Posterior Superior Mesenteric Artery (SMA) First Approach vs. Standard Pancreaticoduodenectomy in Patients with Resectable Periampullary Cancers: a Prospective Comparison Focusing on Circumferential Resection Margins.
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.
Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India. sujoypal@hotmail.com.
Sujoy
S
Pal
Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
Joseph
J
George
Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
Anand Narayan
AN
Singh
Department of Pathology, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
Sandeep
S
Mathur
Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
Nihar Ranjan
NR
Dash
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
Pramod
P
Garg
Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
Peush
P
Sahni
Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, RNo 1005, 1st floor PC Block, New Delhi, 110029, India.
T K
TK
Chattopadhyay
D000328:Adult; D000368:Aged; D014670:Ampulla of Vater / Q000473:pathology / Q000601:surgery; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D000072662:Margins of Excision; D017538:Mesenteric Artery, Superior / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis; D011446:Prospective Studies; D013997:Time Factors
Circumferential resection margins; Pancreatoduodenectomy; SMA first