Superior mesenteric artery-first approach in radical antegrade modular pancreatosplenectomy for borderline resectable pancreatic cancer: a technique to obtain negative tangential margins

Early superior mesenteric artery (SMA) dissection from behind the head of the pancreas using an “artery-first approach” has been considered a safe and efficient technique in performing a pancreaticoduodenectomy for pancreatic cancer when SMA involvement is suspected. The goal of this approach for the resection of pancreatic head cancer is complete surgical removal of the tumor, ie, a no-residual-tumor (R0) resection, because the prognostic significance of complete tumor clearance at the resection margins has been demonstrated. Meanwhile, the preoperative diagnostic accuracy of various imaging studies in detecting vascular invasion, especially in borderline resectable pancreatic cancers, is unsatisfactory. For example, the specificity of a CT scan ranges from 67% to 91% due to difficulties in exact differentiation between cancer infiltration and fibrosis or tumor-mimicking adhesions. Therefore, surgical exploration is usually carried out in patients who are categorized as having borderline resectable disease because of the suspicion of arterial infiltration on the basis of imaging criteria. The biggest advantage of the artery-first approach is that it allows surgeons to make a final decision regarding resectability before reaching the “point of no return” during surgery. Many studies have therefore focused on this technique in performing a pancreaticoduodenectomy for cancers of the head of the pancreas, but its significance in pancreatosplenectomy has not been fully discussed. In 2003, Strasberg and colleagues demonstrated a new surgical procedure for cancers of the body and tail of