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COMBINED VENOUS AND ARTERIAL RECONSTRUCTION IN THE TRIANGLE AREA AFTER TOTAL PANCREATODUODENECTOMY

RECONSTRUÇÃO VENOSA E ARTERIAL COMBINADA NA ÁREA DO TRIÂNGULO APÓS PANCREATODUODENECTOMIA TOTAL

DESCRITORES:
Pâncreas; Adenocarcinoma; Pancreaticoduodenectomia; Veias Mesentéricas; Artérias Mesentéricas; Veia porta; Artéria Hepática.

HEADINGS:
Pancreas; Adenocarcinoma; Pancreaticoduodenectomy; Mesenteric Veins; Mesenteric Arteries; Portal Vein; Hepatic Artery.

A 40-year-old woman presented with ductal adenocarcinoma in the body of the pancreas, involving the celiac trunk (CT) completely (encasement), superior mesenteric artery (SMA) (>180o), and superior mesenteric vein (SMV)/portal vein (PV) (>180o). After four cycles of neoadjuvant chemotherapy (FOLFIRINOX), she underwent a total pancreatectomy, lymphadenectomy, total mesopancreas excision11. Jones RP, Psarelli EE, Jackson R, Ghaneh P, Halloran CM, Palmer DH, et al. Patterns of recurrence after resection of pancreatic ductal adenocarcinoma. A secondary analysis of the ESPAC-4 randomized adjuvant chemotherapy trial. JAMA Surg 2019;154: 1038-48. doi: 10.1001/jamasurg.2019.3337.
https://doi.org/10.1001/jamasurg.2019.33...
, and resection of the CT, SMA, and PV/SMV. The stump of the CT was anastomosed to the proper hepatic artery (PHA). A termino-terminal anastomosis was performed in the SMA, and the SMV was anastomosed to the PV. After total mesopancreas excision, the triangle operation is observed (Figure 1a and b) after resection and reconstruction of the three components of the triangle.

Figure 1 -
A and B. Triangle operation with resection and reconstruction of the three components. PV, portal vein; SMV, superior mesenteric vein; PHA, proper hepatic artery; CT, celiac trunk; SMA, superior mesenteric artery.

DISCUSSION

Pancreatoduodenectomy after neoadjuvant chemotherapy is the current treatment in patients with borderline pancreatic ductal adenocarcinoma in the head of the pancreas11. Jones RP, Psarelli EE, Jackson R, Ghaneh P, Halloran CM, Palmer DH, et al. Patterns of recurrence after resection of pancreatic ductal adenocarcinoma. A secondary analysis of the ESPAC-4 randomized adjuvant chemotherapy trial. JAMA Surg 2019;154: 1038-48. doi: 10.1001/jamasurg.2019.3337.
https://doi.org/10.1001/jamasurg.2019.33...
,22. Kalil-Filho FA, Pinto JSP, Borsato EP, Kuretzki CH, Ariede BL, Mathias JEF, Campos ACL, Malafaia O. Multiprofessional electronic protocol for digestive surgery validation. Arq Bras Cir Dig. 2021;34(2):e1583. doi: 10.1590/0102-672020210002e1583.
https://doi.org/10.1590/0102-67202021000...
,33. Torres OJM, Fernandes ESM, Vasques RR, Waechter FL, Amaral PCG, Rezende MB, Costa RM, Montagnini AL. Pancreatoduodenectomy: Brazilian practice patterns. Arq Bras Cir Dig 2017;30(3):190-196. doi: 10.1590/0102-6720201700030007
https://doi.org/10.1590/0102-67202017000...
. The total mesopancreas excision concept includes the resection of the lymphatic structures on the right side of the SMA and along the neuronal plexus of the pancreatic head. Complete clearance of this retroperitoneal area may increase the R0 resection rate in patients with adenocarcinoma in the head of the pancreas. This area is an important location of perineural infiltration of tumor cells in patients with pancreatic ductal adenocarcinoma44. Fernandes ESM, Strobel O, Girão C, Moraes-Junior JMA, Torres OJM. What do surgeons need to know about the mesopancreas. Langenbecks Arch Surg. 2021. doi: 10.1007/s00423-021-02211-y. Epub ahead of print. PMID: 34117891.
https://doi.org/10.1007/s00423-021-02211...
.

Hackert et al55. Hackert T, Strobel O, Michalski CW, Mihaljevic AL, Mehrabi A, Müller-Stich B, Berchtold C, Ulrich A, Büchler MW. The TRIANGLE operation - radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study. HPB (Oxford). 2017;19(11):1001-1007. doi: 10.1016/j.hpb.2017.07.007.
https://doi.org/10.1016/j.hpb.2017.07.00...
described the term “triangle operation” as a new surgical technique for patients with locally advanced pancreatic ductal adenocarcinoma and stable disease following neoadjuvant therapy. This area is defined by SMV/PV, celiac axis/common hepatic artery, and SMA, representing the typical view after completion of the resection. However, according to the definition of the authors, the procedure should be performed without arterial resection. Recently, Loss et al66. Loos M, Kester T, Klaiber U, Mihaljevic AL, Mehrabi A, Müller-Stich BM, Diener MK, Schneider MA, Berchtold C, Hinz U, Feisst M, Strobel O, Hackert T, Büchler MW. Arterial Resection in Pancreatic Cancer Surgery: Effective After a Learning Curve. Ann Surg. 2020 Jun 12. doi: 10.1097/SLA.0000000000004054. Epub ahead of print. PMID: 33055587.
https://doi.org/10.1097/SLA.000000000000...
and Schneider et al77. Schneider M, Hackert T, Strobel O, Büchler MW. Technical advances in surgery for pancreatic cancer. Br J Surg. 2021;108(7):777-785. doi: 10.1093/bjs/znab133. PMID: 34046668.
https://doi.org/10.1093/bjs/znab133...
observed that arterial resection is effective in patients with locally advanced pancreatic cancer after neoadjuvant chemotherapy, with better long-term survival than with palliative treatment. However, this procedure should be performed in experienced pancreatic centers. After neoadjuvant chemotherapy and centers with expertise in pancreatic resection, arterial resection is perfectly possible with acceptable morbidity and mortality.

REFERENCES

  • 1
    Jones RP, Psarelli EE, Jackson R, Ghaneh P, Halloran CM, Palmer DH, et al. Patterns of recurrence after resection of pancreatic ductal adenocarcinoma. A secondary analysis of the ESPAC-4 randomized adjuvant chemotherapy trial. JAMA Surg 2019;154: 1038-48. doi: 10.1001/jamasurg.2019.3337.
    » https://doi.org/10.1001/jamasurg.2019.3337
  • 2
    Kalil-Filho FA, Pinto JSP, Borsato EP, Kuretzki CH, Ariede BL, Mathias JEF, Campos ACL, Malafaia O. Multiprofessional electronic protocol for digestive surgery validation. Arq Bras Cir Dig. 2021;34(2):e1583. doi: 10.1590/0102-672020210002e1583.
    » https://doi.org/10.1590/0102-672020210002e1583
  • 3
    Torres OJM, Fernandes ESM, Vasques RR, Waechter FL, Amaral PCG, Rezende MB, Costa RM, Montagnini AL. Pancreatoduodenectomy: Brazilian practice patterns. Arq Bras Cir Dig 2017;30(3):190-196. doi: 10.1590/0102-6720201700030007
    » https://doi.org/10.1590/0102-672020170003000
  • 4
    Fernandes ESM, Strobel O, Girão C, Moraes-Junior JMA, Torres OJM. What do surgeons need to know about the mesopancreas. Langenbecks Arch Surg. 2021. doi: 10.1007/s00423-021-02211-y. Epub ahead of print. PMID: 34117891.
    » https://doi.org/10.1007/s00423-021-02211-y
  • 5
    Hackert T, Strobel O, Michalski CW, Mihaljevic AL, Mehrabi A, Müller-Stich B, Berchtold C, Ulrich A, Büchler MW. The TRIANGLE operation - radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study. HPB (Oxford). 2017;19(11):1001-1007. doi: 10.1016/j.hpb.2017.07.007.
    » https://doi.org/10.1016/j.hpb.2017.07.007
  • 6
    Loos M, Kester T, Klaiber U, Mihaljevic AL, Mehrabi A, Müller-Stich BM, Diener MK, Schneider MA, Berchtold C, Hinz U, Feisst M, Strobel O, Hackert T, Büchler MW. Arterial Resection in Pancreatic Cancer Surgery: Effective After a Learning Curve. Ann Surg. 2020 Jun 12. doi: 10.1097/SLA.0000000000004054. Epub ahead of print. PMID: 33055587.
    » https://doi.org/10.1097/SLA.0000000000004054
  • 7
    Schneider M, Hackert T, Strobel O, Büchler MW. Technical advances in surgery for pancreatic cancer. Br J Surg. 2021;108(7):777-785. doi: 10.1093/bjs/znab133. PMID: 34046668.
    » https://doi.org/10.1093/bjs/znab133
  • 1
    How to cite this article: Fernandes ESM, Moraes-Junior JMA, Vasques RR, Belotto M, Torres OJM. ABCD Arq Bras Cir Dig. 2022;35:e1643. https://doi.org/10.1590/0102-672020210002e1643
  • Financial source: none.

Publication Dates

  • Publication in this collection
    17 June 2022
  • Date of issue
    2022

History

  • Received
    22 Dec 2021
  • Accepted
    25 Jan 2022
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