Periarterial divestment in pancreatic cancer surgery

Published:October 05, 2020DOI:



      Modern pancreatic cancer surgery changed with the introduction of effective neoadjuvant therapies. Complete tumor resection is the mainstay for long-term, disease-free, and overall survival and has been a prerequisite for decreasing local recurrence. The medial resection margin in the area of the superior mesenteric vessels limits the radicalness of the resection, especially in borderline and locally advanced cases. Therefore, the periarterial soft tissue around the peripancreatic visceral arteries must be completely cleared. This procedure, namely periarterial divestment, is technically demanding but often represents an alternative to arterial resection.


      Here we describe the technique and our initial experience with periarterial divestment along the peripancreatic visceral arteries during pancreatic surgery. This technique, in combination with previously published resection strategies, such as artery first maneuver and mesenterico-portal venous bypass first, enables tumor resection in locally advanced pancreatic cancer.


      Periarterial divestment can prevent the need for arterial resection in borderline and locally advanced pancreatic cancer, especially after neoadjuvant therapy. The feasibility, improved safety, and oncologic equivalence of arterial divestment versus arterial resection for pancreatic cancer surgery must be evaluated by clinical trials.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Global Cancer Observatory (GLOBOCAN) Web site. Accessed 5 July, 2020.

        • Strobel O.
        • Hank T.
        • Hinz U.
        • et al.
        Pancreatic cancer surgery: The new R-status counts.
        Ann Surg. 2017; 265: 565-573
        • Hank T.
        • Hinz U.
        • Tarantino I.
        • et al.
        Validation of at least 1 mm as cut-off for resection margins for pancreatic adenocarcinoma of the body and tail.
        Br J Surg. 2018; 105: 1171-1181
        • Neoptolemos J.P.
        • Palmer D.H.
        • Ghaneh P.
        • et al.
        Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): A multicentre, open-label, randomised, phase 3 trial.
        Lancet. 2017; 389: 1011-1024
        • Conroy T.
        • Hammel P.
        • Hebbar M.
        • et al.
        FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer.
        N Engl J Med. 2018; 379: 2395-2406
        • Michalski C.W.
        • Kleeff
        • Wente M.N.
        • Diener M.K.
        • Büchler M.W.
        • Friess H.
        Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer.
        Br J Surg. 2007; 94: 265-273
        • Eskander M.F.
        • de Geus S.W.
        • Kasumova G.G.
        • Ng S.C.
        • Al-Refaie W.
        • Ayata G.
        • Tseng J.F.
        Evolution and impact of lymph node dissection during pancreaticoduodenectomy for pancreatic cancer.
        Surgery. 2017; 161: 968-976
        • Tanaka M.
        • Mihaljevic A.L.
        • Probst P.
        • et al.
        Meta-analysis of recurrence pattern after resection for pancreatic cancer.
        Br J Surg. 2019; 106: 1590-1601
        • Kim K.S.
        • Kwon J.
        • Kim K.
        • Chie E.K.
        Impact of resection margin distance on survival of pancreatic cancer: A systematic review and meta-analysis.
        Cancer Res Treat. 2017; 49: 824-833
        • Hackert T.
        • Strobel O.
        • Michalski C.W.
        • et al.
        The TRIANGLE operation—Radical surgery after neoadjuvant treatment for advanced pancreatic cancer: A single arm observational study.
        HPB (Oxford). 2017; 19: 1001-1007
        • Inoue Y.
        • Saiura A.
        • Yoshioka R.
        • et al.
        Pancreatoduodenectomy with systematic mesopancreas dissection using a supracolic anterior artery-first approach.
        Ann Surg. 2015; 262: 1092-1101
        • Kawabata Y.
        • Tanaka T.
        • Ishikawa N.
        • Hayashi H.
        • Tajima Y.
        Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer.
        Eur J Surg Oncol. 2016; 42: 698-705
        • Groot V.P.
        • Blair A.B.
        • Gemenetzis G.
        • et al.
        Recurrence after neoadjuvant therapy and resection of borderline resectable and locally advanced pancreatic cancer.
        Eur J Surg Oncol. 2019; 45: 1674-1683
        • Tempero M.A.
        • Malafa M.P.
        • Behrman S.W.
        • et al.
        Pancreatic adenocarcinoma, version 2.2014: Featured updates to the NCCN guidelines.
        J Natl Compr Canc Netw. 2014; 12: 1083-1093
        • Miao Y.
        • Jiang K.
        • Cai B.
        • et al.
        Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC).
        Pancreatology. 2016; 16: S59
        • Cai B.
        • Lu Z.
        • Jiang K.
        • et al.
        Survival of unresectable pancreatic cancer patients after artery divestment combined pancreatectomy: A retrospective and propensity score-matched analysis.
        Ann Pancreat Cancer. 2018; 1: AB081
        • Tee M.C.
        • Krajewski A.C.
        • Groeschl R.T.
        • et al.
        Indications and perioperative outcomes for pancreatectomy with arterial resection.
        J Am Coll Surg. 2018; 227: 255-269
        • Del Chiaro M.
        • Rangelova E.
        • Halimi A.
        • et al.
        Pancreatectomy with arterial resection is superior to palliation in patients with borderline resectable or locally advanced pancreatic cancer.
        HPB (Oxford). 2019; 21: 219-225
        • Hackert T.
        • Sachsenmaier M.
        • Hinz U.
        • et al.
        Locally advanced pancreatic cancer: Neoadjuvant therapy with Folfirinox results in resectability in 60% of the patients.
        Ann Surg. 2016; 264: 457-463
        • Ferrone C.R.
        • Marchegiani G.
        • Hong T.S.
        • et al.
        Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer.
        Ann Surg. 2015; 261: 12-17
        • Weitz J.
        • Rahbari N.
        • Koch M.
        • Büchler M.W.
        The “artery first” approach for resection of pancreatic head cancer.
        J Am Coll Surg. 2010; 210: e1-e4
        • Sanjay P.
        • Takaori K.
        • Govil S.
        • Shrikhande S.V.
        • Windsor J.A.
        ‘Artery-first’ approaches to pancreatoduodenectomy.
        Br J Surg. 2012; 99: 1027-1035
        • Akita M.
        • Yamasaki N.
        • Miyake T.
        • et al.
        Cattell-Braasch maneuver facilitates the artery-first approach and complete excision of the mesopancreas for pancreatoduodenectomy.
        J Surg Oncol. 2020; 121: 1126-1131
        • Schneider M.
        • Strobel O.
        • Hackert T.
        • Büchler M.W.
        Pancreatic resection for cancer—The Heidelberg technique.
        Langenbecks Arch Surg. 2019; 404: 1017-1022
        • Cao F.
        • Li J.
        • Li A.
        • Li F.
        Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis.
        BMC Surg. 2017; 17: 67
      2. Schmidt T, Strobel O, Schneider M, et al. Cavernous transformation of the portal vein in pancreatic cancer surgery – venous bypass graft first [E-pub ahead of print]. Langenbecks Arch Surg. 2020. Accessed September 26, 2020.

        • Tol J.A.
        • Gouma D.J.
        • Bassi C.
        • et al.
        Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: A consensus statement by the International Study Group on Pancreatic Surgery (ISGPS).
        Surgery. 2014; 156: 591-600
        • Mihaljevic A.L.
        • Kleeff J.
        • Friess H.
        Adenocarcinoma of the pancreas.
        in: Graeme J. Poston G.J. D’Angelica M. Adam R. Surgical management of hepatobiliary and pancreatic disorders. Informa Healthcare, London2011: 380-400
        • McCulloch P.
        • Cook J.A.
        • Altman D.G.
        • et al.
        IDEAL framework for surgical innovation 1: The idea and development stages.
        BMJ. 2013; 346: f3012
        • Cai S.
        • Hong T.S.
        • Goldberg S.I.
        • et al.
        Updated long-term outcomes and prognostic factors for patients with unresectable locally advanced pancreatic cancer treated with intraoperative radiotherapy at the Massachusetts General Hospital, 1978 to 2010.
        Cancer. 2013; 119: 4196-4204
        • Strobel O.
        • Hartwig W.
        • Hackert T.
        • et al.
        Re-resection for isolated local recurrence of pancreatic cancer is feasible, safe, and associated with encouraging survival.
        Ann Surg Oncol. 2013; 20: 964-972
        • Ghaneh P.
        • Palmer D.H.
        • Cicconi S.
        • et al.
        ESPAC-5F: Four-arm, prospective, multicenter, international randomized phase II trial of immediate surgery compared with neoadjuvant gemcitabine plus capecitabine (GEMCAP) or FOLFIRINOX or chemoradiotherapy (CRT) in patients with borderline resectable pancreatic cancer.
        J Clin Oncol. 2020; 38: 4505