Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki, 309-1793, Japan.
Surg Today. 2021 Jun;51(6):872-879. doi: 10.1007/s00595-020-02150-z. Epub 2020 Sep 22.
When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.
当胰头癌侵犯肠系膜上动脉（SMA）时，根治性切除术即被放弃。术前影像学诊断以确定手术的可切除性尚未超过术中通过检查、触诊和试探性解剖获得的信息。胰十二指肠切除术（PD）是治疗壶腹周围癌的标准措施。在传统的 PD 中，SMA 的侵犯通常通过解剖门静脉后的后腹膜层来确定，该层连接了钩突和 SMA 神经丛。在胰头癌的 PD 中，这种腹膜后边界经常影响手术的可切除性。在 PD 中首先处理 SMA 的方法是通过切断胰腺颈部后首先解剖 SMA，以便在手术早期评估胰腺癌对 SMA 的侵犯。首例此类方法的报道随后引发了各种现在统称为“动脉优先”方法的操作报告。我们根据（1）SMA 入路所在的结肠系膜侧（结肠上或结肠下）和（2）入路方向（右侧或左侧和前侧或后侧）对这些方法进行分类进行综述。报告的 PD 程序的步骤根据时间线编号，并使用 SMA 的解剖分区进行总结。
