title: Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis.
abstract: BACKGROUND
  The superior mesenteric artery (SMA) first approach was proposed recently as a new modification of the standard pancreaticoduodenectomy. Increasing evidence showed that a periadventiceal dissection of the SMA with early transection of the inflow during pancreaticoduodenectomy associates better early perioperative results, and setup the scene for long-term oncological benefits. The objectives of the current study are to compare the operative results and long-term oncological outcomes of SMA first approach pancreaticoduodenectomy (SMA-PD) with standard pancreaticoduodenectomy (S-PD).
  
  
  METHODS
  Electronic search of the PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Library was performed until July 2015. We considered randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) comparing SMA-PD with S-PD to be eligible if they included patients with periampullary cancers.
  
  
  RESULTS
  A total of one RCT and thirteen NRCSs met the inclusion criteria, involving 640 patients with SMA-PD and 514 patients with S-PD. The SMA-PD was associated with less intraoperative bleeding, less blood transfusions and higher rate of associated venous resections. The pancreatic fistula and delayed gastric emptying had a significantly lower rate in the SMA-PD group. There were no differences between the two approaches regarding overall complications, major complication rates and in-hospital mortality. There was no difference regarding R0 resection rate, and one-, two- or three-year overall survival. The SMA-PD was associated with a lower local, hepatic and extrahepatic metastatic rate.
  
  
  CONCLUSIONS
  The SMA-PD is associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, and delayed gastric emptying. Although the one-, two- or three-year overall survival rate is not superior, the SMA-PD has a lower local and metastatic recurrence rate.
authors.affiliation: General Surgery Department, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania. negoiionut@gmail.com.
authors.forename: Ionut
authors.initials: I
authors.lastname: Negoi
authors.forename: Sorin
authors.initials: S
authors.lastname: Hostiuc
authors.forename: Alexandru
authors.initials: A
authors.lastname: Runcanu
authors.forename: Ruxandra Irina
authors.initials: RI
authors.lastname: Negoi
authors.forename: Mircea
authors.initials: M
authors.lastname: Beuran
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D018589:Gastroparesis / Q000209:etiology; D017052:Hospital Mortality; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary; D017538:Mesenteric Artery, Superior / Q000601:surgery*; D009364:Neoplasm Recurrence, Local; D016017:Odds Ratio; D010185:Pancreatic Fistula / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome