Periarterial divestment in pancreatic cancer surgery.

Published on May 1, 2021in Surgery3.356
· DOI :10.1016/J.SURG.2020.08.030
Markus K. Diener48
Estimated H-index: 48
(Heidelberg University),
André L. Mihaljevic20
Estimated H-index: 20
(Heidelberg University)
+ 11 AuthorsMarkus W. Büchler173
Estimated H-index: 173
(Heidelberg University)
Sources
Abstract
Abstract Background Modern pancreatic cancer surgery changed with the introduction of effective neoadjuvant therapies. Complete tumor resection is the mainstay for long-term, disease-free, and overall survival and has been a prerequisite for decreasing local recurrence. The medial resection margin in the area of the superior mesenteric vessels limits the radicalness of the resection, especially in borderline and locally advanced cases. Therefore, the periarterial soft tissue around the peripancreatic visceral arteries must be completely cleared. This procedure, namely periarterial divestment, is technically demanding but often represents an alternative to arterial resection. Objective Here we describe the technique and our initial experience with periarterial divestment along the peripancreatic visceral arteries during pancreatic surgery. This technique, in combination with previously published resection strategies, such as artery first maneuver and mesenterico-portal venous bypass first, enables tumor resection in locally advanced pancreatic cancer. Conclusion Periarterial divestment can prevent the need for arterial resection in borderline and locally advanced pancreatic cancer, especially after neoadjuvant therapy. The feasibility, improved safety, and oncologic equivalence of arterial divestment versus arterial resection for pancreatic cancer surgery must be evaluated by clinical trials.
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#1Thomas Schmidt (Heidelberg University)H-Index: 31
#2Oliver Strobel (Heidelberg University)H-Index: 50
Last. Markus W. Büchler (Heidelberg University)H-Index: 173
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Background In recent years, several techniques have been introduced to allow safe oncologic resections of cancers of the pancreatic head. While resections of the mesenterico-portal axis became now a part of the routine treatment, patients with a cavernous transformation of the portal vein still pose a surgical challenge and are regularly deemed unresectable. Objective Here, we describe a technique of initial venous bypass graft placement between the superior mesenteric vein or its tributaries an...
3 CitationsSource
#1Masayuki AkitaH-Index: 2
#2Nobuaki YamasakiH-Index: 1
Last. Kunihiko KanedaH-Index: 6
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6 CitationsSource
#1Paula Ghaneh (University of Liverpool)H-Index: 62
#2Daniel H. PalmerH-Index: 44
Last. John P. Neoptolemos (University of Liverpool)H-Index: 125
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4505Background: Patients with borderline resectable pancreatic cancer have poor survival and low resection rates. Neoadjuvant therapy may improve the outcome for these patients. The aim of this tri...
29 CitationsSource
#1Martin Schneider (Heidelberg University)H-Index: 23
#2Oliver Strobel (Heidelberg University)H-Index: 50
Last. Markus W. Büchler (Heidelberg University)H-Index: 173
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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.
17 CitationsSource
#1Masayuki Tanaka (Heidelberg University)H-Index: 8
#2André L. Mihaljevic (Heidelberg University)H-Index: 20
Last. T. Hackert (Heidelberg University)H-Index: 17
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ANTECEDENTES: El mapeo del patron de recidiva inicial tras la reseccion de un adenocarcinoma ductal pancreatico (pancreatic ductal adenocarcinoma, PDAC) podria ayudar a estratificar subpoblaciones de pacientes para un seguimiento postoperatorio optimo. El objetivo de esta revision sistematica con metaanalisis fue investigar los patrones de recidiva inicial de PDAC y correlacionarlos con factores clinico-patologicos. METODOS: Se realizaron busquedas sistematicas en las bases de datos MEDLINE y We...
41 CitationsSource
#1Vincent P. Groot (UU: Utrecht University)H-Index: 16
#2Alex B. Blair (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 17
Last. Jin He (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 40
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Abstract Introduction The incidence, timing, and implications of recurrence in patients who underwent neoadjuvant treatment and surgical resection of borderline resectable (BRPC) or locally advanced (LAPC) pancreatic cancer are not well established. Materials and methods Patients with BRPC/LAPC who underwent post-neoadjuvant resection between 2007 and 2015 were included. Associations between clinicopathologic characteristics and specific recurrence locations, recurrence-free survival (RFS), and ...
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#1Marco Del Chiaro (Karolinska University Hospital)H-Index: 31
#2Elena Rangelova (Karolinska University Hospital)H-Index: 13
Last. Caroline S. Verbeke (University of Oslo)H-Index: 39
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Abstract Background Few studies have investigated the outcome of pancreatectomy associated with artery resection (PAR). Methods Retrospective analysis of a cohort of operated borderline or locally advanced pancreatic cancer patients with surgically confirmed arterial involvement. Short and long-term outcome were analyzed and compared in patients who underwent PAR (Group 1) and palliative surgery (Group 2). Results Of 73 patients who underwent surgical exploration with intent of resection, 34 und...
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Abstract Background Among patients with metastatic pancreatic cancer, combination chemotherapy with fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) leads to longer overall surviv...
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#1Thomas Hank (University Hospital Heidelberg)H-Index: 11
#2Ulf Hinz (University Hospital Heidelberg)H-Index: 17
Last. Oliver Strobel (University Hospital Heidelberg)H-Index: 50
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BACKGROUND: The definition of resection margin (R) status in pancreatic cancer is under debate. Although a margin of at least 1 mm is an independent predictor of survival after resection for pancreatic head cancer, its relevance to pancreatic body and tail cancers remains unclear. This study aimed to validate R status based on a 1-mm tumour-free margin as a prognostic factor for resected adenocarcinoma involving the pancreatic body and tail. METHODS: Patients who underwent distal or total pancre...
37 CitationsSource
#1May C. Tee (Mayo Clinic)H-Index: 6
#2Adam C. Krajewski (Mayo Clinic)H-Index: 5
Last. Mark J. Truty (Mayo Clinic)H-Index: 31
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Background Pancreatectomy with arterial resection (AR) is performed infrequently. As indications evolve, we evaluated indications, outcomes, and predictors of mortality, morbidity, and survival after AR. Study Design We performed a single-institution review of elective pancreatectomies with AR (from July1990 to July 2017). Univariate and multivariate analyses were performed for predictors of outcomes and survival. Results A total of 111 patients underwent pancreatectomy with AR including any hep...
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Cited By14
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#1Martin Schneider (Heidelberg University)H-Index: 23
#2T. Hackert (Heidelberg University)H-Index: 17
Last. M.W. Büchler (Heidelberg University)H-Index: 79
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BACKGROUND Multimodal treatment concepts enhance options for surgery in locally advanced pancreatic ductal adenocarcinoma (PDAC). This review provides an overview of technical advances to facilitate curative-intent resection in PDAC. METHODS A review of the literature addressing current technical advances in surgery for PDAC was performed, and current state-of-the-art surgical techniques summarized. RESULTS Artery-first and uncinate-first approaches, dissection of the anatomical triangle between...
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#1Danko MikulićH-Index: 4
#2Anna MrzljakH-Index: 8
Last. Anna Mrzljak (University Hospital Centre Zagreb)H-Index: 2
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Borderline resectable pancreatic cancer and vascular resections in the era of neoadjuvant therapy
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#1Thomas Hank (University of Vienna)
#2Ulla Klaiber (University of Vienna)
Last. Oliver Strobel (University of Vienna)
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Periampullary neoplasms are a heterogeneous group of different tumor entities arising from the periampullary region, of which pancreatic ductal adenocarcinoma (PDAC) is the most common subgroup with 60-70%. As typical for pancreatic adenocarcinomas, periampullary pancreatic cancer is characterized by an aggressive growth and early systemic progression. Due to the anatomical location in close relationship to the papilla of Vater symptoms occur at an earlier stage of the disease, so that treatment...
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#1Benedict Kinny-Köster (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 3
#2Joseph R. Habib (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 6
Last. Jin He (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 40
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Purpose null The resection of retropancreatic nerve plexuses for pancreatic head cancer became standard of care during open pancreatoduodenectomy to minimize local recurrences. Since more surgical centers are progressing on the learning curve, robotically-assisted pancreatoduodenectomy is now increasingly performed with decreasing anatomic exclusion criteria. To achieve comparable and favorable oncologic outcomes, advanced surgical techniques should be transferred and implemented when performing...
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#1Rosa Klotz (Heidelberg University)H-Index: 3
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Last. Beat P. Müller-Stich (Heidelberg University)H-Index: 33
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Abstract null null Background null Surgical resection is the mainstay of potential cure for patients with pancreatic cancer, however, local recurrence is frequent. Previously, we have described an extended resection technique for pancreatoduodenectomy aiming at a radical resection of the nerve and lymphatic tissue between celiac artery, superior mesenteric artery and mesenteric-portal axis (TRIANGLE operation). Until now, data on postoperative outcome have not been reported, yet. null null null ...
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#1Eduardo de Souza M. Fernandes (DaimlerChrysler Aerospace)H-Index: 1
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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 resec...
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#1Douglas B. Evans (MCW: Medical College of Wisconsin)H-Index: 116
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#1Asanka Wijetunga (USYD: University of Sydney)H-Index: 3
#2Terence C. Chua (Griffith University)H-Index: 45
Last. Jaswinder S. Samra (USYD: University of Sydney)H-Index: 34
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Abstract Background Pancreatic cancer is the 8th commonest cancer and the 5th commonest cause of cancer-related death in Australia, with a 9% average 5-year survival. This study aims to investigate the effects of neoadjuvant treatment on overall survival (OS) and recurrence-free survival (RFS) in borderline resectable (BRPC) and locally advanced (LAPC) pancreatic adenocarcinoma followed by curative resection. Materials and methods Prospectively-collected demographic, medical, surgical and pathol...
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Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regard...
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#1Yosuke Inoue (JFCR: Japanese Foundation for Cancer Research)H-Index: 16
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Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on a...
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