BACKGROUND: Section of the right posterior attachment (RPA) of the pancreatic head from the adventicia of the superior mesenteric artery (SMA) is the last step of pancreaticoduodenectomy. This procedure might be technically demanding, time consuming and potentially dangerous. A method using a stapler has been proposed to simplify this step of the pancreaticoduodenectomy. METHODS: To evaluate the potential consequences of RPA section using this new method, we used an experimental model of pancreaticoduodenectomy in 20 cadavers. After RPA stapling, the residual areolar tissue located between the staple line and SMA was removed (by sub adventicial dissection) and weighed. This allowed an evaluation of: (1) the theoretical risk of SMA injury and (2) the potential carcinological consequences of using stapling division, in comparison with the lymphadenectomy obtained with the conventional sub-adventicial dissection. RESULTS: A right hepatic artery was accidentaly injured in 10% of cases because of the lack of arterial dissection and arterial anatomy recognition. Forty-three percent of the RPA containing nerves and lymphatics remains in place. Using the stapling technique for RPA division theoretically increases the risk of micro or macroscopically positive margin after surgical resection. CONCLUSION: The result of this human cadaver-based dissection suggests that the use of the mechanical stapling device for final division of the RPA might increase the risk of SMA injury. The risk of vascular injury has been reported in surgical literature and is confirmed by this study. Such results (10% of accidentaly injury) may not be representative in leaving human patients, thanks to the use of a detectable palpable pulse of the SMA. The latter is important in avoiding vascular injury during RPA division. This study also shows that this new technique may increase the risk of incomplete tumor resection.
BACKGROUND: Section of the right posterior attachment (RPA) of the pancreatic head from the adventicia of the superior mesenteric artery (SMA) is the last step of pancreaticoduodenectomy. This procedure might be technically demanding, time consuming and potentially dangerous. A method using a stapler has been proposed to simplify this step of the pancreaticoduodenectomy. METHODS: To evaluate the potential consequences of RPA section using this new method, we used an experimental model of pancreaticoduodenectomy in 20 cadavers. After RPA stapling, the residual areolar tissue located between the staple line and SMA was removed (by sub adventicial dissection) and weighed. This allowed an evaluation of: (1) the theoretical risk of SMA injury and (2) the potential carcinological consequences of using stapling division, in comparison with the lymphadenectomy obtained with the conventional sub-adventicial dissection. RESULTS: A right hepatic artery was accidentaly injured in 10% of cases because of the lack of arterial dissection and arterial anatomy recognition. Forty-three percent of the RPA containing nerves and lymphatics remains in place. Using the stapling technique for RPA division theoretically increases the risk of micro or macroscopically positive margin after surgical resection. CONCLUSION: The result of this human cadaver-based dissection suggests that the use of the mechanical stapling device for final division of the RPA might increase the risk of SMA injury. The risk of vascular injury has been reported in surgical literature and is confirmed by this study. Such results (10% of accidentaly injury) may not be representative in leaving humanpatients, thanks to the use of a detectable palpable pulse of the SMA. The latter is important in avoiding vascular injury during RPA division. This study also shows that this new technique may increase the risk of incomplete tumor resection.
Authors: E Ducasse; F Roy; J Chevalier; D Massouille; M Smith; F Speziale; P Fiorani; P Puppinck Journal: J Vasc Surg Date: 2004-04 Impact factor: 4.268
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Authors: Charles J Yeo; John L Cameron; Keith D Lillemoe; Taylor A Sohn; Kurtis A Campbell; Patricia K Sauter; JoAnn Coleman; Ross A Abrams; Ralph H Hruban Journal: Ann Surg Date: 2002-09 Impact factor: 12.969
Authors: Matthew H G Katz; Huamin Wang; Aparna Balachandran; Priya Bhosale; Christopher H Crane; Xuemei Wang; Peter W T Pisters; Jeffrey E Lee; Jean-Nicolas Vauthey; Eddie K Abdalla; Robert Wolff; James Abbruzzese; Gauri Varadhachary; Xavier Chopin-Laly; Chusilp Charnsangavej; Jason B Fleming Journal: J Gastrointest Surg Date: 2011-11-08 Impact factor: 3.452
Authors: Matthew H G Katz; Nipun B Merchant; Steven Brower; Megan Branda; Mitchell C Posner; L William Traverso; Ross A Abrams; Vincent J Picozzi; Peter W T Pisters Journal: Ann Surg Oncol Date: 2010-09-01 Impact factor: 5.344
Authors: Margaret A Tempero; J Pablo Arnoletti; Stephen W Behrman; Edgar Ben-Josef; Al B Benson; Ephraim S Casper; Steven J Cohen; Brian Czito; Joshua D I Ellenhorn; William G Hawkins; Joseph Herman; John P Hoffman; Andrew Ko; Srinadh Komanduri; Albert Koong; Wen Wee Ma; Mokenge P Malafa; Nipun B Merchant; Sean J Mulvihill; Peter Muscarella; Eric K Nakakura; Jorge Obando; Martha B Pitman; Aaron R Sasson; Anitra Tally; Sarah P Thayer; Samuel Whiting; Robert A Wolff; Brian M Wolpin; Deborah A Freedman-Cass; Dorothy A Shead Journal: J Natl Compr Canc Netw Date: 2012-06-01 Impact factor: 11.908