The Mesopancreas: an Anatomical Reality or a Hazardous Assimilation?

Pancreatic adenocarcinoma is one of the leading causes of cancer death with > 100 000 death in Europe according to WHO report. According to the cancer statistics report of American Cancer Society, the number of annual new cases is estimated to 43 920 with 37 390 deaths. More over mortality of pancreatic cancer is increasing (8,1% in 1981 vs 9,7% in 2009) while the mortality from other cancers in decreased by 15% since mid-1990.Indeed, pancreatic cancer has a worse prognosis because:Diagnosis at advanced stage: according to the US Surveillance Epidemiology and End Results Cancer Statistics Review only 15% to 20% of patients are eligible for radical surgery while 53% had synchronous metastasis and 25% has locally advanced tumour at time of diagnosis. Failure to access surgery: A report from USA in shows an obvious underuse of surgery and 38,2% of patients with early stage pancreatic adenocarcinoma failed to undergo surgery without any identifiable cause.Chemotherapy, radiotherapy: Perioepartive chemotherapy or radiotherapy has weak impact on survival. Pancreatic adenocarcinoma remain one of the chemoresistant cancer.Borderline surgical resection: Standardisation of pathological examination showed high rate of microscopic margin invasion (R1) resection in up to 80% of cases.Surgery remains the only hope of optimal treatment and cure. Technical advances were made with surgical standardization aiming to obtain negative margin with more radical resection.Indeed, total mesopancreas excision was recently introduced and developed by pancreatic surgery centers. This retroportal lymphocellular space is the most frequent site of extra pancreatic invasion and is the main site of R1 resection.Standardization of retroportal clearance by the technique of total mesopancreas excision allows a higher rate of R0 resection as well as a higher number of lymph node resection. This directly impact overall survival and disease free survival.Centralisation of pancreatic surgery in high volume tertiary referral centres allowed standardization of both surgical resection and pathological examination. This represents a corner stone and a major advance in the treatment of pancreatic adenocarcinoma with a direct impact on patient outcome.