Periarterial Divestment of the Superior Mesenteric Artery Utilizing Dual Artery First Approach for Locally Advanced Pancreatic Cancer.

Background: For locally advanced pancreatic cancer (LAPC) involving the superior mesenteric artery (SMA), periarterial and sub-adventitial divestment offers oncologic efficacy while minimizing postoperative complications and mortality. However, safe and standardized techniques for circumferential SMA dissection remain limited.^1,2 We adopted a dual SMA-first strategy-posterior and left-sided approaches-to improve arterial control, enhance surgical exposure, and ensure procedural safety.

Patients and methods: Two patients (a 70-year-old female and a 30-year-old male) with pancreatic uncinate process tumors measuring 34-36 mm, both encasing 180° of the SMA and invading the superior mesenteric vein (SMV), underwent conversion pancreaticoduodenectomy with SMA adventitial divestment and SMV resection. Key operative steps included the Cattell-Braasch maneuver for wide exposure; posterior SMA-first approach for early control and mobilization of a 3-4 cm avascular segment of the artery; and left-sided approach from below the mesentery to access the distal SMA. The inferior pancreaticoduodenal artery (IPDA) and first jejunal artery (JA1) were ligated at their origins to facilitate dissection. A combined proximal-down and distal-up pathway allowed for safe and effective circumferential sub-adventitial divestment. Sharp dissection with angled scissors was employed to minimize vascular trauma, aneurysm formation, or stenosis. The dual approach provided excellent visualization of arterial landmarks and optimal access to the tumor-infiltrated mesopancreas.³ RESULTS: Both patients had uneventful postoperative courses. One developed grade A lymphatic leakage; neither experienced bleeding or pancreatic fistula. Both were discharged within 2 weeks and remained recurrence-free at 20-month follow-up. Literature comparisons highlight lower morbidity and comparable survival in periarterial divestment versus arterial resection.^4,5 CONCLUSIONS: The dual posterior and left-sided SMA-first approach provides a safe, effective, and anatomically strategic method for circumferential SMA divestment in LAPC. Larger series are needed to validate long-term oncologic outcomes.