Safety and efficacy of first arterial approach in management of pancreatic head carcinoma

Objective: This prospective study aimed to evaluate the technical feasibility, safety, and impact of the first arterial approach (FAA) during pancreaticoduodenectomy for pancreatic head adenocarcinoma on R0 resection rates, intraoperative blood loss, operative time, and the early identification of unresectable disease. Patients and Methods: One hundred consecutive patients undergoing pancreaticoduodenectomy for pancreatic head adenocarcinoma at Al-Azhar university hospitals (Jan 2023 – Dec 2024) uniformly employed the FAA, involving initial dissection and control of the SMA and common hepatic artery before pancreatic transection or venous dissection. Primary outcomes were R0 resection rate, intraoperative blood loss, operative time, and proportion of early unresectability identification. Secondary outcomes included postoperative complications (pancreatic fistula, hemorrhage, delayed gastric emptying) and short-term survival. Results: FAA was technically feasible in all cases. An R0 resection was achieved in 88% (88/100) of patients. Mean intraoperative blood loss was 350 ± 120 mL; mean operative time was 380 ± 75 minutes. Unresectable disease was identified early in 10% (10/100) of patients, preventing further extensive dissection. Clinically relevant pancreatic fistula (Grade B/C) was 15%, post-pancreatectomy hemorrhage 7%, and delayed gastric emptying 18%. The 30-day mortality rate was 2%. Conclusion: The first arterial approach in PD for pancreatic head cancer is feasible and safe, facilitating early resectability assessment and contributing to high R0 rates. This approach optimizes surgical strategy by avoiding unnecessary extensive dissection in unresectable cases, offering acceptable perioperative outcomes, and supporting its adoption in specialized centers.