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

DISCUSSION

Pancreatoduodenectomy after neoadjuvant chemotherapy is the current treatment in patients with borderline pancreatic ductal adenocarcinoma in the head of the pancreas^1,2,3. 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 adenocarcinoma⁴.

Hackert et al⁵ 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 al⁶ and Schneider et al⁷ 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.