International consensus on mesopancreas and total mesopancreas excision (MESODELPHI)

Background: The absence of a standardized anatomical definition of the mesopancreas has precluded meaningful comparison across studies on total mesopancreas excision (TMpE). The MESODELPHI consensus aimed to establish international agreement on its definition, surgical boundaries, and clinical role in pancreatic cancer management. Methods: An international modified Delphi process, informed by a prior systematic review, included 43 pancreatic surgery experts from 20 countries across two rounds. Statements were rated on a 5-point Likert scale, with consensus predefined as ≥80% agreement. Results: Consensus was achieved for 19 of 27 statements in Round 1. All participants (100%) agreed the mesopancreas is a retropancreatic compartment of lymphatic, neurovascular, and adipose tissue, with 97.7% agreeing on its anatomical boundaries. Both artery-first and mesenteric-first approaches were considered feasible surgical strategies (97.7%). Most experts (81.4%) favored TMpE over conventional pancreatoduodenectomy for curative-intent surgery. There was strong agreement that further investigation into the impact of TMpE on survival outcomes is necessary (97.7%), and that education on mesopancreas anatomy should be integrated into surgical training programs (93.0%). Conclusions: This consensus provides the first standardized definition of the mesopancreas, recommends “mesopancreas” as the unifying term over alternative nomenclature, and offers an international framework to guide future research and surgical practice.