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Posterior Superior Mesenteric Artery (SMA) First Approach vs. Standard Pancreaticoduodenectomy in Patients with Resectable Periampullary Cancers: a Prospective Comparison Focusing on Circumferential Resection Margins

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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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Authors and Affiliations

  1. Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India

    Sujoy Pal, Joseph George, Anand Narayan Singh, Nihar Ranjan Dash, Peush Sahni & TK Chattopadhyay

  2. Department of Pathology, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India

    Sandeep Mathur

  3. Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India

    Pramod Garg

Authors
  1. Sujoy Pal
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  2. Joseph George
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  3. Anand Narayan Singh
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  4. Sandeep Mathur
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  8. TK Chattopadhyay
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Corresponding author

Correspondence to Sujoy Pal.

Ethics declarations

Ethical Approval

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.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Funding

None received.

Additional information

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

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