Total Pancreatectomy

Abstract

Pancreatectomies with arterial resections were initially characterized by high postoperative mortality and poor long-term survival as reported by Fortner et al. and then abandoned. The introduction of new efficacious chemotherapy regimens (FOLFIRINOX) along with the extensive experience in venous resection for borderline pancreatic tumors has brought renewed interest in extended pancreatic resection for locally advanced malignancy. The experience needed for performing such complex resections goes beyond pancreatic surgery alone and entails skills in vascular surgery. Reconstructing arterial vessels might need autologous and/or heterologous vascular substitutes which should be available immediately and accurate preoperative planning and simulation on the basis of cross-sectional imaging should be the rule. Resection of the superior mesenteric artery could be seen as one of the most challenging arterial resection at the time of pancreatectomy because of: (1) the frequent presence of an associated venous invasion; (2) the variable degree of tumoral infiltration downward through the mesentery; (3) the necessity of a mesenteric approach and complete mesenteric dissection; (4) the need for reconstructing several jejunal and ileal branches; (5) the high mortality rates (20%) reported so far. In this chapter we will describe step-by-step the surgical technique of our standardized approach for superior mesenteric artery resection during pancreaticoduodenectomy. © International Association of Surgeons, Gastroenterologists and Oncologists 2022.