Defining distal splenopancreatectomy by the mesopancreas

Background The implementation of the CRM system for pancreatic head carcinomas (hPDAC) resulted in a dramatic incline of R1 resections, presumably because the mesopancreatic fat (MP) is infiltrated in most of the patients. Therefore, mesopancreatic excision (MPE) has recently been promoted and has demonstrated better local disease control. Patients who suffered from MP infiltration were less likely to receive margin negative resections (R0(CRM-)), fueling the discussion of neoadjuvant downsizing regimes. However, it is unknown to what extent the MP is infiltrated in patients with distal PDACs (dPDAC). The secondary retroperitoneal origin of the pancreatic body/tail reasons enough for the existence of a MP as well. The aim of our study was to analyse MP infiltration and elucidate the influence of resection margin clearance on recurrence and survival in patients with dPDAC. Furthermore, the results were compared to a collective receiving MPE for hPDAC.

Method Clinicopathological and survival data of 302 consecutive patients who underwent surgery for PDAC (n=70 dPDAC and n=232 hPDAC) were evaluated. The CRM evaluation was performed in a standardized fashion by LEEPP. The MP was histopathologically evaluated for cancerous infiltration ([Abb. 1]).

Abb. 1  

Results In 68.6% of all dPDAC patients the MP fat was infiltrated by vital tumor cells. Of all dPDAC patients, R0(CRM-) resections were achieved in 34.3%. The rates of MP infiltration were similar between dPDAC and hPDAC patients (p=0.220), whereas R0(CRM-) resections were achieved more likely in hPDAC patients (p=0.004). Negative MP infiltration status was a significant factor for R0(CRM-) resection status only in hPDAC patients (p=0.001). In follow up analysis of all 281 patients, local recurrence was diagnosed in only 18.9%. Surgical margin clearance in both hPDAC and dPDAC patients was associated with a significant decrease in local recurrence rates (4.5%, p=0.002).

Conclusion While the resection margin status was not affected by the MP status in dPDAC patients, the high MP infiltration rate could yet justify an embryonic derived resection in dPDAC patients. Further multicentric studies on distal PDACs which comprise a greater patient cohort are needed in order to study the relevanz of the mesopancreas in these patients.Treitz fascia and fat infiltration at dorsal resection marginAnatomic preparations (IMV: inferior mesenteric vein, MP: mesopancreas, PT:pancreatic tissue, SA: splenic artery, SV: splenic vein) ([Abb. 2]).

Abb. 2  

Publication History

Article published online:
28 August 2023