Mesopancreas first dissection during pancreaticoduodenal resection: selective approach or paradigm?

BACKGROUND/AIMS: Pancreaticoduodenal resection is the procedure of choice for tumors of the pancreatic head and periampullary region. During pancreaticoduodenectomy resection, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels or intraductal papillary mucinous tumors. This paper aims to reveal the effectiveness of a modified posterior approach pancreaticoduodenectomy in selected indications and to assess the preliminary results. METHODOLOGY: We describe our early approach to the retropancreatic vasculature during pancreaticoduodenal resection by mesopancreas first dissection before any pancreatic or digestive transection. RESULTS: We used this approach in 45 patients. Thirty had hepatic artery anatomic variant. Hepatic artery reconstruction was required in 2 cases. In nine patients with intraductal papillary mucinous tumors the pancreaticoduodenal resection was extended to the body in 6 and totalized in 3 patients. In six patients with adenocarcinoma involving the portomesenteric axis, venous resection and reconstruction was necessary. CONCLUSIONS: Mesopancreas first dissection is useful tool in selected cases of pancreaticoduodenal resection to improve safety and radicality of the procedure.