Ryota Matsuki1, Masanori Sugiyama2, Masaharu Kogure1, Masaaki Yokoyama3, Tetsuya Nakazato1, Yutaka Suzuki1, Toshiyuki Mori1, Nobutsugu Abe1, Yoshihiro Sakamoto4. 1. Department of Surgery, Kyorin University, School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan. 2. Tokyo Rosai Hospital, 4-13-21, Ohmori-Minami, Ohta-ku, Tokyo, 143-0013, Japan. 3. Kosei Hospital, 2-25-1 Wada, Suginami-ku, Tokyo, 166-0012, Japan. 4. Department of Surgery, Kyorin University, School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan. yosakamo@ks.kyorin-u.ac.jp.
Abstract
BACKGROUND: Excision of the mesopancreas with lymphadenectomy is an important component of pancreatoduodenectomy. However, the optimal extent of lymphadenectomy remains unclear. Furthermore, accurate description of the mesopancreatic lymphatic pathways is difficult, probably because of the complex anatomy. Intestinal derotation simplifies the anatomy and facilitates both examination of lymphatic flow and the surgical procedure. The aim of this study was to evaluate lymphatic flow in the mesopancreas using indocyanine green fluorescence imaging with an intestinal derotation technique, and to clarify the optimal extent of mesopancreas excision and lymphadenectomy in pancreatoduodenectomy. METHODS: Indocyanine green solution (2.5 × 10-3 mg) was injected into the pancreatic head parenchyma. After intestinal derotation, the spread of indocyanine green was observed using near-infrared imaging. RESULTS: Participants comprised 10 patients who underwent pancreatoduodenectomy for periampullary neoplasms. With indocyanine green fluorescence imaging, 9 of the 10 patients showed lymphatic flow from the pancreatic head to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery (but not via the second and more distant arteries), with eventual drainage into the paraaortic region. CONCLUSIONS: Lymphatic pathways from the pancreatic head were connected to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery. Excision of the mesopancreas with the inferior pancreaticoduodenal artery and first jejunal artery while preserving the second or more distant arteries appears optimal in pancreatoduodenectomy for periampullary malignancies.
BACKGROUND: Excision of the mesopancreas with lymphadenectomy is an important component of pancreatoduodenectomy. However, the optimal extent of lymphadenectomy remains unclear. Furthermore, accurate description of the mesopancreatic lymphatic pathways is difficult, probably because of the complex anatomy. Intestinal derotation simplifies the anatomy and facilitates both examination of lymphatic flow and the surgical procedure. The aim of this study was to evaluate lymphatic flow in the mesopancreas using indocyanine green fluorescence imaging with an intestinal derotation technique, and to clarify the optimal extent of mesopancreas excision and lymphadenectomy in pancreatoduodenectomy. METHODS:Indocyanine green solution (2.5 × 10-3 mg) was injected into the pancreatic head parenchyma. After intestinal derotation, the spread of indocyanine green was observed using near-infrared imaging. RESULTS:Participants comprised 10 patients who underwent pancreatoduodenectomy for periampullary neoplasms. With indocyanine green fluorescence imaging, 9 of the 10 patients showed lymphatic flow from the pancreatic head to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery (but not via the second and more distant arteries), with eventual drainage into the paraaortic region. CONCLUSIONS: Lymphatic pathways from the pancreatic head were connected to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery. Excision of the mesopancreas with the inferior pancreaticoduodenal artery and first jejunal artery while preserving the second or more distant arteries appears optimal in pancreatoduodenectomy for periampullary malignancies.
Entities:
Keywords:
Indocyanine green fluorescence imaging; Lymphatic pathway; Mesopancreas; Pancreaticoduodenectomy