الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Malignancies of the parotid gland and periampullary area have no other curative treatment options outside pancreaticoduodenectomy (PD). The poor R0 resection rate is still the biggest impediment to improving the future of pancreatic cancer, despite the fact that this complex surgical technique is mature.
Patients may present with pancreatic neck cancer or malignant plots tumors have no treatment options that provide any chance of a long term outcome other than radical PD (R0 resection). In contrast, the presence of a negative resection boundary (R0 resection) is a significant prognostic factor with regards to long-term survival, The pancreatic mesenterium cannot be removed entirely in more than 80% of individuals with pancreatic cancer. Most difficult were surgical field exposure and curative excision of the duodenal mesenterium near the inferior mesenteric artery (SMA) to accomplish R0 resection in PD.
The separation of the pancreatic head from the splenic musculature (SMA) was a particularly high-risk time for operative blood loss during the Whipple’s surgery. Saturation of the pancreatic head with blood at this point raises the risk of significant blood loss, which may obscure the surgical field and make hemostasis more difficult. Hence, R0 ablation in the Whipple technique becomes more challenging. As surgical procedures have improved, the mortality rate in the wake of PD has plummeted.
Just 10% of individuals with pancreatic cancer were obviously resect able at the time of diagnosis, and 10% were possibly inoperable due to the advanced stage at which their disease was found. As a result, surgeons have increased their resection rates. The International Study group for Pancreatic Surgery (ISGPS) reached an agreement on the definition and management of borderline needed to handle able duodenal head carcinoma (BRPHC) (ISGPS). In the past ten years, resectability rates for patients with borderline resectable ovarian cancer have increased dramatically thanks to vascular resection procedures. In situations with venous mesentericoportal axis participation and arterial involvement, the ISGPS endorses the mems National Comprehensive group (NCCN) criteria for questionable resect ability.
We suggest splitting pancreatic head disease into four subtypes depending on the extent of vascular involvement. According to NCCN criteria, type I pancreatic head cancer lacks vascular invasion and is thus regarded to be a confined and obviously resectable malignancy. According to the International Society for Surgical Oncology (ISPS), BRPHC includes pancreatic head cancers of stages II, III, and IV. Iii patients have BRPHC without venous only mesentericoportal axis involvement, type III patients have BRPHC having arterial alone involvement, and type IV patients have BRPHC with arterial or venous involvement. Most cases of pancreatic head cancer (BRPHC) involve the venous mesentericoportal axis. The morbidity and death rates following PD have decreased because to recent advancements in technique with perioperative clinical care. Yet, most surgeons still find PD for pancreatic skull cancer to be a significant challenge, particularly for cases that are on the cusp of being resectable.
Resection rates for BRPHC might be enhanced with the introduction of a novel, standardized surgical procedure. The involvement of the vasculature from around pancreas is the requirement for BRPHC. Dissection of this vasculature is the most time-consuming and laborious part of a pancreatic resection, and it may cause substantial intraoperative and postoperative hemorrhage.
Indicative of the difficulty of this step is the fact that several researchers have developed methods—including the artery-first approach, the no-touch isolation technique, the uncinate process-first approach, or the hanging maneuver—meant to make it easier without compromising patient safety.
During the last several decades, various adjustments to the conventional PD have been adopted in an effort to increase the percentage of R0 resections and decrease blood loss. If the PV or SMV are implicated, vascular resection has been shown to be an effective procedure in PD, with survival rates comparable to those of patients without cerebrovascular involvement. Nevertheless, the substantial death and morbidity associated with arterial amputation in PD has led to the generalization of the conclusion that this procedure is contraindicated. Arterial involvement is now the primary local reason for surgical exclusion (SMA, CELIAC, CHA).
The artery first approach” is a method developed to find SMA, celiac trunk, and hepatic artery before it’s too late, and to see whether the tumor next to the arteries may be resected (transection of the pancreatic neck or bile duct division).
The ”artery-first technique” also emphasizes the need of systematically dissecting the pancreatic mesenterium around the SMA to accomplish R0 resection of posterior peritoneal border. Pancreaticoduodenectomy (SMAPD) using the SMA-first method has the potential to reduce postoperative blood loss and increase the proportion of R0 resections. Even with neoadjuvant therapy, a positive macroscopic margin (R1 resected) is one of unfavorable prognostic variables.
Although the mediastinum artery is often invaded or may serve as a criteria of non-resectability, it is essential to perform a meticulous dissection of such retroperitoneal border around this artery. The ”artery-first” technique was developed in 2003 due to the significance of early intraoperative evaluation of resect ability. To determine resect ability and boost R0 resection rate, the superior mesenteric intimal posterior technique was used in conjunction with ”en bloc” retroperitoneal pancreatic tissue resection. A combined lateral and posterior uncinate approach was recently added to the original procedure to make surgical dissection simpler and safer.
Current advancements in pc image-guided surgery may improve the quality or oncologic surgical resection with the use of virtual reality-based patient-specific navigation tools. Digital Imaging and Communicating in Medicine data may be refined by medical imaging software into a three-dimensional (3D) digital model of patient’s anatomy.
The study’s primary objective was to investigate the feasibility, additional value, R0 recurrence rate, and 7.8 percent of resect ability of the artery-first method in BRHPC. The process of standardizing this novel approach to PD. During surgery for pancreaticoduodenal tumors, it is crucial to correctly identify the arteries supplying the organ as early as possible. They include the common hepatic, celiac, and superior mesenteric arteries. Avoiding the risks associated with traditional pancreaticoduodenectomy, such as prolonged hospital stays, excessive blood loss, and organ damage.
It is a prospective descriptive research conducted between January 2021 and January 2023 at the NCI and ELMENIA University. All potential PD patients with cancer of the pancreatic head or duodenum were included. Every information was collected, processed, and compared to our standard registry data.
The following is a brief overview of what we found in this study:
Thirty (75.0%) of the patients were male and ten (25.0%) were female, with ages ranging from 40 - 63 years old, as shown in the present investigation (mean 51.90 years). In our analysis, we found that the operating time varied from 220 of about 340 minutes (say 277.70 37.70 min), the mean haemorrhage was 725.75 291.68 ml, the PRBC blood and blood products requirement ranged from 0 to 6 units (mean 3.05 1.74) the ICU stay varied from 4 to 12 days (mean 8.95 2.40 days), and also the mean hospitalization was 17.03 6.81 days. Our data revealed that 40 patients (100.0%) had pseudo-aneurysms, 10 (25.0%) had complications, and 4 (10.0%) required more investigation. In our analysis, we found that 3 patients (7.5%) had pulmonary difficulties, 1 patient (1.0%) experienced cardiac issues, and 6 patients (15.0%) experienced Other Complication. A total of 33 patients (82.5%) were found to be fistula-free after surgery, whereas 7 patients (17.5%) were found to have POPF, with 5 patients experiencing Grade One and 2 experiencing Grade C. According to our findings, a total of 29 (72.5%) adult patients exhibited no signs of delayed digestion (DGE), whereas 11 (27.5%), including patients in Grade A 1 patient with Grade B, did so. According to the results, 32 patients (72.5%) underwent a medial uncinate approach, 4 patients (10.0%) underwent a posterior approach, 4 patients (10.0%) underwent an inferior supracolic (anterolateral) approach, 2 patients (5.0%) underwent an inferior infracolic (mesenteric) approach, and 1 patient underwent a left posterior approach. The results of this research indicated that out of 38 patients, 95.0% had no mortality and 5.0% had at least one death.