Artery-first approaches to pancreaticoduodenectomy

Abstract

Artery-first pancreaticoduodenectomy (PD) is a technique to ligate the feeding arteries before the division of the pancreas with intents to reduce the blood loss and to perform more oncologic resection. The superior mesenteric artery (SMA) is the most common site of positive margins after PD, especially in the setting of borderline resectable and locally advanced pancreatic cancer. We use the "Tora-no-Ana" approach, which consists of a division of the ligament of Treitz, an entry into the retroperitoneal space behind the pancreatic body, and dissection around SMA. In order to determine feasibility to achieve negative margins, SMA is first approached in this technique. The R0 ratio has been satisfactory high in our practice utilizing "Tora-no-Ana" approach.