The mesopancreas triangle is a retropancreatic anatomical region critical in pancreatic head cancer surgery. It is defined as a triangular area with the following boundaries:
The term “mesopancreas” was introduced in 2007 by Gockel et al., drawing an analogy to the mesorectum, to describe the retropancreatic perineural and lymphatic tissue dorsal to the pancreas. The specific concept of the mesopancreas triangle was later refined by Adham and Singhirunnusorn in 2012, who provided a detailed anatomical description, characterizing it as an inverted triangle with the boundaries noted above. Their work emphasized its surgical relevance in pancreatic head carcinoma resection, particularly for achieving negative resection margins (R0 resection).
Purpose: TMpE aims to completely remove the mesopancreas, including its neurovascular and lymphatic tissues, during pancreaticoduodenectomy to achieve R0 resection (no residual tumor). The mesopancreas is a common site for R1 resection (microscopic residual tumor), which is associated with higher local recurrence rates (up to 80% within the first postoperative year).
Triangle Operation
Definition: The triangle operation, often associated with TMpE, involves en bloc resection of the mesopancreas within the triangular space defined by the SMA, CA, and PV/SMV, with complete skeletonization of these arteries. It is particularly used for borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) after neoadjuvant therapy.
Controversies and Considerations
The term “mesopancreas” is debated, as it lacks a true fascial boundary, leading some to propose alternative names like “pancreatic head plexus” or “pancreas-major arteries ligament.” However, the term remains widely used for its surgical utility.
Meta-analyisis / Systematic review
👍 PG
↘️ Biliary fistula (2 studies) ↘️ DGE (1 study)
↘️ Multiple surgical complications (1 study) ↘️ LoS (1 study)
↘️ Gastric reflux, pain & abdominal discomfort (1 study)
↘️ Intraabdominal fluide collection (1 study); No difference (2 studies)
Pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) are two surgical techniques used to reconstruct the pancreatic remnant after pancreaticoduodenectomy (Whipple procedure), a surgery for pancreatic head tumors or other periampullary diseases. The choice between PG and PJ remains debated, as each has potential advantages and drawbacks, primarily centered around postoperative complications like pancreatic fistula (POPF), delayed gastric emptying (DGE), and overall morbidity.
Key Differences
Clinical Evidence
Current Practice
Conclusion
Antecolique 🆚 Retrocolic
Meta-analyisis / Systematic review
The choice between antecolic and retrocolic reconstruction after pancreaticoduodenectomy (Whipple procedure) primarily concerns the route of the gastrojejunostomy or duodenojejunostomy, where the stomach or duodenum is anastomosed to the jejunum. This decision impacts postoperative outcomes, particularly the incidence of delayed gastric emptying (DGE), a common complication after this surgery. Below is a concise comparison based on available evidence:
Antecolic Reconstruction
Retrocolic Reconstruction
Clinical Evidence
Current Practice
Conclusion
The Pylorus-Preserving Pancreaticoduodenectomy (PPPD) and the Classic Pancreaticoduodenectomy (Whipple procedure) are surgical approaches used primarily to treat pancreatic head tumors, periampullary tumors, or other conditions requiring resection of the pancreatic head, duodenum, and surrounding structures. Below is a concise comparison of the two procedures based on their key differences, advantages, and disadvantages:
Overview
Key Differences
Advantages
Disadvantages
Clinical Outcomes
Indications
Conclusion
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