Standardization of surgical procedure for initially unresectable locally advanced pancreatic head cancer

Purpose The surgical procedures for initially unresectable locally advanced (URLA) pancreatic head cancer are extremely challenging owing to the severe arterial and portal vein invasions. This study aimed to propose surgical standardization plan and evaluate the efficacy of standardized procedures. Methods Institutional conferences were held in April 2020 and March 2021 to standardize surgical procedures for URLA pancreatic head cancer. URLA cases with invasion around the celiac artery (CA) and superior mesenteric artery (SMA) were classified as UR-CA and UR-SMA types, respectively. The standardized procedures for arterial and portal venous invasion were discussed for each type, and the utility of standardization was evaluated by comparing the surgical outcomes before and after standardization (the early and late groups). Results Five difficult surgical situations arising from arterial and portal vein invasion were identified, and the strategies for these situations were defined as standardized procedures. ''Early pancreatic and splenic vein transection to the left of SMA'' and ''preresection portal vein reconstruction in cases with collateralization'' were the two most important procedures. The early and late groups comprised seven and 11 patients, respectively. The rates of arterial resection (57.1% vs. 72.7%) and portal vein resection (PVR) (85.7% vs. 100%) were higher in the late group. Intraoperative blood loss (1650 mL vs. 530 mL, p = 0.001), blood transfusion rate (42.9% vs. 0%, p = 0.043), and severe complication rate (42.9% vs. 0%, p = 0.043) were significantly lower in the late group. Conclusions Standardization of surgical procedures yielded better surgical outcomes.