Divestment–Adventitia Resection in Order to Decrease Morbidity and Mortality and Improve R0/R1 Ratio in Curative Pancreatoduodenectomy for Advanced Pancreatic Head Carcinoma

Aleksandar  Shumkovski; Ljubomir Ognjenovic; Robert Shumkovski; Arbijon Kolari

doi:10.3889/oamjms.2026.12162

Authors

Aleksandar Shumkovski Clinic of Digestive Surgery, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, Republic of North Macedonia https://orcid.org/0009-0008-6890-8505
Ljubomir Ognjenovic Clinic of Digestive Surgery, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, Republic of North Macedonia
Robert Shumkovski Clinic of Neurosurgery, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, Republic of North Macedonia
Arbijon Kolari Clinic for Surgical Diseases “St. Naum Ohridski”, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, Republic of North Macedonia https://orcid.org/0009-0003-9441-0982

DOI:

https://doi.org/10.3889/oamjms.2026.12162

Keywords:

Pancreatic head carcinoma, Pancreatoduodenectomy, Arterial divestment, Borderline resectable pancreatic cancer, R0 resection

Abstract

BACKGROUND: Pancreatic head carcinoma (PHC) is a highly aggressive malignancy associated with substantial morbidity, mortality, and poor long-term survival. Achieving an R0 resection margin during pancreatoduodenectomy (PD) is crucial for improving oncological outcomes. However, in borderline resectable (BRPHC) and locally advanced pancreatic head carcinoma (LAPHC), arterial involvement often necessitates complex arterial resections associated with high perioperative risks. Periarterial sub-adventitial divestment has emerged as a potential alternative to arterial resection, aiming to improve radicality while reducing complications.

AIM: To evaluate whether sub-adventitial arterial divestment during curative pancreatoduodenectomy decreases perioperative morbidity and mortality and improves the R0/R1 resection ratio in patients with BRPHC and LAPHC.

METHODS: A retrospective study was conducted on 50 consecutive patients with BRPHC or LAPHC treated between 2009 and 2017 following neoadjuvant therapy when indicated. All patients underwent extensive pancreatoduodenectomy with triangle operation, extended lymphadenectomy, and periarterial sub-adventitial divestment of the superior mesenteric, common hepatic, and/or celiac arteries. Clinicopathological data, perioperative morbidity, mortality, length of hospital stay, and R0/R1 resection status were analyzed.

RESULTS: Among the 50 patients, 27 (54%) were male and 23 (46%) were female, with a mean age of 63.1 ± 8.97 years. Overall mortality was 8% (4/50). Major complications included postoperative pancreatic fistula (24%), postoperative biliary fistula (2%), postpancreatectomy hemorrhage (4%), reoperation (6%), necrotizing pancreatitis (4%), thromboembolism (4%), cardiac failure (2%), and pulmonary complications (8%). Venous resection was required in 12% of patients. Postoperative pain relief was achieved in 92% of cases. Mean hospital stay was 10.56 ± 6.09 days. Histopathological examination demonstrated R0 resection in 28 patients (56%) and R1 resection in 22 patients (44%). Morbidity and mortality rates were comparable to standard PD and appeared lower than those reported for PD combined with arterial resection.

CONCLUSION: Sub-adventitial arterial divestment during pancreatoduodenectomy is a feasible and safe technique for selected patients with borderline resectable and locally advanced pancreatic head carcinoma. The procedure provides acceptable morbidity and mortality rates while achieving favorable R0 resection outcomes, representing a promising alternative to arterial resection in specialized high-volume centers.

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