[Pancreatoduodenectomy--past, present and future]

Area of Science:

• Gastroenterology and Surgical Oncology
• Digestive Surgery and Surgical Innovation

Background:

• Pancreaticoduodenectomy, historically complex and high-risk, has evolved into a standard procedure.
• Significant reductions in postoperative mortality (from >30% to <5%) and severe complications are now observed.

Discussion:

• Technical advancements, including the posterior and artery-first approaches, facilitate en-bloc resection of major vessels.
• Complete mesopancreas excision, aided by the posterior approach, is crucial for addressing local recurrence in pancreatic head adenocarcinoma.
• Reconstruction methods (pancreaticogastrostomy vs. pancreaticojejunostomy) show variable results, largely dependent on surgical team expertise.

Key Insights:

• Improved surgical techniques and specialized care in tertiary centers have dramatically enhanced pancreaticoduodenectomy outcomes.
• The posterior approach and complete mesopancreas excision are key innovations for improving local control and survival.
• Surgical team expertise is a critical factor in minimizing postoperative pancreatic fistula rates.

Outlook:

• Future research should focus on the clinical impact of total mesopancreas excision on resection margins, local recurrence, and long-term survival.
• Further investigation into optimizing reconstruction techniques post-pancreaticoduodenectomy is warranted.
• Continued refinement of surgical strategies is essential for advancing pancreatic cancer treatment.