Cattell-Braasch maneuver combined with “superior mesenteric artery first” approach for resection of borderline resectable pancreatic cancer

Pancreatic cancer has a poor prognosis, with up to 90% of cancers diagnosed as locally advanced/unresectable due to vascular invasion involving the portal vein (PV), superior mesenteric vein (SMV), and superior mesenteric artery (SMA) (1). For the 10–15% of patients that are deemed resectable, a pancreaticoduodenectomy (PD) is the only effective treatment for tumors involving the head of the pancreas. The traditional approach to a PD involves confirming resectability based on vascular involvement early in the operation. Arterial involvement of the SMA is considered a contraindication for surgical resection; however, intraoperative identification of SMA involvement typically occurs once there is a commitment to proceeding with a PD when utilizing a traditional approach. A modification of the traditional approach has been proposed for resection of borderline resectable tumors when there is concern for possible SMA involvement. Termed the “SMA first approach”, the aim is to facilitate early recognition of unresectability to avoid a potential microscopic/macroscopically incomplete (R1/R2) resection (2).