ADVANTAGES OF MESENTERIC ACCESS TO PANCREATODUODENAL RESECTION OF PANCREATIC HEAD CANCER WITH INVASION OF THE MAIN VESSELS

Mikael G. Abgaryan; Абгарян Микаэл Грантович; Alexey G. Kotelnikov; Котельников Алексей Геннадьевич; Alexandr N. Polyakov; Поляков Александр Николаевич; Ivan G. Avdyukhin; Авдюхин Иван Геннадьевич; Omar A. Egenov; Егенов Омар Алиевич; Henian Sun; Сунь Хэнянь; Ivan S. Stilidi; Стилиди Иван Сократович

doi:10.35693/SIM687668

ADVANTAGES OF MESENTERIC ACCESS TO PANCREATODUODENAL RESECTION OF PANCREATIC HEAD CANCER WITH INVASION OF THE MAIN VESSELS

Authors: Abgaryan M.G.¹, Kotelnikov A.G.¹, Polyakov A.N.¹, Avdyukhin I.G.¹, Egenov O.A.¹, Sun H.¹, Stilidi I.S.¹
Affiliations:
1. N.N. Blokhin NMRCO
Section: Original study articles
URL: https://innoscience.ru/2500-1388/article/view/687668
DOI: https://doi.org/10.35693/SIM687668
ID: 687668

Cite item

Full Text

Abstract
Full Text
About the authors
References
Supplementary files
Statistics

Abstract

The aim of the study was to compare standard and mesenteric approaches to surgical treatment of patients with pancreatic head cancer that invades the portal and/or superior mesenteric veins, and to evaluate their advantages. Materials and methods: 192 patients with pancreatic head cancer with invasion of the portal and/or superior mesenteric vein underwent surgical treatment, in 43 (22.4%) cases pancreatoduodenal resection was performed through mesenteric access, in the remaining 149 (77.3%) patients a standard approach to surgical treatment was used. Results: The median duration of operations with mesenteric access was 290 minutes, with standard access – 300 minutes, the median blood loss was 1120 ml and 1800 ml, respectively, p=0.0002. There were no statistically significant differences in long–term treatment outcomes with mesenteric and standard approaches: progression of pancreatic head adenocarcinoma was diagnosed in 48.8% and 49%, respectively, the median overall survival was 24.5 months and 22.3 months, the median progression-free survival was 21.3 months and 22.1 months, respectively. An analysis of long-term treatment outcomes depending on the type of access and the degree of radical surgical intervention showed that the incidence of local recurrence with standard access in non-radically operated patients was significantly higher (40.6% vs 7.7%, p=0.001). Conclusion: the advantages of mesenteric access over the standard approach to surgical treatment of patients with pancreatic head cancer with invasion of the portal and/or superior mesenteric vein were as follows: 1) provides an opportunity to assess the prevalence and operability of the tumor already at the beginning of surgery, 2) provides a significantly higher frequency of operations in the volume of R0, 3) provides significantly less blood loss during surgery, 4) after circular resection of the main veins, it provides more opportunities to perform end-to-end plastic surgery, this reduces the risk of thrombosis due to the formation of only one anastomosis and reduces the time of compression of the main veins, reducing the risk of liver and intestinal ischemia.

Keywords

mesenteric access, cancer of the pancreatic head, pancreatoduodenal resection, portal vein resection, superior mesenteric vein resection

Full Text

Introduction
There are very few reports in the literature about mesenteric access to surgical treatment of pancreatic glans (pancreas). The first publication reporting mesenteric access to pancreatoduodenal resection (PDR) appeared only in 1993. Japanese surgeons Nakao et al. [1] proposed mesenteric access, based on the basic rule of oncosurgery – minimal contact with the tumor before its mobilization and ligation of the supply vessels. The authors developed an approach through the mesentery root of the transverse colon so that the branches of the superior mesenteric artery could be sequentially isolated. This made it possible to assess the resectability of the tumor at the beginning of surgery, dissect tissues from the side not affected by the tumor, ligate the inferior pancreatoduodenal artery and other branches of the superior mesenteric artery at the initial stages of the operation, perform lymphadenectomy around the superior mesenteric artery and the superior mesenteric vein, and facilitate the repair of the portal vein during the formation of an anastomosis. "end-to-end", made it possible to reduce venous congestion in the area of the pancreatic head, minimize blood loss during surgery and increase the possibility of radical tumor resection [2]. In 2007, Gockel et al. [3] reported that a total removal of "mesopancreas" was performed through mesenteric access. This anatomical concept has been mentioned in the literature only in recent years by analogy with the concept of "mesorectum" and total mesorectomectomy for rectal cancer [3]. Currently, there is no clear definition of "mesopancreas" yet, despite the fact that the Japanese classification of pancreatic cancer [4] contains a detailed description of the anatomy of the extrapancreatic nerve plexuses. As noted in the literature [5], the "mesopancreas" is identified with the "retroportal plate", meaning the area of retroperitoneal tissue behind the pancreas and BB and anteriorly from the aorta in the area between the base of the superior mesenteric artery and the celiac trunk. However, from an anatomical point of view, this is not entirely true, since microscopically it represents adipose tissue and nerve plexuses of the pancreatic head (PLphI and PLphII), delimited by visceral arteries and not covered with fascia [6]. However, the concept of "mesopancreas" is important from a clinical and surgical point of view, since the removal of the entire described tissue complex is practically a radical resection [7, 8].
Taking into account the urgency of the problem and the practical lack of research on the comparison of mesenteric and standard approaches to surgical treatment of pancreatic head cancer, we present the results of our study conducted at the Blokhin National Research Medical Center of Oncology of the Ministry of Health of the Russian Federation in 2001-2023.
The aim of the study was to compare standard and mesenteric approaches to surgical treatment of patients with pancreatic head cancer that invades the portal and/or superior mesenteric veins, and to evaluate their advantages.

Material and methods
We conducted a retrospective analysis of the data of 192 patients who underwent surgical treatment of pancreatic head cancer with invasion of BB and/or VBV at the Blokhin National Research Medical Center of Oncology of the Ministry of Health of the Russian Federation in 2001-2023. In 43 (22.4%) cases, mesenteric access was used for PD, and 149 (77.3%) patients underwent surgical treatment using a standard approach. Mesenteric access was used in:
― 2 (12.5%) of 16 patients with IV resection,
― 15 (18.1%) out of 83 patients with HBV resection,
― 26 out of 93 with resection of both major veins (BB+VBV).
Circular resection of the main veins was performed in 36 (83.7%) patients with mesenteric access and 108 (72.5%) with standard, the median length of resection was 4 cm (from 1.5 to 8 cm) and 3 cm (from 0.5 to 1 cm), respectively, the median differences are statistically significant, p=0.0009 (Table 1). The reconstruction of the main veins in these patients was performed:
1) having formed an end-to-end anastomosis in 21 (48.8%) and 76 (51%) patients, the median length was 3 cm (from 15 to 7 cm) and 2 cm (from 0.5 to 4.5 cm), respectively, the median differences were statistically significant, p=0.007,
2) using an autovenous prosthesis – in 2 (4.7%) and 4 (2.7%) patients, the median length was 4.5 cm (4 and 5 cm) and 3.5 cm (from 2 to 4 cm),
3) using a Gore-Tex synthetic prosthesis in 13 (30.2%) and 28 (18.8%) people, the differences between the groups were significant, p=0.083. The median lengths were 5 cm and 3 cm, respectively, the differences in the medians were statistically significant, p=0.006.
Parietal resection was performed in 7 (16.3%) and 41 (27.5%) patients, with a median length of 2 cm and 1.5 cm). For plastic surgery, a wall seam was used, the median length of which was 2 cm and 1.5 cm, respectively.

Table 1 – Characteristics of standard and mesenteric accesses to surgical treatment of patients with pancreatic head cancer with invasion of the main veins

Results
Histological examination revealed adenocarcinoma in all 192 patients included in the study. The frequency of tumor resection in volume R0, confirmed histologically, was 97.7% (n=42) with mesenteric access and significantly exceeded the indicator with standard access to surgical treatment – only 78.5% (n=117, p=0.001). Operations in the volume of R1 were performed in 2.3% (n=1) of patients with mesenteric access and 19.5% (n=29, p=0.003) with standard, in the volume of R2 – 0% and 2%, respectively. The median duration of operations with mesenteric and standard accesses is almost similar – 290 min and 300 min, respectively, while the median blood loss with mesenteric access is significantly lower – 1120 ml vs 1800 ml, p=0.0002. Blood loss with mesenteric access ranged from 200 ml to 3,200 ml, with the standard approach – from 50 ml to 8,500 ml.
There were no statistically significant differences in the long-term results of treatment of patients with pancreatic head cancer with major vein invasion depending on access to surgical intervention. Progression of pancreatic head adenocarcinoma was diagnosed in 48.8% (n=21) of patients with mesenteric access and 49% (n=73) with the standard approach. The incidence of local recurrence was 14 (n=6) and 14.8% (n=22), respectively, the incidence of death was 55.8% (n=24) and 56.4% (n=84), the median overall survival was 24.5 months and 22.3 months, the median survival without signs of tumor progression was 21.3 month. and 22.1 months. At the end of the study, 41.9% (n=18) of patients with mesenteric access and 42.3% (n=63) with standard access were alive without symptoms of the disease, 2.3% (n=1) and 1.3% (n=2) were alive with signs of tumor progression, respectively, 9.3% died from complications of surgical treatment. (n=4) and 8.7% (n=13) died from disease progression – 46.5% (n=20) and 47.7% (n=71).
Since we did not find statistically significant differences in long-term treatment outcomes depending on access to surgery, we evaluated its impact together with the degree of radical surgical treatment (Figure 1). This approach made it possible to determine a significantly more frequent development of local recurrence in non-radially operated patients with standard access (40.6% vs 7.7%, p=0.001).

Figure 1 – Types and frequency of progression of pancreatic head cancer with invasion of the main veins, depending on access to surgical treatment and the degree of its radicality

Discussion
Taking into account many years of personal experience, we can say that our comparison of mesenteric and standard approaches to surgical treatment of patients with pancreatic head cancer with invasion of BB and/or HBV has shown the undeniable advantages of the mesenteric approach. Despite the fact that it requires a higher qualification of the operating surgeon, mesenteric access makes it possible to perform radical surgical interventions significantly more often (p=0.001). We were able to perform resections of the tumor invading the main veins in the volume of R0 in 97.7% of patients, similar radical operations with standard access were possible only in 78.5%.
The undoubted advantage of mesenteric access is significantly (p=0.0002) lower blood loss during surgical treatment. In our study, the median blood loss in patients with mesenteric access was 1200 ml, while with the standard approach it reached 1800 ml. The maximum individual blood loss with mesenteric access was 3,200 ml, while with standard access it was 2.6 times greater – 8,500 ml. In our opinion, the reduction in blood loss is due to the fact that mesenteric access makes it possible at the beginning of the operation to assess not only the prevalence and operability of the tumor, but also to ligate the vessels feeding the tissues of the surgical area, for example, gastroduodenal and pancreatoduodenal arteries.
Our analysis of the options for resection and plastic surgery of the main veins, depending on the approach to the surgical field, showed that mesenteric access provides ample opportunities for end-to-end plastic surgery and/or end-to-end surgery without using a prosthesis after circular resection. The formation of only one anastomosis significantly reduces the risk of thrombosis. With mesenteric access, we performed the formation of an end-to-end anastomosis with a statistically significantly longer resection length (p=0.007), which in some cases reached 7 cm.
We did not find a statistically significant effect of access to surgery on the long-term results of treatment of pancreatic head cancer with invasion of the main veins. However, our analysis of long-term outcomes, depending on the access options and the degree of radical surgical intervention, showed a significantly more frequent development of local recurrence with standard access in non-radially operated patients (40.6% vs 7.7%, p=0.001). It should be noted that at the end of the study, the only non-radially operated patient with mesenteric access was alive without signs of tumor progression for 12 months after surgical treatment and adjuvant chemotherapy.
Thus, using mesenteric access in 43 patients, we can identify the following advantages over the standard approach to surgical treatment of patients with pancreatic head cancer with invasion of BB and/or VBV:
1) the ability to assess the prevalence and operability of the tumor already at the beginning of surgery,
2) significantly higher frequency of radical surgery (97.7% vs 78.5%, p=0.001),
3) significantly lower blood loss during surgery (median 1200 ml vs 1800 ml, p= 0.0002), since ligation of vessels feeding the tissues of the surgical area, for example, gastroduodenal and pancreatoduodenal arteries, can be performed before the main resection, which significantly reduces the volume of blood loss. In our study, the maximum blood loss with mesenteric access was 3,200 ml, while with standard access it was 2.6 times greater – 8,500 ml.,
4) After circular resection, there are more opportunities to perform end-to-end IV and/or VBV plastic surgery. The formation of a single anastomosis reduces the risk of thrombosis. In our study, mesenteric access made it possible to perform end-to-end plastic surgery and not use a prosthesis with a significantly (p=0.007) longer resection length, which in some cases reached 7 cm.,
5) end-to-end plastic surgery, compared with using a prosthesis, reduces the compression time of explosives and/or explosives and reduces the risk of liver and intestinal ischemia, since instead of 2 anastomoses, we form only one.

Conclusion
The advantages of mesenteric access over the standard approach to surgical treatment of patients with pancreatic head cancer with invasion of the portal and/or superior mesenteric vein were as follows: 1) provides an opportunity to assess the prevalence and operability of the tumor already at the beginning of surgery, 2) provides a significantly higher frequency of operations in the volume of R0, 3) provides significantly less blood loss during surgery, 4) after circular resection of the main veins, it provides more opportunities to perform end-to-end plastic surgery, this reduces the risk of thrombosis due to the formation of only one anastomosis and reduces the time of compression of the main veins, reducing the risk of liver and intestinal ischemia.

About the authors

Mikael G. Abgaryan

N.N. Blokhin NMRCO

Author for correspondence.
Email: abgaryan.mikael@gmail.com
ORCID iD: 0000-0001-8893-1894
SPIN-code: 1821-6900

Candidate of Medical Sciences, Senior Researcher at the Department of Abdominal Oncology No. 1 of the Institute of Clinical Oncology. Academician of the Russian Academy of Sciences and the Russian Academy of Medical Sciences N.N. Trapeznikova