Top

Langenbeck's Archives of Surgery

Published in:

01-12-2019 | Pancreatoduodenostomy | How-I-Do-It article

Pancreatic resection for cancer—the Heidelberg technique

Authors: Martin Schneider, Oliver Strobel, Thilo Hackert, Markus W. Büchler

Published in: Langenbeck's Archives of Surgery | Issue 8/2019

Abstract

Background

Pancreatic cancer is associated with high recurrence rates, and any surgery should aim to prevent local recurrence. However, systematic resection of putatively tumor-infiltrated soft tissue adjacent to the celiac branches and superior mesenteric artery has not regularly been applied in pancreatic head resection.

Objective

We describe a technique of vessel-oriented pancreatic head resection, allowing for extended removal of lymphatic and neural tissue that is situated in the TRIANGLE in between the celiac trunk, the superior mesenteric artery, and the portal vein.

Conclusions

Vessel-oriented dissection or vascular resection facilitates complete removal of putatively tumor-infiltrated soft tissue, thus potentially reducing the risk of isolated local recurrence in pancreatic cancer.

Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496):1479–1482CrossRef

Hohenberger W et al (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Color Dis 11(4):354–364 discussion 364-5CrossRef

Kiehlmann M, Weber K, Göhl J, Fietkau R, Agaimy A, Hohenberger W, Merkel S (2016) The impact of surgical quality on prognosis in patients undergoing rectal carcinoma surgery after preoperative chemoradiation. Int J Color Dis 31(2):247–255CrossRef

Gasparini G et al (2019) Nerves and pancreatic cancer: new insights into a dangerous relationship. Cancers (Basel) 11(7):E893CrossRef

Verbeke CS, Gladhaug IP (2012) Resection margin involvement and tumour origin in pancreatic head cancer. Br J Surg 99(8):1036–1049CrossRef

Groot VP et al (2018) Patterns, timing, and predictors of recurrence following pancreatectomy for pancreatic ductal adenocarcinoma. Ann Surg 267(5):936–945CrossRef

Strobel O et al (2013) Re-resection for isolated local recurrence of pancreatic cancer is feasible, safe, and associated with encouraging survival. Ann Surg Oncol 20(3):964–972CrossRef

Ghaneh P, Kleeff J, Halloran CM, Raraty M, Jackson R, Melling J, Jones O, Palmer DH, Cox TF, Smith CJ, O'Reilly DA, Izbicki JR, Scarfe AG, Valle JW, McDonald A, Carter R, Tebbutt NC, Goldstein D, Padbury R, Shannon J, Dervenis C, Glimelius B, Deakin M, Anthoney A, Lerch MM, Mayerle J, Oláh A, Rawcliffe CL, Campbell F, Strobel O, Büchler MW, Neoptolemos JP, European Study Group for Pancreatic Cancer (2019) The impact of positive resection margins on survival and recurrence following resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma. Ann Surg 269(3):520–529CrossRef

Hank T, Hinz U, Tarantino I, Kaiser J, Niesen W, Bergmann F, Hackert T, Büchler MW, Strobel O (2018) Validation of at least 1 mm as cut-off for resection margins for pancreatic adenocarcinoma of the body and tail. Br J Surg 105(9):1171–1181CrossRef

10.

Strobel O et al (2017) Pancreatic cancer surgery: the new R-status counts. Ann Surg 265(3):565–573CrossRef

11.

Jones, R.P., et al., Patterns of recurrence after resection of pancreatic ductal adenocarcinoma: a secondary analysis of the ESPAC-4 randomized adjuvant chemotherapy trial. JAMA Surg, 2019.

12.

Tjaden C et al (2016) Clinical impact of structured follow-up after pancreatic surgery. Pancreas 45(6):895–899CrossRef

13.

Hackert T, Sachsenmaier M, Hinz U, Schneider L, Michalski CW, Springfeld C, Strobel O, Jäger D, Ulrich A, Büchler MW (2016) Locally advanced pancreatic cancer: neoadjuvant therapy with folfirinox results in resectability in 60% of the patients. Ann Surg 264(3):457–463CrossRef

14.

Klaiber U, Leonhardt CS, Strobel O, Tjaden C, Hackert T, Neoptolemos JP (2018) Neoadjuvant and adjuvant chemotherapy in pancreatic cancer. Langenbeck's Arch Surg 403(8):917–932CrossRef

15.

Strobel O, Neoptolemos J, Jäger D, Büchler MW (2019) Optimizing the outcomes of pancreatic cancer surgery. Nat Rev Clin Oncol 16(1):11–26CrossRef

16.

Del Chiaro M et al (2015) Cattel-Braasch maneuver combined with artery-first approach for superior mesenteric-portal vein resection during pancreatectomy. J Gastrointest Surg 19(12):2264–2268CrossRef

17.

Hackert T, Werner J, Weitz J, Schmidt J, Büchler MW (2010) Uncinate process first—a novel approach for pancreatic head resection. Langenbeck's Arch Surg 395(8):1161–1164CrossRef

18.

Weitz J, Rahbari N, Koch M, Büchler MW (2010) The “artery first” approach for resection of pancreatic head cancer. J Am Coll Surg 210(2):e1–e4CrossRef

19.

Stauffer JA et al (2009) Aberrant right hepatic arterial anatomy and pancreaticoduodenectomy: recognition, prevalence and management. HPB (Oxford) 11(2):161–165CrossRef

20.

Heye T, Zausig N, Klauss M, Singer R, Werner J, Richter GM, Kauczor HU, Grenacher L (2011) CT diagnosis of recurrence after pancreatic cancer: is there a pattern? World J Gastroenterol 17(9):1126–1134CrossRef

21.

Adham M, Singhirunnusorn J (2012) Surgical technique and results of total mesopancreas excision (TMpE) in pancreatic tumors. Eur J Surg Oncol 38(4):340–345CrossRef

22.

Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA (2012) Artery-first’ approaches to pancreatoduodenectomy. Br J Surg 99(8):1027–1035CrossRef

23.

Esposito I, Kleeff J, Bergmann F, Reiser C, Herpel E, Friess H, Schirmacher P, Büchler MW (2008) Most pancreatic cancer resections are R1 resections. Ann Surg Oncol 15(6):1651–1660CrossRef

24.

Tummers WS et al (2019) Impact of resection margin status on recurrence and survival in pancreatic cancer surgery. Br J Surg 106(8):1055–1065CrossRef

25.

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

26.

Ironside N et al (2018) Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival. Br J Surg 105(6):628–636CrossRef

27.

Hirono S et al (2018) Mesenteric approach vs. conventional approach for pancreatic cancer during pancreaticoduodenectomy: study protocol for a multicenter randomized controlled trial of 354 patients with pancreatic ductal adenocarcinoma. Trials 19(1):613CrossRef

28.

Hackert T, Strobel O, Michalski CW, Mihaljevic AL, Mehrabi A, Müller-Stich B, Berchtold C, Ulrich A, Büchler MW (2017) The TRIANGLE operation - radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study. HPB (Oxford) 19(11):1001–1007CrossRef

29.

Mitra A, Pai E, Dusane R, Ranganathan P, DeSouza A, Goel M, Shrikhande SV (2018) Extended pancreatectomy as defined by the ISGPS: useful in selected cases of pancreatic cancer but invaluable in other complex pancreatic tumors. Langenbeck's Arch Surg 403(2):203–212

30.

Yamamoto KN et al (2017) Personalized management of pancreatic ductal adenocarcinoma patients through computational modeling. Cancer Res 77(12):3325–3335CrossRef

31.

Mahajan UM, Langhoff E, Goni E, Costello E, Greenhalf W, Halloran C, Ormanns S, Kruger S, Boeck S, Ribback S, Beyer G, Dombroswki F, Weiss FU, Neoptolemos JP, Werner J, D'Haese JG, Bazhin A, Peterhansl J, Pichlmeier S, Büchler MW, Kleeff J, Ganeh P, Sendler M, Palmer DH, Kohlmann T, Rad R, Regel I, Lerch MM, Mayerle J (2018) Immune cell and stromal signature associated with progression-free survival of patients with resected pancreatic ductal adenocarcinoma. Gastroenterology 155(5):1625–1639 e2CrossRef

Title: Pancreatic resection for cancer—the Heidelberg technique
Authors: Martin Schneider
Oliver Strobel
Thilo Hackert
Markus W. Büchler
Publication date: 01-12-2019
Publisher: Springer Berlin Heidelberg
Keywords: Pancreatoduodenostomy
Pancreatic Head Resection
Pancreatoduodenostomy
Pancreatic Head Resection
Pancreatic Cancer
Pancreatic Cancer
Published in: Langenbeck's Archives of Surgery / Issue 8/2019
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-019-01839-1

At a glance: The STEP trials

Springer Medicine

Pancreatic resection for cancer—the Heidelberg technique

Abstract

Background

Objective

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Objective

Conclusions

Please log in to get access to this content

Other articles of this Issue 8/2019

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

Poly-ε-caprolactone scaffold for the reinforcement of stapled small intestinal anastomoses: a randomized experimental study

Central pancreatectomy: a comprehensive, up-to-date meta-analysis

Results of portosystemic shunts during extended pancreatic resections

Posterior enucleation of the pancreatic head: an alternative route of access for parenchyma-sparing pancreatic resection

Diaphragmatic herniation following total gastrectomy: review of the long-term experience of a tertiary institution