Artery first approaches to Pancreatoduodenectomy: Current evidence

1. Artery first approaches to Pancreatoduodenectomy
Sanjay Pandanaboyana, MS, FRCS
HPB & Transplant Surgeon
Department of Hepatobiliary and Transplant surgery
Auckland city hospital
Auckland, New Zealand

2. 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.
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borderline resectable pancreatic cancer, Ann. Surg. 261 (1) (2015 Jan) 12e17.

3. • 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.

5. 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.

6. 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

8. 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.

11. Is AFA beneficial in improving long term outcomes?

14. P = 0.122 P = 0.220

15. Metaanalysis : SMA first PD versus Standard PD
SMA first PD Standard PD P
Blood loss 750 mls 996 mls <0.006
Operating time 400 mins 440 mins <0.04
PV resection 25% 17% 0.17
R0 resection 79% 60% 0.04
Pancreatic fistula 15% 20% 0.26
Morbidity 32% 43% 0.003
Overall survival HR 0.73 [0.57, 0.94] 0.01
11 studies including 881 patients
Study period 2009-2016
AFA: 480 Standard PD: 401 patients
NAC was not used in any of the studies

16. 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

17. 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.