was the SMA, despite some controversies about its existence that are due to the absence of fibrous sheath or fascia. Complete removal of this lamina might improve clearance and R0 resection [33]. ...
... For posterior lateral mesopancreas, the fascia is located between the lateral margin of the duodenum and the left margin of the aorta, extending continuously from the posterior surface of the pancreatic head and the third portion of the duodenum to the posterior aspect of the mesenteric vessels [22,30,48,49]. ...
Background
Pancreatoduodenectomy is the only treatment with a promise of cure for patients with pancreatic head adenocarcinoma, and a negative resection margin is an important factor related to overall survival. Complete clearance of the medial margin with removal of the so-called mesopancreas may decrease the recurrence rate after pancreatic resection. Here, we present some important information about the mesopancreas, total mesopancreas excision, and technical aspects to achieve negative resection margins. The area named mesopancreas is defined as the tissue located between the head of the pancreas and the superior mesenteric vessels and the celiac axis and consists of the nerve plexus, lymphatic tissue, and connective tissue. The superior mesenteric and celiac arteries define the border of the mesopancreas. En bloc resection of anterior and posterior pancreatoduodenal nodes, hepatoduodenal nodes, along the superior mesenteric artery nodes, pyloric nodes, and nodes along the common hepatic artery is necessary.Conclusions
Improved knowledge of the surgical anatomy of the region and technical refinements of excision of the mesopancreas along with standardized pathological examination are important to increase and to determine radical resection of pancreatic head cancer.
... A common mesentery behind the SMA was formed by the mesentery of the third and fourth parts of the duodenum (supplied by the inferior pancreaticoduodenal artery) and the mesentery of the proximal jejunum (dominated by the first jejunal artery), and was reported to have a common origin at the left posterior aspect of the SMA in 71.6% [9] or 74.3% [12] of cases, although alternatively, the inferior pancreatoduodenal artery may branch from the first jejunal artery and supply the pancreatic head via the posterior aspect of the SMA [12]. Therefore, it is difficult to separate "the PLph II" from the mesentery of the first jejunal artery. ...
... A common mesentery behind the SMA was formed by the mesentery of the third and fourth parts of the duodenum (supplied by the inferior pancreaticoduodenal artery) and the mesentery of the proximal jejunum (dominated by the first jejunal artery), and was reported to have a common origin at the left posterior aspect of the SMA in 71.6% [9] or 74.3% [12] of cases, although alternatively, the inferior pancreatoduodenal artery may branch from the first jejunal artery and supply the pancreatic head via the posterior aspect of the SMA [12]. Therefore, it is difficult to separate "the PLph II" from the mesentery of the first jejunal artery. ...
... Then, the concept of "total mesopancreas excision (TMpE)" was proposed and performed in 52 patients [1], 60 patients [5], 120 cases [26]. Additionally, a modified total meso-pancreatoduodenum excision (tMPDe) procedure was employed in 14 patients [11], as well as a modified tMPDe technique (m-tMPDe) in 55 patients [12], pancreatoduodenectomy with systematic mesopancreas dissection (SMD-PD) in 82 patients [9], and intestinal derotation pancreatoduodenectomy in 117 patients [25]. These authors advocated complete mesopancreas resection and excision of the proximal jejunum, and total mesopancreas excision was found to increase the R0 resection rate and improving the prognosis of patients with pancreatic cancer. ...
PurposeTotal mesopancreas excision has been found to be helpful for increasing no residual tumor resection rate and improving the prognosis of pancreatic cancer. This study analyzed the relationships among the mesopancreas and pancreatic head plexus from the morphological, developmental, and clinical perspectives.Methods
Twenty-four cadavers were employed. The upper abdominal viscera were resected en-bloc with the hepatoduodenal ligament, abdominal aorta, and nerve plexuses, and the innervation of the pancreas was dissected. Ten additional cadavers were used for histological examination of the pancreatic head and neck, part of the duodenum, the superior mesenteric artery (SMA) and its surrounding tissues, and the related arteries and veins.ResultsAs results, cross-sections of the SMA revealed 6–9 layers of membranous structures resembling the layers of an onion, and the nerve fibers of the superior mesenteric plexus ran between the layers. Loose areolar tissue, adipose tissue, and lymphatics existed between the SMA and the pancreatic head/uncinate process, along with abundant thin blood vessels and capillaries, but very few nerves were found approaching the pancreas. Several parallel layers of collagen fibers (so-called Treitz's fusion fascia) existed between the dorsal aspect of the pancreatic head and the aortocaval plane.Conclusion
The mesopancreas was continuous and connected with the para-aortic area. It may be better termed the mesopancreatoduodenum than the mesopancreas, as the duodenum–pancreas–SMA forms a complex morphological, developmental, functional, and pathological structure.
... Gemelli" IRCCS of Rome from January 2004 to January 2013 were retrospectively enrolled. The decision to include in the analysis ampullary and distal bile duct tumors was based on the proven benefits of MP excision for both these types of diseases in terms of local tumor control and long-term outcomes [26]. ...
... Furthermore, benefits in terms of DFS may be evidenced when a MP excision is performed. Moreover, as already reported in previous studies [19,26,36], MP resection does not influence the shortterm outcomes. ...
PurposeFew comparative studies are available on the long-term prognostic role of mesopancreas (MP) excision after pancreaticoduodenectomy (PD). We compared the long-term outcomes of patients undergoing standard PD (sPD) and PD with MP excision (PD-MPe).Methods
Sixty sPDs were compared to 60 matched PD-MPe patients for intraoperative and postoperative data, histopathological findings, and long-term outcomes.ResultsR0 rate was similar in the two groups (p = 0.17). However, PD-MPe related to a lower rate of MP resection margin positivity (16.7% vs 5%; p = 0.04) and to a higher harvested lymph nodes number (19.8 ± 7.6 vs 10.1 ± 5.1; p < 0.0001). Local tumor recurrence was more frequent in the sPD cohort (55.5% vs 26.8% in the PD-MPe group; p = 0.002), with a consequent worse disease-free survival (DFS) (14.8% vs 22.3%; p = 0.04). An inferior 5-year overall survival (OS) was noted in case of MP margin positivity compared with MP margin negativity (0% vs 29%; p < 0.0001). MP positivity resulted as an independent prognostic factor for both a worse OS and DFS at the multivariate analysis.ConclusionPD-MPe offers clinical advantages in terms of MP resection margin status, local recurrence, long-term mortality, and DFS. The lower MP positivity rate, achieved with PD-MPe, leads to better outcomes both in terms of OS and DFS.
... Updated data have associated TMpE with significantly less blood loss and decreased loco-regional recurrence rates (66). However, further analyses did not show any significant improvements for overall survivals for both biliary tract cancers (67) and PDAC (68). ...
Pancreatic ductal adenocarcinoma (PDAC) is a disease with a grim prognosis. Pancreatectomy represents the single hope for long-term survival in a patient with PDAC. Recurrence is a common event after curative-intent surgery for PDAC, mainly related to incomplete removal at the site of resection margins; medial/ superior mesenteric margins are the most often positive. The concept of total mesopancreas excision (TMpE) in PDAC was proposed in analogy to the concept of total mesorectal excision for rectal cancer, to better control loco-regional recurrence. This paper aims to discuss the current evidence for the value of TMpE in PDAC.
... These studies included 1204 patients undergoing PD: 903 MP resection and PD, and 301 classical PD included in the control groups. Although the vast majority of patients were diagnosed with pancreatic cancer, one series comprised exclusively patients with biliary tract cancers [12], others described periampullary tumors with no specific origin, and some included patients with benign pathology. ...
... In most studies that include a control group (five series), the group is not randomized ( Table 1); and if there is a randomized control group there is no explanation of how it was obtained, thus making it impossible to compare the two populations [4,14,22,24,28,30]. Broadly, the data published regarding MP resection can be summed up as follows: the rate of postoperative complications, mortality and hospital stay in patients undergoing MP resection are comparable to those obtained with the conventional technique, and better in terms of operative time and blood loss [12,[14][15][16]. Some articles suggest that dissection of the two sides of the SMA increases the risk of postoperative diarrhea and chylous ascites and should be avoided unless there is obvious involvement; however, only four series provide concrete data on these complications. ...
... TMPDE, the technique introduced by Kawabata et al. deserves special mention as it is the one that focuses most specifically on the MP. TMPDE appears to increase the number of resected nodes and the R0 resection rate and reduces locoregional recurrence compared with the traditional approach, and does not increase the complication rate [4,5,12,22,30]. It allows easy identification of SMA invasion and hepatic artery abnormalities, safe lymph node dissection around the SMA, complete clearance of peripancreatic retroperitoneal tissue, and simple venous reconstruction if necessary [4,12,22,30]. In their safety and feasibility study of TMPDE, Kawabata et al. observed a decrease in intraoperative bleeding, earlier tolerance, shorter operative stay, more resected nodes, higher R0 rate and less recurrence without a greater number of complications [22]. ...
Background:
In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP.
Methods:
An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian).
Results:
The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series.
Conclusion:
MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.
