Skip to main content

Advertisement

SpringerLink
Log in

An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer

  • Review Article
  • Published:
Surgery Today Aims and scope Submit manuscript

Abstract

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as “artery-first” approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117–27.

    Article  CAS  PubMed  Google Scholar 

  2. Gockel I, Domeyer M, Wolloscheck T, Konerding MA, Junginger T. Resection of the mesopancreas (RMP). a new surgical classification of a known anatomical space. World J Surg Oncol 2007;5:44.

  3. Agrawal MK, Thakur DS, Somashekar U, Chandrakar SK, Sharma D. Mesopancreas: myth or reality? JOP. 2010;11(3):230–3.

    PubMed  Google Scholar 

  4. Delpero JR, Bachellier P, Regenet N, Le Treut YP, Paye F, et al. Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a French multicentre prospective evaluation of resection margins in 150 evaluable specimens. HPB (Oxford). 2014;16(1):20–33.

    Article  Google Scholar 

  5. Pessaux P, Varma D, Arnaud JP. Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg. 2006;10(4):607–11.

    Article  PubMed  Google Scholar 

  6. Ohigashi H, Ishikawa O, Eguchi H, Yamada T, Sakaki Y, Noura S, et al. Early ligation of the inferior pancreatoduodenal artery to reduce blood loss during pancreaticoduodenectomy. Hepatogastroenterol. 2004;51:4–5.

    Google Scholar 

  7. Varty PP, Yamamoto H, Farges O, Belghiti J, Sauvanet A. Early retropancreatic dissection during pancreaticoduodenectomy. Am J Surg. 2005;189(4):488–91.

    Article  PubMed  Google Scholar 

  8. Popescu I, David L, Dumitra A, Dorobantu B. The posterior approach in pancreaticoduodenectomy: preliminary results. Hepatogastroenterol. 2007;54:921–6.

    Google Scholar 

  9. Shah OJ, Gagloo MA, Khan IJ, Ahmad R, Bano S. Pancreaticoduodenectomy: a comparison of superior approach with classical Whipple's technique. Hepatob. Pancreatic Dis. Int. 2013;12(2):196–203.

    Article  Google Scholar 

  10. Zimmitti G, Manzoni A, Addeo P, Garatti M, Zaniboni A, Bachellier P, et al. Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc. 2016;30(4):1670–1.

    Article  PubMed  Google Scholar 

  11. Nakao A, Takagi H. Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein. Hepatogastroenterol. 1993;40:426–8.

    CAS  Google Scholar 

  12. Horiguchi A, Ishihara S, Ito M, Nagata H, Shimizu T, Furusawa K, et al. Pancreatoduodenectomy in which dissection of the efferent arteries of the head of the pancreas is performed first. J Hepatobiliary Pancreat Sci. 2007;14:575–8.

    Article  Google Scholar 

  13. Weitz J, Rahbari N, Koch M, Buchler MW. The "artery first" approach for resection of pancreatic head cancer. J Am Coll Surg. 2010;210(2):e1–4.

    Article  PubMed  Google Scholar 

  14. Mizuno S, Isaji S, Tanemura A, Kishiwada M, Murata Y, Azumi Y, et al. Anterior approach to the superior mesenteric artery by using nerve plexus hanging maneuver for borderline resectable pancreatic head carcinoma. J Gastrointest Surg. 2014;18(6):1209–15.

    Article  PubMed  Google Scholar 

  15. Zhang Y, Sun D, Chen X. The uncinate process first approach in laparoscopic pancreaticoduodenectomy; a single-institution experience. Surg Laparosc Endsc Percutan Tech. 2017;27:4.

    Google Scholar 

  16. Inoue Y, Saiura A, Yoshioka R, Ono Y, Takahashi M, Arita J, et al. Pancreatoduodenectomy with systematic mesopancreas dissection using a supracolic anterior artery-first approach. Ann Surg. 2015;262(6):1092–101.

    Article  PubMed  Google Scholar 

  17. Zhu J, Han D, Li X, Pan F, Ma J, Kou J, Fan H, et al. Inferior infracolic 'superior mesenteric artery first' approach with a no-touch isolation surgical technique in patients with a borderline resectable cancer of the pancreatic head. Ann Surg Oncol. 2016;23(Suppl 5):976–80.

    Article  PubMed  Google Scholar 

  18. 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. Hepatogastroenterol. 2007;54:1728–30.

    CAS  Google Scholar 

  19. Hackert T, Werner J, Weitz J, Schmidt J, Buchler MW. Uncinate process first–a novel approach for pancreatic head resection. Langenbecks Arch Surg. 2010;395(8):1161–4.

    Article  PubMed  Google Scholar 

  20. Kurosaki I, Minagawa M, Takano K, Hatakeyama K. Left posterior approach to the superior mesenteric vascular pedicle in pancreaticoduodenectomy for cancer of the pancreatic head. JOP. 2011;12(3):220–9.

    PubMed  Google Scholar 

  21. Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol. 2012;38(7):574–9.

    Article  CAS  PubMed  Google Scholar 

  22. Jackson BB. An approach to stenotic lesions of the proximal superior mesenteric artery. Am J Surg. 1962;104:86–8.

    Article  CAS  PubMed  Google Scholar 

  23. Stoney RJ, Ehrenfeld WK, Wylie EJ. Revascularization methods in chronic visceral ischemia caused by atherosclerosis. Ann Surg. 1977;186(4):468–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Paturet J. Traite d'anatomie humaine, vol. 3. Paris: Masson Editeur; 1958.

    Google Scholar 

  25. Hivet M, Lagadec B, Poilleux J. Chirurgie des arteres digestives. France; 1970.

  26. Michels NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. Philadelphia: Lippincott; 1955.

    Google Scholar 

  27. Suzuki T, Nakayasu A, Kawabe K, Takeda H, Honjo I. Surgical significance of anatomic variatiow of the hepatic artery. Am J Surg. 1971;122:505–12.

    Article  CAS  PubMed  Google Scholar 

  28. Pedziwiatr M, Pisarska M, Malczak P, Major P, Wierdak M, Radkowiak D, et al. Laparoscopic uncinate process first pancreatoduodenectomy-feasibility study of a modified 'artery first' approach to pancreatic head cancer. Langenbecks Arch Surg. 2017;402(6):917–23.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Vallance AE, Young AL, Pandanaboyana S, Lodge JP, Smith AM. Posterior superior mesenteric artery first dissection versus classical approach in pancreaticoduodenectomy: outcomes of a case-matched study. Pancreas. 2017;46(2):276–81.

    Article  PubMed  Google Scholar 

  30. Zhou HY, Wang Y, Zhang J, Ruan CP, Wang WJ, Sun YP, et al. Retrograde vs conventional dissection technique in pancreaticoduodenectomy: a pilot study. JAMA Surg. 2014;149(6):604–7.

    Article  PubMed  Google Scholar 

  31. Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA. 'Artery-first' approaches to pancreatoduodenectomy. Br J Surg. 2012;99(8):1027–35.

    Article  CAS  PubMed  Google Scholar 

  32. Dumitrascu T, David L, Popescu I. Posterior versus standard approach in pancreatoduodenectomy: a case-match study. Langenbecks Arch Surg. 2010;395(6):677–84.

    Article  PubMed  Google Scholar 

  33. Ironside N, Brenner D, Heyer E, Chen CJ, Robison T, Christophe B, et al. Systematic review and meta-analysis of perioperative and long-term outcomes in patients receiving statin therapy before carotid endarterectomy. Acta Neurochir (Wien). 2018;160(9):1761–71.

    Article  Google Scholar 

  34. Negoi I, Hostiuc S, Runcanu A, Negoi RI, Beuran M. Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis. Hepatobiliary Pancreatic Dis. Int. 2017;16(2):127–38.

    Article  Google Scholar 

  35. Neoptolemos JP, Stocken DD, Dunn JA, Almond J, Beger HG, Pederzoli P, et al. Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial. Ann Surg. 2001;234(6):758–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Luttges J, Vogel I, Menke M, Henne-Bruns D, Kremer B, Kloppel G. The retroperitoneal resection margin and vessel involvement are important factors determining survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas. Virchows Arch. 1998;433(3):237–42.

    Article  CAS  PubMed  Google Scholar 

  37. Pessaux P, Marzano E, Rosso E. A plea for the artery-first dissection during pancreaticoduodenectomy. J Am Coll Surg. 2010;211(1):142–3.

    Article  PubMed  Google Scholar 

  38. Pessaux P, Rosso E, Panaro F, Marzano E, Oussoultzoglou E, Bachellier P, et al. Preliminary experience with the hanging maneuver for pancreaticoduodenectomy. Eur J Surg Oncol. 2009;35(9):1006–100.

    Article  CAS  PubMed  Google Scholar 

  39. Borrelly J. Abord sus-mesocolique droit de l'artere mesenterique superieure a son origine. J Chir. 1973;105(2):167–70.

    CAS  Google Scholar 

  40. Bonnichon P, Rossat-Mignod JC, Corlieu P, Aron C, Yandza T, Chapuis Y. Surgical approach to the superior mesenteric artery by the Kocher Maneuver: anatomy study and clinical applications. Ann Vasc Surg. 1986;4:505–8.

    Article  Google Scholar 

  41. Hirono S, Kawai M, Okada KI, Fujii T, Sho M, Satoi S, et al. MAPLE-PD trial (mesenteric approach vs. conventional approach for pancreatic cancer during pancreaticoduodenectomy): study protocol for a multicenter randomized controlled trial of 354 patients with pancreatic ductal adenocarcinoma. Trials. 2018;19(1):613.

Download references

Author information

Authors and Affiliations

  1. Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan

    Junji Yamamoto, Hiroki Kudo, Yusuke Kyoden, Yoshinori Ajiro, Masaya Hiyoshi, Takayuki Okuno, Hiroshi Kawasaki, Masaru Nemoto & Fuyo Yoshimi

Authors
  1. Junji Yamamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hiroki Kudo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yusuke Kyoden
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yoshinori Ajiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Masaya Hiyoshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Takayuki Okuno
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hiroshi Kawasaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Masaru Nemoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Fuyo Yoshimi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors meet the International Committee of Medical Journal Editors authorship criteria.

Corresponding author

Correspondence to Junji Yamamoto.

Ethics declarations

Conflict of interest

Junji Yamamoto and other co-authors have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yamamoto, J., Kudo, H., Kyoden, Y. et al. An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer. Surg Today 51, 872–879 (2021). https://doi.org/10.1007/s00595-020-02150-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00595-020-02150-z

Keywords

Search

Navigation