Mesopancreas excision in pancreatic ductal adenocarcinoma: recurrence patterns - a single-arm descriptive study

Mesopancreas excision has emerged as a critical component of pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC), potentially improving oncological outcomes. However, comprehensive data on recurrence patterns following mesopancreas excision remain limited.

To analyze recurrence patterns in patients with PDAC who underwent pancreaticoduodenectomy with mesopancreas excision at a tertiary care center in Egypt.

This single-arm, single-center, retrospective descriptive cohort study with prospective follow-up included 86 patients with PDAC who underwent pancreaticoduodenectomy with complete mesopancreas excision at Liver and GIT Hospital, Minia University, between February 2018 and February 2024. Patients were followed for a minimum of 24 months, with data collection concluding in February 2026. Data collected included demographics, tumor characteristics, surgical outcomes, pathological findings, and recurrence patterns. The primary outcome was disease recurrence; secondary outcomes included recurrence-free survival (RFS), overall survival (OS), and patterns of recurrence distribution.

Of 86 patients (mean age 58.4 ± 9.2 years, 61.6% male), R0 resection was achieved in 73 patients (84.9%). During follow-up, 52 patients (60.5%) developed recurrence at a median of 11.3 months. Local recurrence occurred in 18 patients (34.6%), distant metastases in 21 patients (40.4%), and combined recurrence in 13 patients (25.0%). The liver was the most common site of distant recurrence, involved in 42.3% of all recurrent cases, followed by lungs (23.1%) and peritoneum (19.2%). Median RFS was 13.2 months (95% CI: 10.8-15.6), and median OS was 18.7 months (95% CI: 16.3-21.1). Lymph node positivity (HR 2.34, p = 0.003), poor differentiation (HR 1.89, p = 0.012), and elevated CA19-9 (HR 1.67, p = 0.028) were independent predictors of recurrence.

Despite complete mesopancreas excision, PDAC demonstrates high recurrence rates with a predominant distant metastatic pattern. Early systemic therapy and intensive surveillance protocols may be warranted for high-risk patients. This study describes the recurrence patterns following complete mesopancreas excision; however, due to the absence of a concurrent control group and the exclusion of patients requiring vascular resection/reconstruction, any superiority in the observed R0 resection rate cannot be directly attributed to the surgical technique itself, and prospective randomized controlled trials remain necessary to establish the oncological benefit of complete mesopancreas excision over standard pancreaticoduodenectomy.