Comparison of ‘Posterior (SMA-First)-Approach’ to ‘Standard-Approach’ in Terms of Circumferential Resection Margin, Lymph Node Retrieval and Long-Term Survival after Pancreaticoduodenectomy for Periampullary and Pancreatic Carcinoma: A Randomized Controlled Trial

Abstract

Introduction: SMA-first-approach to pancreatoduodenectomy (PD) was found to be associated with better oncological outcomes as compared to the standard-approach in our pilot study. Hence, we performed a randomized controlled trial to compare these two-approaches in terms of resection margins, lymphnode-retrieval and long-term survival. Methods: Between January2014 to December2018, all consecutive patients undergoing PD for periampullary cancer at the Department of Gastrointestinal Surgery, AIIMS, New Delhi were assessed for randomization. Primary outcomes were R0 resection-rate and number of lymphnodes retrieved. The secondary outcomes were operating-time, blood-loss, postoperative-complications, recurrence-free and overall-survival. Results: Of 299 patients assessed, 203 were randomized and 183 analyzed(20:excluded after randomization, 90:patients-SMA, 93:patients-classical). The median age of the study population was 56(14-78) years, with predominantly male(138, 68%) and with periampullary tumours(89%). The demographic-profile, preoperative clinical and laboratory parameters were comparable. The blood-loss was significantly higher in SMA-first group (675vs600 ml, p=0.02) however the operating time and the need for blood transfusion were comparable in both the groups. ISGPS Grade B/C pancreatojejunostomy leak(20vs24.7%, p=0.68), post-pancreatectomy haemorrhage(8.8vs14%, p=0.38), delayed gastric emptying(37.8vs40.9%, p=0.67) and Clavien–Dindo grade ≥III complications(27.7vs31.2, p=0.85) were similar in both the groups. The R0 resection-rates(82.2vs78.5%, p=0.53) and total lymphnodes retrieved(18vs17, p=0.63) were similar between the two groups. Both groups were comparable in terms of median recurrence-free(48vs44 months, p=0.85) and overall-survival(53vs51 months, p=0.69). Conclusions: ‘Posterior-(SMA-first)-approach’ and ‘Standard-approach’ for pancreatoduodenectomy for periampullary cancer yielded equivalent results in terms of R0 resection-rate, number of lymphnodes retrieved, recurrence-free and overall-survival.