First jejunal vein oriented mesenteric excision for pancreatoduodenectomy

Background: Dissection of the pancreatic head from the superior mesenteric vein (SMV) and artery (SMA) are major points of bleeding in pancreaticoduodenectomy (PD) because of congestion of the pancreatic head. The "SMA-first" approach, which involves ligating the artery from the SMA first, can be used to solve this problem. However, the SMA-first approach has problematic anatomical issues. We applied a new surgical approach, first jejunal vein oriented mesenteric excision (FME), for PD. This study aimed to clarify the effect of FME on reduction of bleeding during PD. Methods: The jejunal vein, the most frequent source of bleeding during dissection of the mesoduodenum, was identified at the beginning of dissection of the pancreatic head from SMV and SMA. The mesoduodenum, including plural IPDAs, was completely divided before dissection of the pancreatic head from the SMV. The perioperative outcomes of two groups, patients who underwent FME-based PD and patients who underwent standard PD, were compared. Additionally, the spatial characteristics of the first jejunal vein (FJV) were analyzed using computed tomography. Results: FME-based PD significantly reduced intraoperative blood loss compared with conventional PD (569 vs. 1094 ml, P = 0.0315). The median distance of the FJV was 0 mm from the middle colic artery and 0 mm from the third portion of the duodenum. The FJV was posterior to the SMA in the majority of the patients but was anterior to the SMA in 16.7 % of patients. Conclusions: FME is useful for reducing intraoperative bleeding.