title: Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer.
abstract: BACKGROUND
  A superior mesenteric artery (SMA)-first approach has been considered to be an efficient technique in pancreaticoduodenectomy when the SMA is a factor of borderline resectable pancreatic head cancer (BRPHC). However, this excellent procedure has limitations in terms of tumor resection with an intact coverage including the pancreatic tumor and the tumor-draining lymphovascular systems and the ability to achieve a complete regional lymphadenectomy.
  
  
  METHODS
  A modified mesenteric plane procedure has been developed that provides improved regional lymphadenectomy and permits adjustment of the surgical approach, which is based on the direction of the tumor infiltration.
  
  
  RESULTS
  Of 55 patients taken to surgery, 19 had peritoneal dissemination and/or liver metastasis at staging laparoscopy, and the procedure revealed tumor infiltration to the SMA and/or hepatic artery (HA) in 4 patients. Finally, 32 patients with BRPHC have undergone the procedure between April 2009 and June 2015. Twenty-four of 32 patients (75.0%) had negative resection margins, and the median number of lymph nodes harvested was 34. Lymph nodes around the SMA tested positive for metastasis in 13 patients (40.6%), and those around the HA tested positive for metastasis in 7 patients (21.9%). Complications occurred in 14 patients (43.7%), with no perioperative mortality. Overall survival rates were 65.3% at 1 year and 35.2% at 3 years.
  
  
  CONCLUSIONS
  Short-term results with the procedure may encourage surgical management for BRPHC.
authors.affiliation: Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan. Electronic address: batayan5@med.shimane-u.ac.jp.
authors.forename: Y
authors.initials: Y
authors.lastname: Kawabata
authors.affiliation: Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Tanaka
authors.affiliation: Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
authors.forename: N
authors.initials: N
authors.lastname: Ishikawa
authors.affiliation: Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
authors.forename: H
authors.initials: H
authors.lastname: Hayashi
authors.affiliation: Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
authors.forename: Y
authors.initials: Y
authors.lastname: Tajima
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods; D008297:Male; D017538:Mesenteric Artery, Superior / Q000601:surgery; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome
keywords: Artery-first approach; Borderline resectable pancreatic cancer; Meso-pancreatoduodenum; Mesopancreatic plane surgery; Pancreaticoduodenectomy