Overview
Definition:
The artery-first approach in pancreaticoduodenectomy (PD), also known as the Whipple procedure, is a surgical technique that prioritizes the dissection and ligation of the superior mesenteric artery (SMA) and/or celiac axis early in the operation
This contrasts with traditional approaches that often begin with portal vein dissection
The primary goal is to achieve early control of arterial supply to the specimen, potentially facilitating broader lymph node dissection and improving oncological margins.
Epidemiology:
Pancreaticoduodenectomy is primarily performed for resectable periampullary malignancies, including adenocarcinoma of the head of the pancreas, distal common bile duct, duodenum, and ampulla of Vater
Pancreatic cancer is a significant health concern, with an increasing incidence in some regions
The artery-first approach is a refinement of the standard Whipple procedure, gaining traction in centers with high volumes of pancreatic surgery.
Clinical Significance:
This approach offers potential advantages in managing complex cases, particularly those with locally advanced disease or significant inflammation surrounding the celiac axis and SMA
Early arterial control can simplify the dissection plane and allow for more aggressive nodal clearance, which is crucial for improving oncological outcomes
It may also aid in achieving negative margins, a key determinant of survival in pancreatic cancer
Understanding this technique is vital for surgical residents preparing for complex GI surgery cases and examinations.
Indications
Absolute Indications:
Resectable adenocarcinoma of the pancreatic head, uncinatable segment of the pancreas, distal common bile duct, or ampulla of Vater
Benign conditions requiring pancreaticoduodenectomy such as chronic pancreatitis with specific ductal anatomy or cystic neoplasms in specific locations.
Relative Indications:
Tumors with suspected involvement of the celiac axis or SMA that may benefit from early arterial control
Cases with extensive lymphadenopathy
Patients requiring neoadjuvant therapy where early assessment of resectability and potential for complete clearance is paramount.
Contraindications:
Metastatic disease
Unresectable local invasion into major vessels (e.g., SMV or portal vein involvement making reconstruction impossible)
Significant comorbidities precluding major surgery
Inability to achieve R0 resection based on preoperative imaging and intraoperative assessment.
Preoperative Preparation
Imaging Evaluation:
High-resolution contrast-enhanced CT scan is essential for assessing tumor resectability, involvement of mesenteric vessels (SMA, celiac axis, SMV, portal vein), and presence of distant metastases
MRI may be used for further characterization of liver lesions or pancreatic ductal anatomy
MRCP is valuable for evaluating biliary and pancreatic ductal systems.
Nutritional Assessment:
Malnutrition is common in pancreatic cancer patients
Nutritional support, including enteral or parenteral nutrition, should be initiated preoperatively to optimize patient status
Pancreatic enzyme supplementation may be considered.
Laboratory Tests:
Complete blood count (CBC), liver function tests (LFTs), renal function tests (RFTs), coagulation profile, serum amylase and lipase, carbohydrate antigen 19-9 (CA 19-9) for baseline and monitoring
Blood type and crossmatch for potential transfusion.
Anesthesia Considerations:
This is a prolonged and complex procedure requiring meticulous anesthetic management
Close monitoring of hemodynamics, fluid balance, and temperature is critical
Epidural analgesia may be considered for postoperative pain control.
Procedure Steps Artery First
Initial Laparotomy And Assessment:
Exploratory laparotomy to confirm resectability and assess for peritoneal spread or occult metastases
Confirmation of the absence of widespread metastatic disease.
Arterial Dissection And Ligation:
Careful dissection of the celiac axis and superior mesenteric artery (SMA)
The gastroduodenal artery (GDA), a branch of the common hepatic artery (which arises from the celiac axis), is identified and ligated
The origin of the SMA is dissected, and if involved or for aggressive nodal clearance, the SMA itself may be ligated and divided distally.
Portal Vein Dissection:
Following arterial control, the portal vein and superior mesenteric vein (SMV) are dissected
The portal vein is often divided proximally to the confluence with the SMV
The SMV may be ligated and divided distally, depending on the extent of lymphadenectomy required.
Specimen Mobilization:
Mobilization of the pancreatic head, duodenum, and distal stomach
The uncinate process of the pancreas is dissected from the SMV and SMA
The common hepatic artery is identified and divided
The gastrocolic trunk and right colic artery may also require division.
Pancreaticojejunostomy And Anastomoses:
After specimen removal, reconstruction involves creating a pancreaticojejunostomy (often a duct-to-mucosa or invagination technique), a choledochojejunostomy (biliary-enteric anastomosis), and a gastrojejunostomy (gastric-enteric anastomosis)
The order of reconstruction may vary.
Postoperative Care
Icu Monitoring:
Close monitoring in an intensive care unit (ICU) for hemodynamic stability, respiratory function, fluid balance, and pain management
Monitoring of drain output and biochemical parameters.
Pain Management:
Aggressive pain control is essential
This may include patient-controlled analgesia (PCA), epidural analgesia, and judicious use of opioids
Multimodal pain management strategies are preferred.
Nutritional Support:
Continued nutritional support, often starting with clear liquids and advancing to a regular diet as tolerated
Pancreatic enzyme replacement therapy is crucial for managing maldigestion and steatorrhea
Enteral feeding via a post-pyloric tube may be necessary.
Drain Management:
Surgical drains are typically placed in the pancreaticojejunostomy site and the subhepatic space
Drain management involves monitoring output, amylase levels, and determining the appropriate time for removal, often guided by drain characteristics and absence of leak.
Early Mobilization:
Early ambulation and mobilization are encouraged to prevent deep vein thrombosis (DVT), pneumonia, and promote gut motility
Respiratory physiotherapy is also important.
Complications
Early Complications:
Pancreatic fistula (most common and serious complication) with leak from the pancreaticojejunostomy
Biliary leak
Hemorrhage from arterial or venous dissection sites
Intra-abdominal abscess
Delayed gastric emptying
Pancreatitis
Cholangitis.
Late Complications:
Bowel obstruction (adhesions)
Marginal ulcer
Weight loss and malabsorption
Recurrence of malignancy
Strictures at the anastomotic sites.
Prevention Strategies:
Meticulous surgical technique, particularly in handling the pancreatic remnant and securing the pancreaticojejunostomy
Careful ligation of all vessels
Intraoperative use of fibrin glue or pancreatic stenting for the pancreaticojejunostomy
Prophylactic antibiotics
Judicious use of drains
Aggressive pain and glycemic control
Postoperative nutritional support with enzyme replacement.
Key Points
Exam Focus:
The artery-first approach aims for early arterial control to facilitate dissection and nodal clearance in PD
Key vessels controlled early are the SMA and/or celiac axis
This approach is particularly useful in complex cases or locally advanced tumors
Pancreatic fistula remains the most significant complication.
Clinical Pearls:
Thorough preoperative imaging is paramount to assess vascular involvement and resectability
Early identification and ligation of the GDA is a crucial first step
If SMA is ligated, ensure adequate collateral flow to the bowel
Reconstruction sequence (pancreas, bile duct, stomach) is critical and may vary
prioritize secure pancreatic anastomosis.
Common Mistakes:
Inadequate lymphadenectomy
Incomplete dissection of the uncinate process from the SMV/SMA, leading to bleeding or positive margins
Injudicious division of the SMA without assessing collateral circulation
Insecure pancreaticojejunostomy, leading to fistula formation
Failure to manage postoperative pancreatic enzyme deficiency.