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Commentary: Periadventitial dissection of the superior mesenteric artery at pancreatoduodenectomy for locally advanced pancreatic cancer

Published:December 19, 2020DOI:https://doi.org/10.1016/j.surg.2020.10.046
      Cancer cells routinely infiltrate from adenocarcinomas of the pancreas (PDAC) into the soft tissues and nerves that lie between the head of the gland and the superior mesenteric artery (SMA).
      • Bapat A.A.
      • Hostetter G.
      • Von Hoff D.D.
      • Han H.
      Perineural invasion and associated pain in pancreatic cancer.
      These cells, which are often radiographically occult, serve as a possible nidus for postoperative cancer “recurrence” if left in situ after a pancreatoduodenectomy (PD). Therefore, we at the University of Texas MD Anderson Cancer Center in Houston, TX, have long advocated meticulous periadventitial dissection of the right lateral aspect of the SMA at PD for every patient with PDAC, irrespective of the apparent distance between their primary tumor and the SMA on either cross-sectional imaging studies or on direct inspection of the retroperitoneum.
      • Katz M.H.
      • Wang H.
      • Balachandran A.
      • et al.
      Effect of neoadjuvant chemoradiation and surgical technique on recurrence of localized pancreatic cancer.
      Periadventitial dissection of the right lateral aspect of the SMA is now accepted as a quality standard for pancreatic surgery.
      • Vreeland T.
      • Tzeng C.W.
      • Katz M.H.G.
      Pancreatoduodenectomy: Superior mesenteric artery dissection. American College of Surgeons Web site.
      When the primary tumor appears distant from the artery, the technique is used to maximize the clearance of potential cancer-bearing soft tissues adjacent to the pancreatic head. When direct abutment of the artery by a solid tumor is obvious, the same technique can be used to cleanly separate the tumor from the artery. In either case, the technique maximizes the distance between tumor cells and the SMA margin, and thereby minimizes the possibility of a microscopically positive (R1) resection.
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