Standardized Approach to Superior Mesenteric Artery Resection for Locally Advanced Pancreatic Cancer

Novel multimodal treatment strategies might enable curative-intent resection of locally advanced pancreatic cancer (LAPC). While venous resections are routinely performed, arterial resections remain part of individualized treatment strategies in a few expert centers. Historically, SMA involvement, by definition, precluded resectability. However, in selected patients with excellent response to preoperative treatment, arterial resection has been associated with satisfactory outcomes in high-volume centers with significant experience in extended and vascular resections. Even though arterial divestment is increasingly performed if technically possible, arterial resection is still required when the arterial wall cannot be preserved to achieve macroscopically complete resection, especially if the SMA is encased along with its branches in SMA segment 2. Usually, the SMV is also encased in these tumors, and combined arterial and venous resections are necessary. Here, we describe our approach to SMA resection and reconstruction after neoadjuvant treatment in a 64-year-old female patient with locally advanced pancreatic ductal adenocarcinoma (PDAC) and complete encasement of the SMA in segment 2. Critical steps in this situation are assessing the feasibility of SMA and SMV resection using an infracolic artery first approach, performing a wide Kocher maneuver to access the SMA from the right, and the Cattell-Braasch maneuver to enable tension-free direct end-to-end anastomoses.