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01-05-2020 | Original Articles

Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes

Authors: Giuseppe Quero, Claudio Fiorillo, Roberta Menghi, Caterina Cina, Federica Galiandro, Fabio Longo, Francesco Sofo, Fausto Rosa, Antonio Pio Tortorelli, Maria Cristina Giustiniani, Frediano Inzani, Sergio Alfieri

Published in: Langenbeck's Archives of Surgery | Issue 3/2020

Abstract

Purpose

Few 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.

Results

R0 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.

Conclusion

PD-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.

Wagner M, Redaelli C, Lietz M, Seiler C, Friess H, Büchler M (2004) Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg 91(5):586–594CrossRef

Hartwig W, Hackert T, Hinz U, Gluth A, Bergmann F, Strobel O, Buchler MW, Werner J (2011) Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg 254(2):311–319. https://doi.org/10.1097/SLA.0b013e31821fd334 CrossRefPubMed

Fortner JG (1973) Regional resection of cancer of the pancreas: a new surgical approach. Surgery 73(2):307–320PubMed

Nakao A, Takagi H (1993) Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein. Hepatogastroenterology 40(5):426–429PubMed

Carrere N, Sauvanet A, Goere D, Kianmanesh R, Vullierme MP, Couvelard A, Ruszniewski P, Belghiti J (2006) Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head. World J Surg 30(8):1526–1535. https://doi.org/10.1007/s00268-005-0784-4 CrossRefPubMed

Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Buchler MW, Weitz J (2011) Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 254(6):882–893. https://doi.org/10.1097/SLA.0b013e31823ac299 CrossRefPubMed

Zhou Y, Zhang Z, Liu Y, Li B, Xu D (2012) Pancreatectomy combined with superior mesenteric vein–portal vein resection for pancreatic cancer: a meta-analysis. World J Surg 36(4):884–891CrossRef

Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Kloppel G, Dhaene K, Michelassi F, Lymphadenectomy Study Group (1998) Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Ann Surg 228(4):508–517. https://doi.org/10.1097/00000658-199810000-00007 CrossRefPubMedPubMedCentral

Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH (2002) Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg 236(3):355–366; discussion 366-358. https://doi.org/10.1097/00000658-200209000-00012 CrossRefPubMedPubMedCentral

10.

Adham M, Singhirunnusorn J (2012) Surgical technique and results of total mesopancreas excision (TMpE) in pancreatic tumors. Eur J Surg Oncol 38(4):340–345. https://doi.org/10.1016/j.ejso.2011.12.015 CrossRefPubMed

11.

Agrawal MK, Thakur DS, Somashekar U, Chandrakar SK, Sharma D (2010) Mesopancreas: myth or reality? JOP 11(3):230–233PubMed

12.

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 5:44. https://doi.org/10.1186/1477-7819-5-44 CrossRefPubMedPubMedCentral

13.

Gaedcke J, Gunawan B, Grade M, Szoke R, Liersch T, Becker H, Ghadimi BM (2010) The mesopancreas is the primary site for R1 resection in pancreatic head cancer: relevance for clinical trials. Langenbeck's Arch Surg 395(4):451–458. https://doi.org/10.1007/s00423-009-0494-8 CrossRef

14.

Pessaux P, Rosso E, Panaro F, Marzano E, Oussoultzoglou E, Bachellier P, Jaeck D (2009) Preliminary experience with the hanging maneuver for pancreaticoduodenectomy. Eur J Surg Oncol 35(9):1006–1010. https://doi.org/10.1016/j.ejso.2009.04.009 CrossRefPubMed

15.

Pessaux P, Varma D, Arnaud JP (2006) Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg 10(4):607–611. https://doi.org/10.1016/j.gassur.2005.05.001 CrossRefPubMed

16.

Varty PP, Yamamoto H, Farges O, Belghiti J, Sauvanet A (2005) Early retropancreatic dissection during pancreaticoduodenectomy. Am J Surg 189(4):488–491. https://doi.org/10.1016/j.amjsurg.2005.01.007 CrossRefPubMed

17.

Weitz J, Rahbari N, Koch M, Buchler MW (2010) The “artery first” approach for resection of pancreatic head cancer. J Am Coll Surg 210(2):e1–e4. https://doi.org/10.1016/j.jamcollsurg.2009.10.019 CrossRefPubMed

18.

Jiang X, Yu Z, Ma Z, Deng H, Ren W, Shi W, Jiao Z (2020) Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: a meta-analysis. Int J Surg 73:14–24. https://doi.org/10.1016/j.ijsu.2019.11.007 CrossRefPubMed

19.

Aimoto T, Mizutani S, Kawano Y, Matsushita A, Yamashita N, Suzuki H, Uchida E (2013) Left posterior approach pancreaticoduodenectomy with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery for pancreatic head carcinoma. J Nippon Med Sch 80(6):438–445CrossRef

20.

Dumitrascu T, David L, Popescu I (2010) Posterior versus standard approach in pancreatoduodenectomy: a case-match study. Langenbeck's Arch Surg 395(6):677–684. https://doi.org/10.1007/s00423-009-0499-3 CrossRef

21.

Kawabata Y, Nishi T, Tanaka T, Tajima Y (2014) Safety and feasibility of a pancreaticoduodenectomy with total meso-pancreatoduodenum excision: analysis in various periampullary disorders. Hepatogastroenterology 61(131):821–827PubMed

22.

Kawabata Y, Tanaka T, Ishikawa N, Hayashi H, Tajima Y (2016) Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer. Eur J Surg Oncol 42(5):698–705. https://doi.org/10.1016/j.ejso.2016.02.241 CrossRefPubMed

23.

Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y (2012) Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 38(7):574–579. https://doi.org/10.1016/j.ejso.2012.04.007 CrossRefPubMed

24.

Kurosaki I, Minagawa M, Takano K, Takizawa K, Hatakeyama K (2011) Left posterior approach to the superior mesenteric vascular pedicle in pancreaticoduodenectomy for cancer of the pancreatic head. JOP 12(3):220–229PubMed

25.

Xu J, Tian X, Chen Y, Ma Y, Liu C, Tian L, Wang J, Dong J, Cui D, Wang Y, Zhang W, Yang Y (2017) Total mesopancreas excision for the treatment of pancreatic head cancer. J Cancer 8(17):3575–3584. https://doi.org/10.7150/jca.21341 CrossRefPubMedPubMedCentral

26.

Kawabata Y, Hayashi H, Ishikawa N, Tajima Y (2016) Total meso-pancreatoduodenum excision with pancreaticoduodenectomy in lower biliary tract cancer. Langenbeck's Arch Surg 401(4):463–469. https://doi.org/10.1007/s00423-016-1435-y CrossRef

27.

Rosenthal R, Hoffmann H, Clavien PA, Bucher HC, Dell-Kuster S (2015) Definition and Classification of Intraoperative Complications (CLASSIC): Delphi study and pilot evaluation. World J Surg 39(7):1663–1671. https://doi.org/10.1007/s00268-015-3003-y CrossRefPubMed

28.

Irita K (2011) Risk and crisis management in intraoperative hemorrhage: human factors in hemorrhagic critical events. Korean J Anesthesiol 60(3):151–160. https://doi.org/10.4097/kjae.2011.60.3.151 CrossRefPubMedPubMedCentral

29.

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196. https://doi.org/10.1097/SLA.0b013e3181b13ca2 CrossRefPubMed

30.

Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula D (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13. https://doi.org/10.1016/j.surg.2005.05.001 CrossRef

31.

(2001) In: Holzheimer RG, Mannick JA (eds) Surgical treatment: evidence-based and problem-oriented. Munich

32.

Campbell F, Foulis A, Verbeke C (2010) Dataset for the histopathological reporting of carcinomas of the pancreas, ampulla of Vater and common bile duct. R Coll Pathol

33.

Japanese Gastric Cancer A (2017) Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer 20(1):1–19. https://doi.org/10.1007/s10120-016-0622-4 CrossRef

34.

Sener SF, Fremgen A, Menck HR, Winchester DP (1999) Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985–1995, using the National Cancer Database. J Am Coll Surg 189(1):1–7CrossRef

35.

Wellner UF, Krauss T, Csanadi A, Lapshyn H, Bolm L, Timme S, Kulemann B, Hoeppner J, Kuesters S, Seifert G, Bausch D, Schilling O, Vashist YK, Bruckner T, Langer M, Makowiec F, Hopt UT, Werner M, Keck T, Bronsert P (2016) Mesopancreatic stromal clearance defines curative resection of pancreatic head cancer and can be predicted preoperatively by radiologic parameters: a retrospective study. Medicine (Baltimore) 95(3):e2529. https://doi.org/10.1097/MD.0000000000002529 CrossRef

36.

Sharma D, Isaji S (2016) Mesopancreas is a misnomer: time to correct the nomenclature. J Hepatobiliary Pancreat Sci 23(12):745–749. https://doi.org/10.1002/jhbp.402 CrossRefPubMed

Title: Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes
Authors: Giuseppe Quero
Claudio Fiorillo
Roberta Menghi
Caterina Cina
Federica Galiandro
Fabio Longo
Francesco Sofo
Fausto Rosa
Antonio Pio Tortorelli
Maria Cristina Giustiniani
Frediano Inzani
Sergio Alfieri
Publication date: 01-05-2020
Publisher: Springer Berlin Heidelberg
Published in: Langenbeck's Archives of Surgery / Issue 3/2020
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-020-01873-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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