The Artery-First Approach in Pancreatic Cancer Surgery

Upfront resection for pancreatic cancer has a high incidence of margin positive resection. The six different technical descriptions of artery first approaches to pancreatic cancer aimed to identify a positive SMA margin at an earlier stage during pancreatoduodenectomy and avoid a futile margin positive resection. Each approach has a technical justification providing exposure to SMA along its course from the aorta, through the pancreas into the small bowel mesentery depending on the location of the tumor within the pancreas. Several retrospective studies showed improved perioperative and survival outcomes with an artery first approach including a reduction in R1 resections, which were further confirmed in systematic reviews comparing the artery first pancreatoduodenectomy with standard pancreatoduodenectomy. However more recent evidence from randomised controlled trials to corroborate this is lacking. Further trials are warranted comparing various artery first approaches with standard pancreatoduodenectomy before it is considered standard of care.