Standardized Approach to Superior Mesenteric Artery Resection for Locally Advanced Pancreatic Cancer

Summary

Superior mesenteric artery (SMA) resections are increasingly reported for the treatment of locally advanced pancreatic cancer (LAPC) with involvement of the superior mesenteric vessels in pancreatic ductal adenocarcinoma. Here, we describe an approach for SMA resections and reconstructions in LAPC with SMA encasement and excellent response to neoadjuvant treatment.

Abstract

Novel multimodal treatment strategies might enable curative-intent resection of locally advanced pancreatic cancer (LAPC). While venous resections are routinely performed, arterial resections remain part of individualized treatment strategies in a few expert centers. Historically, SMA involvement, by definition, precluded resectability. However, in selected patients with excellent response to preoperative treatment, arterial resection has been associated with satisfactory outcomes in high-volume centers with significant experience in extended and vascular resections. Even though arterial divestment is increasingly performed if technically possible, arterial resection is still required when the arterial wall cannot be preserved to achieve macroscopically complete resection, especially if the SMA is encased along with its branches in SMA segment 2. Usually, the SMV is also encased in these tumors, and combined arterial and venous resections are necessary. Here, we describe our approach to SMA resection and reconstruction after neoadjuvant treatment in a 64-year-old female patient with locally advanced pancreatic ductal adenocarcinoma (PDAC) and complete encasement of the SMA in segment 2. Critical steps in this situation are assessing the feasibility of SMA and SMV resection using an infracolic artery first approach, performing a wide Kocher maneuver to access the SMA from the right, and the Cattell-Braasch maneuver to enable tension-free direct end-to-end anastomoses.

Introduction

Surgery remains the only treatment option with curative potential for PDAC. However, only 20%-30% of patients qualify for upfront surgery, while 30% present with LAPC and the remaining ones with distant metastasis¹. Recent advances in surgical techniques, multimodal treatments, and perioperative care have led to an increased number of patients with tumors initially staged as locally advanced and unresectable that are reconsidered for curative-intent resection after neoadjuvant therapy. Retrospective data suggests successful resection of initially unresectable LAPC in up to 60% of cases with FOLFIRINOX-based induction chemotherapy

Protocol

The present protocol follows the ethics guidelines of the Medical University of Vienna, and informed consent was obtained from the patient for this article and video.

The appropriate consent for surgical exploration and potential extended resection with vascular resection is obtained from the patient after extensive discussion of the risks and potential benefits associated with this procedure. The patient needs to be aware that no high-quality evidence currently supports arterial resections in PDAC.

1. Preoperative management

1. Perform a high-quality contrast-enhanced triple-phase CT sc....

Results

The case is a 64-year-old female who was diagnosed with locally advanced PDAC of the pancreatic head with encasement of the SMA (Figure 1). The surgery lasted 7 h and 35 min with an estimated blood loss of 950 mL. The intraoperative situs is depicted in Figure 2. A pylorus-resecting pancreatoduodenectomy was performed with resection and reconstruction of the SMA and SMV. The postoperative course was uneventful. We initiated proph.......

Discussion

This article describes our approach at the Medical University of Vienna for SMA resections and reconstructions in LAPC following neoadjuvant treatment. High-quality preoperative diagnostics, careful selection of surgical candidates, and preoperative planning of the resection strategy are essential for arterial resections in PDAC surgery. However, in cases of stable disease on imaging and biochemical response, we go for exploration, as CT scans are well known to be unreliable in assessing tumor burden after neoadjuvant tr.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Computed Tomography	Canon medical systems
MRI	Siemens
Folfirinox	Adcock ingram
piperacillin	Pfizer
tazobactam	Pfizer
low molecular weight heparin	Merck