Optimal Extent of Superior Mesenteric Artery Dissection during Pancreaticoduodenectomy for Pancreatic Cancer: Balancing Surgical and Oncological Safety

  • Yosuke Inoue
  • Akio SaiuraEmail author
  • Atsushi Oba
  • Shoji Kawakatsu
  • Yoshihiro Ono
  • Takafumi Sato
  • Yoshihiro Mise
  • Takeaki Ishizawa
  • Yu Takahashi
  • Hiromichi Ito
Original Article



We describe the short- and long-term outcomes for PDAC patients after tailored mesopancreas dissection using supracolic artery-first approach followed by adjuvant therapy.


This study analyzed 233 consecutive patients who underwent artery-first pancreaticoduodenectomy for PDAC. Dissection extent for the superior mesenteric artery (SMA) was categorized into three levels: level 2 (LV2) including regional lymph nodes, level 3 (LV3) with hemicircumferential nerve plexus dissection, and extended-level 3 (E-LV3) including borderline resectable cases for the SMA. All clinical, pathological, and survival outcomes were reviewed.


LV2/3/E-LV3 dissection was performed in 77/115/41 patients. The short-term outcomes were similar among groups without mortality. Although postoperative diarrhea requiring opioids was significantly more frequent in the E-LV3 group (76%) than other groups (vs. LV2 (21%), P < .0001; vs. LV3 (34%), P < .0001; LV2 vs. LV3, P = 0.20), most cases of diarrhea were well controlled. Adjuvant chemotherapy was introduced similarly among groups (LV2, 76%; LV3, 81%; E-LV3, 88%, P = 0.29). The 3- and 5-year overall survival rates in the LV2/3/E-LV3 groups were 42/33/42% and 27/22/26%, respectively, showing no significant difference among groups.


Our tailored dissection and preemptive use of opioid antidiarrheal effectively prevents intractable diarrhea, increasing the success of adjuvant chemotherapy.


Pancreaticoduodenectomy Artery first Superior mesenteric artery Diarrhea Adjuvant therapy 





superior mesenteric artery


pancreatic ductal adenocarcinoma


the nerve plexus around the SMA


lymph node


level 2


level 3


borderline resectable


extended-level 3


adjuvant chemotherapy


portal vein


hepatic artery


postoperative pancreatic fistula


delayed gastric emptying



We thank Mr. Koki Tazoe (a free graphic designer, Nerima-ku, Tokyo) for the valuable edition of digital illustration as schemata in the article.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Yosuke Inoue
    • 1
  • Akio Saiura
    • 1
    Email author
  • Atsushi Oba
    • 1
  • Shoji Kawakatsu
    • 1
  • Yoshihiro Ono
    • 1
  • Takafumi Sato
    • 1
  • Yoshihiro Mise
    • 1
  • Takeaki Ishizawa
    • 1
  • Yu Takahashi
    • 1
  • Hiromichi Ito
    • 1
  1. 1.Department of Gastrointestinal SurgeryCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan

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