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Department of HBP Surgery, University of Ulsan College of
Medicine
& Asan Medical Center, Seoul, Korea
Song Cheol Kim,M.D.
2013 38th KHBP
“SMA first” in advanced pancreatic head cancer
“Artery First” in pancreatic cancer resection : early and
deliberate dissection of peripancreatic arteries before
other dissection
SMA , CHA, CA
Purpose
Determining the resectability in early stage
Achieving the negative resection margin more clearly
What is “Artery First “ in pancreatic
cancer resection?
“SMA First “
“SMA First” : early and deliberate dissection of SMA adventitial layer to clean
up the lymphatics and nerve tissues around the SMA( esp. right side)
“SMA margin”
posteromedial margin, radial margin
traditional PD : last step on resection, sometimes irreversible step (R2)
preop pancreas dynamic CT :95% accurate for resectability
in BR : 25% accurate, less accurate in neoadjuvant setting for
resectability prediction
20-80% ;positive tumor rate , to achieve more accurate and wide
negative resection margin
Traditional PD
Superior approach
Posterior approach
Right/medial uncinate approach
Inferior infracolic (mesenteric) approach
Inferior supracolic ( anterior) approach
Left posterior approach
SMA
LRV
IPDA
Aorta
IVC
Posterior approach Right/medial uncinate approach
SMA
SMV
IPDA
UP
Hanging up technique using anterior and posterior approach
SMA
SMA
Inferior infracolic (mesenteric) approach
SMA MCA
SV
IPDA
DJF
SMV
MCV
P
SMV
Left posterior approach
SMV
SMA
Inferior infracolic (mesenteric) approach
T.colon
Left posterior approach
First jejunal vein SMA
Inferior supracolic(anterior) approach
CHA
PV
SA
SV
IPDA IMV
SMA
Superior approach
CHA
PV
GDA
SA
SMA
Evidence
Post approach : Figuerasa et al , Dumitrascu et al; no difference in RM
status, survival, less blood loss
Right/medial uncinate approach : Shrikhande et al ; no differnece in blood
loss, cx, lymph node yield, margin status
Inferior infracolic (mesenteric) approach : Nakao et al ( routine divide of MCA)
:no data
Left posterior approach : Pessaux et al ; no difference in cx, blood loss,
fewer recurrence ( 10 vs 37%) , improved survival ( 53.2 vs 16% in 5YSVR)
Inferior supracolic(anterior) approach : Hirota et al ; R0 82%
Superior approach : no data
Case I : BR pancreas cancer s/p neoadjuvant chx
(Ant approach)
Before neoadjuvant After neoadjuvant
DUCTAL ADENOCARCINOMA, MODERATELY DIFFERENTIATED,
2 x 1.8 x 1.3 cm, UNCINATE PROCESS OF PANCREAS,
( s/p neoadjuvant chemotherapy for adenocarcinoma of
pancreas; 12B-7612 )
with 1) extension to peripancreatic soft tissue.
2) no involvement of ampulla of Vater, common bile
duct, duodenal wall and superior mesenteric
artery.
3) lymphovascular invasion: not identified.
4) PERINEURAL INVASION: PRESENT.
5) no involvement of peripancreatic radial,
pancreatic, common bile duct, proximal duodenal
and distal duodenal resection margins.
6) METASTASIS IN 1 OF 6 LYMPH NODES ( 1/6 )
( LN #8; 0/5, regional LN; 1/1 ).
( metastatic tumor size: 3 ㎜,
without extranodal extension ).
DUCTAL ADENOCARCINOMA, POORLY DIFFERENTIATED, 5 x 3.3 x 1.7 cm,
HEAD OF PANCREAS,
with 1) extension to peripancreatic soft tissue.
2) INVOLVEMENT OF AMPULLA OF VATER AND COMMON BILE
DUCT.
3) no involvement of duodenal wall.
4) LYMPHOVASCULAR INVASION: PRESENT. ( See note )
5) PERINEURAL INVASION: PRESENT.
6) direct extension to superior mesenteric vein.
7) no involvement of peripancreatic radial, pancreatic, retroperitoneal,
common bile duct, proximal and distal duodenal resection margins.
8) METASTASIS IN 4 OF 30 LYMPH NODES ( 4/30 )
( para-aortic LN; 0/1, LN #16; 0/3, LN #8; 0/4,
LN; 0/4, peripancreatic LN; 2/15,
mesenteric LN; 2/3 )
( largest metastatic tumor size: 7 ㎜,
with extranodal extension: 1 ㎜ ).
Conclusion
“SMA first” approach for resection of pancreatic head cancer aims for radical
resection of the post and right side of the SMA and for determining the
radical resection before the “point of no return”.
It is useful and convenient that pancreatic surgeon is familiar with the various
“artery first” techniques when performing pancreas surgery including
combined vascular resection depending on the location of the lesion.
Additional studies are needed to demonstrate the real efficacy of the ‘SMA
first “ techniques in the future.
Superior approach
Posterior approach
Right/medial uncinate approach
Inferior infracolic (mesenteric) approach
Inferior supracolic(anterior) approach
Left posterior approach
