Surgical Technique of Pancreatic Parenchyma Transection-Delayed Approach (PPTDA) in Hepatopancreatoduodenectomy for Hilar Cholangiocarcinoma

Background: The combination of major hepatectomy and pancreatoduodenectomy (PD), that is, a hepatopancreatoduodenectomy (HPD), is the only curative treatment for bile duct cancer with extensive horizontal tumor spread invading both the hepatic hilum and the intrapancreatic bile duct. However, this aggressive procedure remains controversial with regard to the balance between the survival benefit and high risk of mortality and morbidity, especially the risk for postoperative hepatic failure and postoperative pancreatic fistula. Here, we describe the efficacy of a novel modified technique of HPD with delayed division of the pancreatic parenchyma for hilar cholangiocarcinoma, and focus on the surgical technique and the short-term outcomes, with a representative case. Technical Presentation: This new surgical technique involves dissection of the pancreatic parenchyma and relevant mesoduodenum at the final step after dissecting the required parts on the inferior side and superior side of the tumor, enabling excision of the resected specimen. This technique described herein can prevent saponification of the resected surface of the pancreas by dissecting the pancreatic parenchyma toward the latter half of the surgical procedure as much as possible. The results suggest that there may also be a relationship between this technique and the prevention of postoperative pancreatic fistula. Conclusion: This new surgical technique of HPD may be able to prevent postoperative pancreatic fistula by performing intraoperative dissection of the pancreatic parenchyma as late as possible, which in turn, may improve the safety of HPD.