Abstract
Background
The ‘SMA-first’ (P-SMA) pancreatoduodenectomy (PD) allows dissection directly on the right lateral aspect of superior mesenteric artery (SMA) which may decrease circumferential resection margin (CRM) positivity. This comparative study between standard PD (sPD) and P-SMA approach was planned focusing on CRM involvement.
Methods
This was a prospective study comparing consecutive patients with resectable periampullary cancers (PACA) undergoing PD using the standard or P-SMA approach. The perioperative outcomes and the CRM positivity rates (specimens analysed according to the standardized Leeds pathology protocol (LEEPP)) were compared.
Results
Overall, 39 patients (28 men; mean age 54 years; sPD 21, P-SMA 18) were included. Both groups were comparable with regard to demographic/tumour characteristics and perioperative outcomes. The P-SMA technique was significantly faster (321.1 ± 54.0 vs. 357.6 ± 55.8 min; p = 0.05). Though the mean tumour size (2.2 vs. 2.1 cm; p = 0.84) and T stage (T2 and T3) distribution were similar in both groups, lymph node yield was significantly higher in the P-SMA group (10.7 vs. 5.95; p = 0.001; mean 8 (2–21)). Though CRM positivity (margin <1 mm) occurred in 8 (21.1%), we did not find the P-SMA PD to yield significantly lower CRM positivity rates compared to the sPD (3/17 (17.6%) vs. 5/21(23.8%); p = 0.71). At a median follow-up of 28 months, fewer patients in the P-SMA PD group developed recurrence (2/15 vs. 5/19; p = 0.3) or died (3/15 vs. 7/19; p = 0.19), though this difference was not significant.
Conclusions
In patients with resectable PACA, P-SMA PD was significantly faster and yielded higher lymph node counts in the specimen but did not lower the rate of CRM positivity as determined by the LEEPP.
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References
Yekebas EF, Bogoevski D, Cataldegirmen G, Kunze C, Marx A, Vashist YK, et al. En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg. 2008;247:300–9.
Tseng JF, Tamm EP, Lee JE, Pisters PW, Evans DB. Venous resection in pancreatic cancer surgery. Best Pract Res Clin Gastroenterol. 2006;20:349–64.
Martin 2nd RC, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA. Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes. Arch Surg. 2009;144:154–9.
Pessaux P, Varma D, Arnaud JP. Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg. 2006;10:607–11.
Varty PP, Yamamoto H, Farges O, Belghiti J, Sauvanet A. Early retropancreatic dissection during pancreaticoduodenectomy. Am J Surg. 2005;189:488–91.
Popescu I, David L, Dumitra AM, Dorobantu B. The posterior approach in pancreaticoduodenectomy: preliminary results. Hepato-Gastroenterology. 2007;54:921–6.
Chang DK, Johns AL, Merrett ND, Gill AJ, Colvin EK, Scarlett CJ, et al. Margin clearance and outcome in resected pancreatic cancer. J Clin Oncol. 2009;27:2855–62.
Hatzaras I, George N, Muscarella P, Melvin WS, Ellison EC, Bloomston M. Predictors of survival in periampullary cancers following pancreaticoduodenectomy. Ann Surg Oncol. 2010;17:991–7.
Menon KV, Gomez D, Smith AM, Anthoney A, Verbeke CS. Impact of margin status on survival following pancreatoduodenectomy for cancer: the Leeds Pathology Protocol (LEEPP). HPB. 2009;11:18–24.
Verbeke CS, Leitch D, Menon KV, McMahon MJ, Guillou PJ, Anthoney A. Redefining the R1 resection in pancreatic cancer. Br J Surg. 2006;93:1232–7.
Schlitter AM, Esposito I. Definition of microscopic tumor clearance (R0) in pancreatic cancer resections. Cancers. 2010;2(4):2001–10.
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5(6):649–55.
Varadhachary GR, Tamm EP, Abbruzzese JL, Xiong HQ, Crane CH, Wang H, et al. Borderline resectable pancreatic cancer:definitions, management, and role of preoperative therapy. Ann Surg Oncol. 2006;13(8):1035–46.
Gangavatiker R, Pal S, Javed A, Dash NR, Sahni P, Chattopadhyay TK. Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial. J Gastrointest Surg. 2011;15(5):843–52.
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007a;142(5):761–8.
Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007b;142(1):20–5.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, International Study Group on Pancreatic Fistula Definition, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.
Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226:248–57.
Dumitrascu T, David L, Popescu I. Posterior versus standard approach in pancreatoduodenectomy: a case-match study. Langenbeck's Arch Surg. 2010;395:677–84.
Inoue Y, Saiura A, Yoshioka R, Ono Y, Takahashi M, Arita J, et al. Pancreatoduodenectomy with systematic mesopancreas dissection using a supracolic anterior artery-first approach. Ann Surg. 2015;262(6):1092–101.
Weitz J, Kienle P, Schmidt J, Friess H, Buchler MW. Portal vein resection for advanced pancreatic head cancer. J Am Coll Surg. 2007;204:712–6.
Verbeke CS. Resection margins and R1 rates in pancreatic cancer—are we there yet? Histopathology. 2008;52:787–96.
Esposito I, Kleeff J, Bergmann F, Reiser C, Herpel E, Friess H, et al. Most pancreatic cancer resections are R1 resections. Ann Surg Oncol. 2008;15:1651–60.
Rau BM, Moritz K, Schuschan S, Alsfasser G, Prall F, Klar E. R1 resection in pancreatic cancer has significant impact on long-term outcome in standardized pathology modified for routine use. Surgery. 2012;152:S103–11.
Shrikhande SV, Barreto SG, Bodhankar YD, Suradkar K, Shetty G, Hawaldar R, et al. Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes. Langenbeck's Arch Surg. 2011;396:1205–12.
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All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Informed consent was obtained from all individual participants included in the study.
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Synopsis: A prospective comparative study designed to address whether the posterior SMA first approach to pancreatoduodenectomy is more efficacious than the standard pancreatoduodenectomy as far as circumferential resection margins are concerned in patients with resectable periampullary tumours.
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Pal, S., George, J., Singh, A.N. et al. Posterior Superior Mesenteric Artery (SMA) First Approach vs. Standard Pancreaticoduodenectomy in Patients with Resectable Periampullary Cancers: a Prospective Comparison Focusing on Circumferential Resection Margins. J Gastrointest Canc 49, 252–259 (2018). https://doi.org/10.1007/s12029-017-9933-x
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DOI: https://doi.org/10.1007/s12029-017-9933-x