Artery first approaches to Pancreatoduodenectomy

Sanjay Pandanaboyana, MS, FRCSHPB & Transplant Surgeon

Department of Hepatobiliary and Transplant surgeryAuckland city hospital

Auckland, New Zealand

SMA first approach: why the need? • PV-SMV involvement is not a contraindication for PD.

• Increase in the number of PSMVR performed during PD, linked to the increasing trend towards using NAC for borderline resectable tumours

• Lack of high quality evidence regarding whether PVR improves margin status and long term survival.

R. Ravikumar, C. Sabin, M. Abu Hilal, et al., Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study, J. Am. Coll. Surg. 218 (3) (2014 Mar) 401e411.

C.R. Ferrone, G. Marchegiani, T.S. Hong, et al., Radiological and surgical im- plications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer, Ann. Surg. 261 (1) (2015 Jan) 12e17.

• Sixteen studies including 4145 patients

• 1207 patients who had PVR and 2938 had no N-PSMVR

• Four of the sixteen studies were defined as high volume (average > 20 PDs per year)

• Study cohort sizes ranged from 50 to 1070 patients.

Rationale for SMA first approach • Resection of the SMA increases postoperative morbidity and mortality without

demonstrable improvement in survival and is largely abandoned.

• Resectability is now dictated by whether or not SMA is involved.

• Infiltration of SMA is usually identified toward the end of the resection process, when the surgeon is committed to resection

• Nakao A, Takeda S, Inoue S, Nomoto S, Kanazumi N, Sugimoto H, Fujii T. Indication and techniques of extended resection for pancreatic cancer. World J Surg 2006;30:976-982.

Definition • The AFA has come to mean that a trial dissection is directed towards

the early determination of whether there is SMA involvement before committing an irreversible step in the operation.

• The use of the term ‘artery first’ does not preclude previous manoeuvres, including exposure of the PV.

• Depending on the location of the tumour it could be SMA or CHA

SMA first pancreatoduodenectomy • Hackert T, Werner J, Weitz J, Schmidt J, Bu chler MW. Uncinate process first – a novel approach for pancreatic ̈

head resection. Langenbecks Arch Surg 2010; 395: 1161–1164. • Shukla PJ, Barreto G, Pandey D, Kanitkar G, Nadkarni MS, Neve R et al. Modification in the technique of

pancreaticoduodenectomy: supracolic division of jejunum to facilitate uncinate process dissection. Hepatogastroenterology 2007; 54: 1728–1730.

• Hirota M, Kanemitsu K, Takamori H, Chikamoto A, Tanaka H, Sugita H et al. Pancreatoduodenectomy using a no-touch isolation technique. Am J Surg 2010; 199: e65 – e68.

• Kurosaki I, Minagawa M, Takano K, Takizawa K, Hatakeyama K. Left posterior approach to the superior mesenteric vascular pedicle in pancreaticoduodenectomy for cancer of the pancreatic head. JOP 2011; 12: 220 – 229.

• Nakao A, Takagi H. Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein. Hepatogastroenterology 1993; 40: 426–429.

• WeitzJ,RahbariN,KochM,Bu chlerMW. The artery first approach for resection of pancreatic head cancer. ̈ J Am CollSurg 2010; 210: e1 – e4.

Is AFA beneficial in improving long term outcomes?

P = 0.122 P = 0.220

Metaanalysis : SMA first PD versus Standard PD

SMA first PD Standard PD P

Blood loss 750 mls 996 mls <0.006Operating time 400 mins 440 mins <0.04PV resection 25% 17% 0.17R0 resection 79% 60% 0.04Pancreatic fistula 15% 20% 0.26Morbidity 32% 43% 0.003Overall survival HR 0.73 [0.57, 0.94] 0.01

11 studies including 881 patientsStudy period 2009-2016AFA: 480 Standard PD: 401 patientsNAC was not used in any of the studies

11 Patients : NAC Median blood loss was 500 mL (range 100 to 1,030).

The median no of lymph nodes : 26 (range 9 to 80).

R0 8/11 (77%)

At the median follow-up time of 12.4 months 1 patient had a recurrence of in the liver

Conclusions • Increasing trend towards using AFA for PD

• Early evidence suggests AFA may reduce postoperative morbidity and increases R0 resection rates

• No definitive published data to suggest AFA improves long term survival • The predominant role of AFA is to facilitate trial dissection of SMA in assessing

true resectability particularly in patients with borderline resectable Pancreatic cancer.