1. Department of Surgery, National Taiwan University Hospital
Pancreaticoduodenectomy with or without systematic Mesopancreas Dissection: Comparison of Morbidity, Mortality and Short-term Outcome 胰十二指腸切除合併系統化胰內緣軟組織廓清：手術併發症、死亡率及短期預後比較
吳健暉、郭庭均、吳經閔、楊卿堯、田郁文
台灣大學附設醫院一般外科
Chien-Hui Wu, M.D., Ting-Chun Kuo, M.D., Jin-Ming Wu, M.D., Ph.D., Ching-Yao Yang, M.D., Ph.D., Yu-Wen Tien, M.D., Ph.D
Department of Surgery, National Taiwan University Hospital

2. Concept of mesopancreas dissection
First pancreaticoduodenectomy (Whipple,Ann Surg 1935)
Regional pancreatectomy in 1970s failed to improve outcomes (Yeo, Ann Surg 2002)(Nguyen, J Gastrointest Surg 2003)(Pedrazzoli, Ann Surg 1998)
Resection margin(R0/R1) impacts long-term survival
ISGPS (Surgery 2014) : extensive lymphadenectomy including 16 para-aortic area and complete lymphadenectomy around the superior mesenteric artery (SMA) are not routinely recommended
The goal of mesopancreatic resection (area around the SMA) is for the margin (R-factor) rather than to stage or control the nodal spread (N-factor) (Peparini, 2015 and 2016)
Neoadjuvant treatment era in the future

3. Mesopancreas is primary site of R1 resection
Prospectively tested , 100 pancreatic head specimens
35 were excluded owing to the pathohistological diagnosis
32 cancer resections were classified R0 (49.2%)
33 cancer resections were classified R1 (50.8%)
Mesopancreas was infiltrated in 22 of the 33 R1 resection specimens (66.6%)
Gaedcke, Langenbecks Arch Surg, 2010

4. What is mesopancreas Gockel,2007 WORLD J SURG ONCOL
Perineural lymphatic layer located dorsal to the pancreas, extending from the posterior surface of the pancreatic head to behind the mesenteric vessels (SMV and SMA)
Gaedcke,2010
Langenbecks Arch Surg
Peripancreatic fatty tissue posterior to the pancreatic head and lateral to the SMA
Adham,2012
Eur J Surg Oncol
Triangle with : posterior surface of the SMV and portal vein; anterior surface of the aorta between the celiac trunk and the origin of the SMA; lateral boundaries limited by the right semicircumferences of the celiac trunk and SMA plexus
Kawabata,2012
Cluster of soft connective tissues along the IPDA and the first jejunal artery (FJA) including circumferential tissue of SMA

5. Systematic mesopancreas dissection
plPh-I and plPh-II: first and second nerve plexuses of the pancreas head
pl-SMA: nerve plexus around the SMA
IPDA: inferior pancreatoduodenal arteries
JA: jejunal arteries
JV: jejunal veins
HGCT: Henle's gastrocolic trunk
(Inoue, Ann Surg 2015)

6. Systematic mesopancreas dissection
(Inoue, Ann Surg 2015)

7. Systematic mesopancreas dissection
Level 1 dissection-Simple mesopancreas division without LN dissection
preserving pl-SMA, JAs, and JVs
no dissection on the left side of SMA
mesojejunum can be preserved
(Inoue, Ann Surg 2015)

8. Systematic mesopancreas dissection
Level 2 dissection - En bloc LNs dissection in the mesopancreas by the
central vessel ligation technique
central vessel ligation, IPDA is ligated at its root (common trunk with JA)
resection of the corresponding LNs and mesojejunum
(Inoue, Ann Surg 2015)

9. Systematic mesopancreas dissection
Level 3 dissection - En bloc mesopancreas resection with right hemicircumferential
pl-SMA dissection
encompassing the right hemicircle of the pl-SMA (11 to 5 o’clock, peeling off the pl-SMA like a plate)
dissection along the SMA, the corresponding mesojejunum is also resected
(Inoue, Ann Surg 2015)

10. Mesopancreas dissection experience in NTUH

11. Level 1 mesopancreas dissection in NTUH

12. Level 1 mesopancreas dissection in NTUH

13. Level 2 mesopancreas dissection in NTUH

14. Level 2 mesopancreas dissection in NTUH

15. Level 2 mesopancreas dissection in NTUH

16. Level 3 mesopancreas dissection in NTUH

17. Level 3 mesopancreas dissection in NTUH

18. Level 3 mesopancreas dissection in NTUH

19. Compare conventional systematic mesopancreas dissection PD
Conventional PD
Systematic mesopancreas dissection PD
Period
No. 34 35
Male(%)
61.7
58.3
Age(yr)
65.7
64.2
Operative time(min)
223
240 *
Vascular resection(No.) 3 6
Blood loss(cc)
272
308
PDAC(%)
64.7
72.2
IPMN/IPMC(%) 25
13.9
Reoperation(No.) 1
Level I - 10
Level II 16
Level III 9

20. Compare conventional systematic mesopancreas dissection PD
Conventional PD
systematic mesopancreas dissection PD
PDAC No. 12
LN exam
9.5(5-15)
13.4(11-20) *
LN postive No 10 7
R1 No. 9 5
R1 site
retroperitonel(7) vascular groove CBD
peripancreatic tissue(2) SMA portal vein superior margin pancreatic resection
Lymph-Vascular invasion 8 6
Perineural Invasion T3

21. Compare different level mesopancreas dissection PD
Level 1 PD
Level 2 PD
Level 3 PD
No. 10 16 9
Operative time(min)
205
245
273 *
Vascular resection(No.) 3
Blood loss(cc)
270
320
Reoperation(No.) 1
PDAC rate(%) 40 56 67 **
Benign rate(%) 30 31 22

22. Discussion
More level 3 diseection in pancreatic cancer(44/52) and PV/SMV vascular resection(32/82)
More diarrhea in systematic mesopancreas dissection PDs(14/82) than conventional PDs(8/80)
More opioid antidiarrheal agents use(13/14) than conventional PDs (4/8), especially level 3 (12/13)
Point of SMA abutment by invasive tumor in 20 patients
(Inoue, Ann Surg 2015)

23. Discussion (NTUH experience)
Longer operative time, more vesculaer resection, more blood loss in systematic mesopancreas dissection
Systematic mesopancreas dissection increase R0 resection rate and LN exam number
Further study issue:
Long-term survival effect
Definition of level three dissection
More frozen pathology exam or more precise preoperative plan
Total pancreatectomy or other procedure

24. 吳健暉、郭庭均、吳經閔、楊卿堯、田郁文 台灣大學附設醫院一般外科
Thank you
吳健暉、郭庭均、吳經閔、楊卿堯、田郁文
台灣大學附設醫院一般外科