Skip to main content
Erschienen in: Surgical Endoscopy 12/2019

22.07.2019 | Dynamic Manuscript

Follow “the superior mesenteric artery”: laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy

verfasst von: Edouardo Morales, Giuseppe Zimmitti, Claudio Codignola, Alberto Manzoni, Marco Garatti, Valentina Sega, Edoardo Rosso

Erschienen in: Surgical Endoscopy | Ausgabe 12/2019

Einloggen, um Zugang zu erhalten

Abstract

Background

The prognosis of patients affected by pancreatic adenocarcinoma and periampullary tumors is dismal, mainly due to aggressive tumor biology and low rate of resectability at the diagnosis. Among resectable patients, the quality of surgical resection, with a particular focus on the complete resection of the retropancreatic tissue (the so-called “mesopancreas”) encircling the superior mesenteric artery (SMA), has a cardinal role. With this assumption, many pancreatic surgeons recommend periadventitial dissection of the SMA in order to obtain a total mesopancreas excision (TMpE), maximizing surgical margin and minimizing R1 resection rate.

Objective

To introduce our approaches for periadventitial dissection of the SMA, tailored to patient and tumor characteristics and aiming at obtaining a TMpE, during laparoscopic pancreatoduodenectomy (LPD).

Methods

Three different approaches for the SMA periadventitial dissection during LPD are described: the right, the right–left, and the anterior SMA-first approach. Indications, advantages, and technical aspects of each technique are reported, as well as pathologic results, particularly focusing on resection margin status and removed lymphnodes number, safety, and feasibility.

Results

Overall, R0 rate and number of lymphnodes retrieved were 86% and 26, respectively, without significant differences according to the SMA approach performed. Rate of conversion to laparotomy due to intraoperative bleeding during SMA dissection step was 6% (3/48) among patients who underwent the right SMA approach and nil among remaining patients.

Conclusion

During LPD, a tailored approach for periadventitial dissection of SMA makes TMpE feasible, safe, and oncologic valid, when performed by a team experienced with mininvasive approach and pancreatic surgery.
Anhänge
Nur mit Berechtigung zugänglich
Literatur
1.
Zurück zum Zitat Adham M, Singhirunnusorn J (2012) Surgical technique and results of total mesopancreas excision (TMpE) in pancreatic tumors. EJSO 38:340–345CrossRef Adham M, Singhirunnusorn J (2012) Surgical technique and results of total mesopancreas excision (TMpE) in pancreatic tumors. EJSO 38:340–345CrossRef
2.
Zurück zum Zitat Nappo G, Perinel J, El Bechwaty M, Adham M (2016) The standardization of pancreatoduodenectomy: where are we? Pancreas 45(4):493–502CrossRef Nappo G, Perinel J, El Bechwaty M, Adham M (2016) The standardization of pancreatoduodenectomy: where are we? Pancreas 45(4):493–502CrossRef
3.
Zurück zum Zitat Borghi F, Gattolin A, Garbossa D, Bogliatto F, Garavoglia M, Levi AC (1998) Embryologic bases of extended radical resection in pancreatic cancer. Arch Surg 133:297–301CrossRef Borghi F, Gattolin A, Garbossa D, Bogliatto F, Garavoglia M, Levi AC (1998) Embryologic bases of extended radical resection in pancreatic cancer. Arch Surg 133:297–301CrossRef
4.
Zurück zum Zitat Kontis E, Prassas E, Srinivasan P, Prachalias AA (2016) Extended lymphadenectomy and “mesopancreas” excision during pancreatoduodenectomy for cancer; is it worth it? Review of current evidence. J Pancreas 17:149–153 Kontis E, Prassas E, Srinivasan P, Prachalias AA (2016) Extended lymphadenectomy and “mesopancreas” excision during pancreatoduodenectomy for cancer; is it worth it? Review of current evidence. J Pancreas 17:149–153
5.
Zurück zum Zitat Butler JR, Ahmad SA, Katz MH, Cioffi JL, Zyromski NJ (2016) A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 18(4):305–311CrossRef Butler JR, Ahmad SA, Katz MH, Cioffi JL, Zyromski NJ (2016) A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 18(4):305–311CrossRef
6.
Zurück zum Zitat Peparini N (2015) Mesopancreas: a boundless structure, namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma. World J Gastroenterol 21(10):2865–2870CrossRef Peparini N (2015) Mesopancreas: a boundless structure, namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma. World J Gastroenterol 21(10):2865–2870CrossRef
7.
Zurück zum Zitat Sharma D, Isaji S (2016) Mesopancreas is a misnomer: time to correct the nomenclature. J Hepatobiliary Pancreat Sci 23:745–749CrossRef Sharma D, Isaji S (2016) Mesopancreas is a misnomer: time to correct the nomenclature. J Hepatobiliary Pancreat Sci 23:745–749CrossRef
8.
Zurück zum Zitat Bouassida M, Mighri MM, Chtourou MF, Sassi S, Touinsi H, Hajji H, Sassi SM (2013) Retroportal lamina or mesopancreas? Lessons learned by anatomical and histological study of thirty three cadaveric dissections. Int J Surg 11:834–836CrossRef Bouassida M, Mighri MM, Chtourou MF, Sassi S, Touinsi H, Hajji H, Sassi SM (2013) Retroportal lamina or mesopancreas? Lessons learned by anatomical and histological study of thirty three cadaveric dissections. Int J Surg 11:834–836CrossRef
9.
Zurück zum Zitat Gockel I, Domeyer M, Wolloscheck T, Konerding MA, Junginger T (2007) Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space. World J Surg Oncol 5:44CrossRef Gockel I, Domeyer M, Wolloscheck T, Konerding MA, Junginger T (2007) Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space. World J Surg Oncol 5:44CrossRef
10.
Zurück zum Zitat Wu W, Wang X, Wu X (2016) Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases. Chin J Cancer Res 28:423–428CrossRef Wu W, Wang X, Wu X (2016) Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases. Chin J Cancer Res 28:423–428CrossRef
11.
Zurück zum Zitat Chirletti P, Caronna R (2017) Role of the total mesopancreas excision in the surgical radical treatment of pancreatic head cancer. J Pancreas 18:216 Chirletti P, Caronna R (2017) Role of the total mesopancreas excision in the surgical radical treatment of pancreatic head cancer. J Pancreas 18:216
12.
Zurück zum Zitat Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA (2012) ‘Artery-first’ approaches to pancreatoduodenectomy. Br J Surg 99(8):1027–1035CrossRef Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA (2012) ‘Artery-first’ approaches to pancreatoduodenectomy. Br J Surg 99(8):1027–1035CrossRef
13.
Zurück zum Zitat Asbun HJ, Harada E, Stauffer JA (2016) Tips for laparoscopic pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 23:E5–E9CrossRef Asbun HJ, Harada E, Stauffer JA (2016) Tips for laparoscopic pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 23:E5–E9CrossRef
14.
Zurück zum Zitat Zimmitti G, Manzoni A, Addeo P, Garatti M, Zaniboni A, Bachellier P, Rosso E (2015) Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc 30:1670–1671CrossRef Zimmitti G, Manzoni A, Addeo P, Garatti M, Zaniboni A, Bachellier P, Rosso E (2015) Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc 30:1670–1671CrossRef
15.
Zurück zum Zitat Azagra JS, Arru L, Estévez S, Makkai-Popa ST, Poulain V, Goergen M (2015) Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery. Wideochir Inne Tech Maloinwazyjne 10:450–457PubMedPubMedCentral Azagra JS, Arru L, Estévez S, Makkai-Popa ST, Poulain V, Goergen M (2015) Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery. Wideochir Inne Tech Maloinwazyjne 10:450–457PubMedPubMedCentral
16.
Zurück zum Zitat Cho A, Yamamoto H, Kainuma O (2014) Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video). J Hepatobiliary Pancreat Sci 21:E19–E21CrossRef Cho A, Yamamoto H, Kainuma O (2014) Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video). J Hepatobiliary Pancreat Sci 21:E19–E21CrossRef
17.
Zurück zum Zitat Verbeke CS (2008) Resection margins and R1 rates in pancreatic cancer–are we there yet? Histopathology 52:787–796CrossRef Verbeke CS (2008) Resection margins and R1 rates in pancreatic cancer–are we there yet? Histopathology 52:787–796CrossRef
18.
Zurück zum Zitat Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8(5):408–410CrossRef Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8(5):408–410CrossRef
19.
Zurück zum Zitat Kendrick ML, Cusati D (2010) Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch Surg 145:19–23CrossRef Kendrick ML, Cusati D (2010) Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch Surg 145:19–23CrossRef
20.
Zurück zum Zitat Bachellier P, Rosso E, Fuchshuber P, Addeo P, David P, Oussoultzoglou E, Lucescu I (2014) Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension. Surgery 155:449–456CrossRef Bachellier P, Rosso E, Fuchshuber P, Addeo P, David P, Oussoultzoglou E, Lucescu I (2014) Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension. Surgery 155:449–456CrossRef
21.
Zurück zum Zitat Addeo P, Marzano E, Rosso E, Pessaux P (2011) Hanging maneuver during pancreaticoduodenectomy: a technique to improve R0 resection. Surg Endosc 25:1697–1698CrossRef Addeo P, Marzano E, Rosso E, Pessaux P (2011) Hanging maneuver during pancreaticoduodenectomy: a technique to improve R0 resection. Surg Endosc 25:1697–1698CrossRef
22.
Zurück zum Zitat Pessaux P, Marzano E, Rosso E (2010) A plea for the artery-first dissection during pancreaticoduodenectomy. J Am Coll Surg 211:142–143CrossRef Pessaux P, Marzano E, Rosso E (2010) A plea for the artery-first dissection during pancreaticoduodenectomy. J Am Coll Surg 211:142–143CrossRef
23.
Zurück zum Zitat Pal S, George J, Singh AN, Mathur S, Dash NR, Garg P, Sahni P, Chattopadhyay TK (2018) Posterior superior mesenteric artery (SMA) first approach vs. standard pancreaticoduodenectomy in patients with resectable periampullary cancers: a prospective comparison focusing on circumferential resection margins. J Gastrointest Cancer. 49(3):252–259CrossRef Pal S, George J, Singh AN, Mathur S, Dash NR, Garg P, Sahni P, Chattopadhyay TK (2018) Posterior superior mesenteric artery (SMA) first approach vs. standard pancreaticoduodenectomy in patients with resectable periampullary cancers: a prospective comparison focusing on circumferential resection margins. J Gastrointest Cancer. 49(3):252–259CrossRef
24.
Zurück zum Zitat Lee ES, Lee JM (2014) Imaging diagnosis of pancreatic cancer: a state-of-the-art review. World J Gastroenterol 20:7864–7877CrossRef Lee ES, Lee JM (2014) Imaging diagnosis of pancreatic cancer: a state-of-the-art review. World J Gastroenterol 20:7864–7877CrossRef
Metadaten
Titel
Follow “the superior mesenteric artery”: laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy
verfasst von
Edouardo Morales
Giuseppe Zimmitti
Claudio Codignola
Alberto Manzoni
Marco Garatti
Valentina Sega
Edoardo Rosso
Publikationsdatum
22.07.2019
Verlag
Springer US
Erschienen in
Surgical Endoscopy / Ausgabe 12/2019
Print ISSN: 0930-2794
Elektronische ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-019-06994-6

Weitere Artikel der Ausgabe 12/2019

Surgical Endoscopy 12/2019 Zur Ausgabe

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

CME: 2 Punkte

Prof. Dr. med. Gregor Antoniadis Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis
Berufsverband der Deutschen Chirurgie e.V.

S2e-Leitlinie „Distale Radiusfraktur“

CME: 2 Punkte

Dr. med. Benjamin Meyknecht, PD Dr. med. Oliver Pieske Das Webinar S2e-Leitlinie „Distale Radiusfraktur“ beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske
Dr. med. Benjamin Meyknecht
Berufsverband der Deutschen Chirurgie e.V.

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

CME: 2 Punkte

Dr. med. Mihailo Andric
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric
Berufsverband der Deutschen Chirurgie e.V.