Superior Mesenteric Artery First Versus Standard Approach in Pancreaticoduodenectomy

Overview

"Pancreatic cancer, especially pancreatic ductal adenocarcinoma, is one of the most serious and deadly cancers. Its outlook is very poor, with fewer than 10% of patients surviving five years after diagnosis. This is largely because the disease is often discovered at a late stage and because it frequently comes back even after surgery. When the tumor is located in the head of the pancreas, the only treatment that can potentially cure the disease is a major operation called a pancreaticoduodenectomy, also known as the Whipple procedure. This surgery is now safely performed in specialized hospitals, but it remains complex and carries a high risk of complications. Importantly, even after surgery, cancer cells often remain, leading to a high rate of local recurrence. A newer surgical technique, known as the "artery-first" approach, changes the order of the operation. By carefully exposing a major blood vessel near the pancreas at the beginning of the surgery, surgeons can better assess whether the tumor can be completely removed and can improve the precision of the operation. This research protocol aims to compare this artery-first technique with the standard surgical approach. The goal is to determine whether starting the operation by addressing the artery allows for more complete tumor removal and reduces the risk of cancer coming back in patients with pancreatic cancer of the head of the pancreas."

"Pancreatic ductal adenocarcinoma (PDAC) is projected to become the second leading cause of cancer death in the United States and Europe by 2030. It remains the worst prognostic gastrointestinal cancer, with a 7-9% five-year overall survival (OS) rate. The majority of patients are diagnosed at an advanced stage, i.e., locally advanced (30%) or metastatic (50%), and more than 60% of the operated patients relapse within 3 years after surgery. Pancreaticoduodenectomy: standard approach Pancreaticoduodenectomy (PD) is the only potentially curative technique for PDAC of the pancreatic head. The procedure, commonly named the Whipple procedure, was described in 1935 when O.Whipple reported the previously modified technique by A.Codinivillan and W.Keusch. In its current form, the Whipple procedure owes its evolution to many physicians and surgeons' groundbreaking and innovative work. The procedure is now performed with an acceptable mortality rate of \< 4% in expert centers and and nevertheless 30% morbidity. Pancreaticoduodenectomy: SMA first approach, peri-adventitial dissection Whipple procedure with mesenteric first approach is a technique described and validated in surgery for pancreatic adenocarcinoma. This technique, which involves dissecting the peri-adventitial tissues of the superior mesenteric artery, has been reported mainly in borderline or locally advanced tumors of the head of the pancreas, to control the artery and improve the quality of the resection. This technique allows exposure of the right hemicircumference of the artery and clearance of the origin of the celiac trunk before sectioning the key elements of the duodenopancreatectomy cephalic. Six surgical approaches that can be considered as "artery first" have been reported by Sanjay et al. Two approaches to avoid technical biases in SMA dissection and arterial margins will be considered: the right posterior approach and the anterior approach. Although PD is mature, the low R0 resection rate remains a major issue, and most patients will develop a local recurrence, as demonstrated by autopsy studies. The investigators hypothesise that the SMA first approach (SMA-PD) improves R0 resection margins compared to the standard procedure (ST-PD) during PD in patients with pancreatic head adenocarcinoma."