“Total Arterial Devascularization First” Technique for Resection of Pancreatic Head Cancer during Pancreaticoduodenectomy

Summary： Integrated resection of the pancreatic head is the most difficult step in radical pancreati- coduodenectomy （RPD） in patients with the portal vein （PV） and superior mesenteric vein （SMV） inva- sion or oppression by the tumor. This study introduced a new idea and skill named the ＂total arterial devascularization first＂ （TADF） technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta （AA） by completely transecting neural and connective tissue between superior mesenteric artery （SMA） and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h （ranging 4.5-8.1 h）. The median intraoperative blood loss was 450 mL （ranging 200-900 mL）. No intraoperative and postoperative bleeding of pancreatic head region oc- curred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical ap- proach for RPD.