Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival

Abstract

The artery-first approach to pancreatoduodenectomy may be associated with improved perioperative outcomes and survival.

Pancreatic cancer: An update on diagnosis and management

“…20,21 Since involvement of major visceral arteries is often a key determinant of resectability, early dissection along the arteries has become an important principle that may be associated with improved perioperative outcomes. 22 Distal pancreatectomy for pancreatic cancer mandates splenectomy in order to achieve the required lymphadenectomy, and appropriate vaccinations should be administered preoperatively. Total pancreatectomy results in type 3c diabetes, which is characterised by pancreatic exocrine and endocrine insufficiency.…”

Local radicality and survival outcome of pancreatic cancer surgery

“…It should be noted that at present the available evidence for these advantages of artery‐first approaches is relatively low because it is limited to retrospective cohort studies . A recent systematic review and meta‐analysis of artery‐first versus standard pancreatoduodenectomy identified 16 retrospective cohort or case‐control studies and one very small randomized controlled trial (six vs six patients) on this topic . In the meta‐analysis of 771 artery‐first versus 701 standard pancreatoduodenectomies the intraoperative blood loss, the need for blood transfusion, the perioperative morbidity, and the rate of clinically relevant postoperative pancreatic fistula were significantly lower, while the R0 rate and overall survival were significantly higher in the artery‐first group .…”

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

“…Performing venous resection (VR) followed by reconstruction of the mesenteric-portal venous axis during pancreatic resections for PDAC may allow "en-bloc" resection facilitated by the superior mesenteric artery (SMA) "first" approach (34,35). Pancreaticoduodenectomies (PDs) are associated with VR in up to 25% of cases in France and Europe (less frequently in the US and more frequently in Japan).…”

“…Bachellier et al (121) reported 118 pancreatectomies (51 PD, 18 TP, and 49 DP) with ARs [CA (50), HA (29), SMA (35), and other segments (4)] including 85% with reconstruction and 89% with simultaneous VR (LE 4). Overall mortality and morbidity were 5.1 and 41.5%, respectively.…”

“…ARs are therefore very rarely indicated, often associated with venous resection (24, 97, 120, 121) (LE 3), and must be "planned" since they require routine neoadjuvant treatment and frequent preoperative arterial embolization. Surgery should always begin with an "artery first" approach (34,35) to accurately evaluate any persistent arterial involvement confirmed by frozen section examination (34,35,116). Forty (121) to 70% (24, 119) of patients do not receive postoperative chemotherapy (primarily single agent gemcitabine) due to postoperative morbidity and prolonged recovery time and there are few data on patient quality of life.…”