Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes

Abstract

SMA first is a safe technique. It compares well with the uncinate first approach in terms of operative time, blood loss, number of lymph nodes retrieved, margin positivity and operative morbidity. Both techniques may be useful in situations such as a large uncinate process tumor or when superior mesenteric vein/portal vein/superior mesenteric artery involvement is suspected or present. Further studies, evaluating data related to specific predefined uncinate tumors, would be the next logical step in further defining the precise role of these techniques.

Tricks and tips in pancreatoduodenectomy

“…Previously, Shukla et al [17] described the dissection of the uncinate process from the mesenteric vessels, facilitating tumor removal and demonstrating the involvement of these vessels early during surgery. This approach is recommended in uncinate tumors and in cases with suspected involvement of the SMV or SMA [2] . Another advan-tage of this approach is the early ligation of the IPDA, but it does not allow early identification of an anomalous RHA [9] .…”

“…Figueras et al [3] compared classical PD with the posterior artery-first approach, reporting a reduction in complications and hospital stay, while Dumitrascu et al [1] found no significant differences in hospital stay, early morbidity, mortality, or overall survival. Shrikhande et al [2] compared classical PD with the "uncinate artery-first approach" and found no evidence of significant differences in blood loss, operative time, margin involvement, lymph node yield, or complications.…”

“…Pancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy [1][2][3] . Since its initial description in 1935 by Whipple et al [4] , this complex surgical technique has evolved and, although the mortality rate has been reduced by regionalizing interventions in high volume centers [1,3] , morbidity remains high, with a rate close to 40% [5,6] .…”

Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy

“…Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk [1][2][3][4]. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course [5][6][7][8][9]. We describe our technique of LPD with SMAfirst approach and pancreatogastrostomy assisted by minilaparotomy.…”

Clinical Impact of Intraoperative Navigation Using a Doppler Ultrasonographic Guided Vessel Tracking Technique for Pancreaticoduodenectomy

“…6,7 Recently, several procedures for artery-first approaches such as posterior, uncinated, and mesenteric approach have been introduced for improving perioperative outcomes such as curability and decreasing blood loss and morbidity. [8][9][10][11] Incidentally, it has been well known that early ligation of the inferior pancreaticoduodenal artery (IPDA)-one of the efferent arteries of the pancreas head-considerably reduces intraoperative bleeding and postoperative complications. [12][13][14] Owing to the various anatomic origins of IPDA, identification is difficult in some patients.…”