Artery first approach to pancreatoduodenectomy: current status

Pandanaboyana, Sanjay; Bell, R.; Windsor, John A.

doi:10.1111/ans.13249

Cited by 17 publications

(17 citation statements)

References 75 publications

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“…However, the long-term survival of these patients remains unsatisfactory, with a median survival time of 10–28 months and a 5-year overall survival of 6–30% [1–5]. In recent years, new surgical approaches for resectable or borderline resectable pancreatic cancer, including the artery-first approach [6–9], superior mesenteric vein/portal vein resection and reconstruction [10–13], intraoperative radiotherapy [14, 15] and preoperative chemo-radiotherapy [16–18], have been increasingly applied to pancreaticoduodenectomy to achieve R0 resection for carcinomas of the head of the pancreas. Despite the highly aggressive nature of the disease and early regional lymph node metastasis, adenocarcinomas of the body and tail of the pancreas have attracted significantly less clinical attention.…”

Section: Introductionmentioning

confidence: 99%

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

Cao

et al. 2017

BMC Surg

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BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS), first reported by Strasberg in 2003, has attracted increasing attention in the treatment of left-sided pancreatic cancer. The limited number of cases eligible for RAMPS makes it difficult to perform any prospective randomized trial of RAMPS versus the standard procedure. Therefore, we performed this systemic review and meta-analysis of the current data to clarify the role of the RAMPS procedure.MethodsA literature search was performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing RAMPS with the standard procedure were included in this meta-analysis. R0 resection rate, recurrence rate at the end of the follow-up, overall survival (OS) and disease-free survival (DFS) were measured as primary outcomes. Revman 5.3 was used to perform the analysis.ResultsSix retrospective cohort studies with a total number of 378 patients were included in our analysis. Meta-analysis revealed that RAMPS was correlated with higher R0 resection rates [Odds Ratio (OR) 95% confidence interval (CI), 2.19 (1.16 ~ 4.13); P = 0.02] and successful harvest of more lymph nodes [weighted mean difference (WMD) 95% CI, 7.06 (4.52 ~ 9.60); P < 0.01] compared with the standard procedure. However, no statistically significant difference was found between the procedures with respect to recurrence rates [OR 95% CI, 0.66 (0.40 ~ 1.09); P = 0.10], OS [Hazard ratio (HR) 95% CI, 0.65 (0.42 ~ 1.00); P = 0.05] or DFS [HR 95% CI, 1.02 (0.62 ~ 1.68); P = 0.93].ConclusionsRAMPS is safe and oncologically superior to the standard procedure for the treatment of left-sided pancreatic cancer. However, high-grade evidence will be necessary to confirm the potential survival benefits of RAMPS.Electronic supplementary materialThe online version of this article (doi:10.1186/s12893-017-0259-1) contains supplementary material, which is available to authorized users.

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Section: Introductionmentioning

confidence: 99%

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

Cao

et al. 2017

BMC Surg

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“…In recent years, a new modification of the standard PD has been proposed, a concept termed SMA first approach. 9,10 The benefits of this method has been reported in many studies. The first advantage is the early detection of arterial involvement before committing to the irreversible step of operating.…”

Section: Discussionmentioning

confidence: 97%

Perioperative outcomes of pancreaticoduodenectomy: Superior mesenteric artery first approach in Rajavithi Hospital, Thailand

et al. 2018

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Aim: Superior mesenteric artery (SMA) first approach has been widely accepted as an effective surgical technique for en-bloc resection in periampullary cancer. There are currently multiple different artery first approach (AFA) techniques. The aim of the present study was to assess the perioperative outcome by comparing two surgical techniques at a single institute. Patients and Methods: This was retrospective study comparing consecutive patients who had undergone pancreatoduodenectomy (PD) with mesenteric and left posterior AFA between July 2012 and March 2017 at Rajavithi Hospital, Thailand. Results: In total, 103 patients were included. Both groups were comparable regarding demographics, tumour characteristics and perioperative outcomes. The mean operative time was 420 min in the SMA PD group and 360 min in the left posterior artery (LPA) PD group. The mean operative blood loss in the SMA PD group and LPA PD group was 750 and 700 cc, respectively. Overall, complications occurred in 45.6 per cent of patients. Eighty-seven patients (84.5 per cent) had negative resection margins, and the median number of lymph nodes harvested was 11 nodes in the MSA PD group and 16 nodes in the LPA group. Conclusion: The AFA to PD has comparable perioperative outcomes with standard PD without increasing morbidity and mortality.

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“…There are several potential advantages of the artery first approach. They include the following: better resection of mesopancreas with a more adequate lymphadenectomy, reduced blood loss and an easier identification of aberrant right hepatic artery [ 16 ]. Although nowadays, triphasic computed tomography or endoscopic ultrasound allows for the delineation of resectable, borderline resectable or non-resectable tumours, they may be insufficient in selected cases.…”

Section: Discussionmentioning

confidence: 99%

Laparoscopic uncinate process first pancreatoduodenectomy—feasibility study of a modified ‘artery first’ approach to pancreatic head cancer

Pędziwiatr

Pisarska

Małczak

et al. 2017

Langenbecks Arch Surg

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PurposeThe aim of this study was to discuss the feasibility of laparoscopic ‘uncinate first’ pancreatoduodenectomy.MethodsThe analysis included prospectively collected data from 12 consecutive patients undergoing elective pure laparoscopic ‘uncinate process first’ pancreatoduodenectomy (Group 1). They were compared with patients previously operated on with a classical laparoscopic approach (Group 2). The primary outcome was the quality of the resected specimen (lymph node (LN) yield, R0 rate, involved resection margins). Secondary outcomes were perioperative parameters.ResultsThe LN yield in Group 1 was 19.3 and in Group 2 it was 13.9 (p = 0.03). R0 resection rates did not vary (66.7 vs. 63.2%, p = 0.84). Although the involvement of the superior mesenteric artery margin and uncinate process margin seemed lower in Group 1, the difference was not significant. Total operative time (467 vs. 425 min, p = 0.13) and resection time (221 vs. 232 min, p = 0.34) were similar in both groups. The estimated blood loss in Group 1 was 408 ml, whereas in Group 2 it was 392 ml (p = 0.33). Complication rates were 66.7% in Group 1 and 63.2% in Group 2 (p = 0.84). Median length of stay was 9 days in both groups (p = 0.36). Postoperative complication rates did not differ between groups.ConclusionsLaparoscopic uncinate first approach is a feasible method for pancreatic head neoplasms. Achieved quality of the specimen is comparable with the traditional laparoscopic approach, whereas intra- and postoperative course is not inferior. However, further studies on larger cohorts are required to fully establish whether the novel approach has potential advantages over classical access in pancreatic head cancer.

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Artery first approach to pancreatoduodenectomy: current status

Abstract: The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.

Cited by 17 publications

References 75 publications

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

Perioperative outcomes of pancreaticoduodenectomy: Superior mesenteric artery first approach in Rajavithi Hospital, Thailand

Laparoscopic uncinate process first pancreatoduodenectomy—feasibility study of a modified ‘artery first’ approach to pancreatic head cancer

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