title: Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes.
abstract: OBJECTIVE
  During pancreatoduodenectomy (PD), two techniques have been described to dissect the head of pancreas, viz. the superior mesenteric artery (SMA) approach by dissecting the uncinate process and the uncinate process first approach.
  
  
  METHODS
  Forty-four consecutive patients, who underwent PD between June 2009 and April 2010, were analyzed. Thirty patients underwent the SMA first approach along with uncinate dissection (group 1), while 14 patients underwent the uncinate process first approach (group 2).
  
  
  RESULTS
  There were 30 male and 14 female patients. The median age was 51 years (range 19-76 years). Median intraoperative blood loss in group 1 was 800 ml, while that in group 2 was 600 ml. A mean of 0.52 units of blood were transfused in group 1 (range 0-3) compared to 0.2 units in group 2 (range 0-1). The median operative time in group 1 was 457.5 min and the median operative time was 450 min in group 2. Complication rate was 40% and 14.3% in groups 1 and 2, respectively. Median duration of hospital stay was 14 days in group 1 and 12.5 days in group 2. Median nodes resected in group 1 were 8 (range 0-26), while in group 2 they were 9 (range 2-14). Resection margins were positive in two cases (one in each group). There were two mortalities in group 1 and no mortalities in group 2. None of the above differences were significant.
  
  
  CONCLUSIONS
  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.
authors: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Tata Memorial Hospital, Mumbai, India. shailushrikhande@hotmail.com
authors: Shailesh V
authors: SV
authors: Shrikhande
authors: Savio George
authors: SG
authors: Barreto
authors: Yashodhan D
authors: YD
authors: Bodhankar
authors: Kunal
authors: K
authors: Suradkar
authors: Guruprasad
authors: G
authors: Shetty
authors: Rohini
authors: R
authors: Hawaldar
authors: Mahesh
authors: M
authors: Goel
authors: Parul J
authors: PJ
authors: Shukla
mesh_terms: D000328:Adult; D000368:Aged; D001707:Biopsy, Needle; D016063:Blood Loss, Surgical / Q000503:physiopathology; D016009:Chi-Square Distribution; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007150:Immunohistochemistry; D008297:Male; D017538:Mesenteric Artery, Superior / Q000601:surgery*; D008875:Middle Aged; D009367:Neoplasm Staging; D010179:Pancreas / Q000033:anatomy & histology / Q000601:surgery*; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D019990:Perioperative Care / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011446:Prospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult