Strategies for the treatment of invasive ductal carcinoma of the pancreas and how to achieve zero mortality for pancreaticoduodenectomy

Although various therapeutic modalities are available for carcinoma of the pancreas, "curative resection" is the most important. Thus, the aim of surgery for carcinoma of the pancreas is local complete resection of the carcinoma. Carcinoma of the head of the pancreas invades through the pancreatic parenchyma, following the arteries, veins, and especially nerves between the parenchyma and fusion fascia, and then spreads horizontally toward the superior mesenteric artery or celiac axis. We suggest techniques for resection of the extrapancreatic nerve plexus in the head of the pancreas during a Whipple procedure for carcinoma of the pancreas, from the perspective of surgical anatomy and pathology, to achieve "curative resection". We suggest that: (1) en-bloc resection of the right side of the superior nerve plexus and the first and second nerve of the pancreatic head should be performed. With this technique, it is possible to avoid cutting these nerves. It is easy to perform this procedure, as follows. First, the superior mesenteric artery and vein are encircled with tape. Next, the superior mesenteric artery should be moved to the right side of the superior mesenteric vein under this vein. In addition, (2) the entire cut end of the nerve plexus should be investigated during the operation, using frozen specimens, and confirmed to be negative for cancer. If the cut end is positive for cancer, additional resection of the nerve plexus should be performed to achieve curative resection. It is impossible to completely determine whether the cut end of the nerve plexus is positive or negative for carcinoma after surgery, because the cut end is long and some specimens are deformed by formalin fixation; thus, it is difficult to identify the true surgical cut end. With regard to reconstruction, we perform a modified Child method with pancreaticojejunostomy (end-to-side), choledochoduodenostomy (also end-to-side), and gastrojejunostomy with Braun's anastomosis. The greater omentum is set around the pancreaticojejunostomy to prevent pancreatic juice from spreading in the abdomen. Careful management of the intraabdominal drainage tubes after the operation is crucial. With the operative procedure and postoperative controls described above, operative mortality was zero in 114 consecutive patients in our series who underwent pancreaticoduodenectomy.