title: The infracolic approach to pancreatoduodenectomy for large pancreatic head tumours invading the colon.
abstract: BACKGROUND
  Tumours arising from the head of the pancreas can invade both the proximal transverse colon and its mesocolon. At laparoscopy, this may be considered a contraindication to proceeding to pancreatoduodenectomy. However, in some patients, pancreatoduodenectomy can still be performed with an R0 resection using an en-bloc resection technique by an infracolic approach.
  
  
  METHODS
  This technique relies on the infracolic control of the superior mesenteric vein (SMV) and is based on the presence of a normal fat cuff around the superior mesenteric artery (SMA) on pre-operative imaging. The dissection is maintained along the adventitial plane of the SMA. Pancreatoduodenectomy is performed in conjunction with en-bloc resection of the transverse colon. In the event of tumour invading the SMV, this is also resected en-bloc with the pancreatic head and transverse colon. We reviewed all such cases performed at our institution between April 2004 and April 2009.
  
  
  RESULTS
  This technique was attempted in eleven patients. In two patients, the procedure had to be abandoned because of unexpected SMA encasement by tumour. In the remaining nine patients this procedure was carried out successfully. In this paper, the infracolic approach to pancreatoduodenectomy, and the associated limitations, are described in detail.
  
  
  CONCLUSIONS
  The infracolic technique may be used to deal with large pancreatic head tumours and all pancreatic surgeons should be familiar with this technique. In the absence of metastatic disease, large pancreatic head tumours involving the colon can be resected en-bloc with the pancreatic head, as long as the SMA is not encased by the tumour.
authors.affiliation: Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of Sydney, St Leonards, NSW 2065, Australia.
authors.forename: R
authors.initials: R
authors.lastname: Alvarado-Bachmann
authors.forename: J
authors.initials: J
authors.lastname: Choi
authors.forename: S
authors.initials: S
authors.lastname: Gananadha
authors.forename: T J
authors.initials: TJ
authors.lastname: Hugh
authors.forename: J S
authors.initials: JS
authors.lastname: Samra
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary / Q000601:surgery*; D000328:Adult; D000368:Aged; D018278:Carcinoma, Neuroendocrine / Q000556:secondary / Q000601:surgery*; D003082:Colectomy; D003110:Colonic Neoplasms / Q000556:secondary / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008638:Mesenteric Arteries / Q000601:surgery; D008642:Mesenteric Veins / Q000601:surgery; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome