title: Posterior Superior Mesenteric Artery First Dissection Versus Classical Approach in Pancreaticoduodenectomy: Outcomes of a Case-Matched Study.
abstract: Posterior superior mesenteric artery (SMA) first dissection in pancreaticoduodenectomy (PD) may allow for early assessment of resectability and aberrant anatomy. Study objectives were to compare resection margins, perioperative outcomes, disease-free survival (DFS) and overall survival (OS) in patients undergoing a posterior SMA first dissection PD to a classical technique PD.
  
  
  
  Patients (n = 77) who underwent a posterior SMA first PD for adenocarcinoma were case matched for patient and tumor characteristics with patients undergoing a classical approach PD from 2006 to 2014 (n = 177).
  
  
  
  The SMA first patients had an improved negative resection margin rate (27 [35.1%] vs 14 [18.2%], P = 0.042) and a higher lymph node yield (median 28 [22-34] vs 21 [17-27], P < 0.001) compared with the classical approach group. No difference was demonstrated in serious complications or 30-day mortality between the SMA first and classical approach patients (Clavien-Dindo 3/4 16 [20.8%] vs 11 [14.3%], P = 0.336; 30-day mortality 3 [3.9%] vs 3 [3.9%], P = 1.00 respectively). Median DFS and OS was similar in SMA first compared with classical approach patients (DFS, 1.6 vs 1.1 years, P = 0.122; OS, 2.5 vs 1.5 years, P = 0.220 respectively).
  
  
  
  A posterior SMA first approach is a comparably safe technique that may improve oncological results in PD compared with classical approach dissection.
authors.affiliation: From the *Department of Pancreatic Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK; and †Department of HPB Surgery, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Abigail E
authors.initials: AE
authors.lastname: Vallance
authors.forename: Alastair L
authors.initials: AL
authors.lastname: Young
authors.forename: Sanjay
authors.initials: S
authors.lastname: Pandanaboyana
authors.forename: Jeremy Peter
authors.initials: JP
authors.lastname: Lodge
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Smith
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000368:Aged; D016022:Case-Control Studies; D015331:Cohort Studies; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D017538:Mesenteric Artery, Superior / Q000601:surgery*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*