Artery-first Approach Versus Standard Pancreaticoduodenectomy: A Systematic Review and Meta-analysis of Surgical Outcomes and Oncological Benefits.

BACKGROUND/AIM: Pancreaticoduodenectomy (PD) is the standard curative option for pancreatic head carcinoma, but R1 resections remain frequent. The superior mesenteric artery (SMA) "artery-first" approach (AFA) may improve oncologic clearance and operative safety. We conducted a systematic review and meta-analysis comparing AFA versus standard PD.

MATERIALS AND

METHODS

Following the PRISMA 2020 guidelines, PubMed and Scopus were searched to January 27, 2025. Comparative studies reporting R0 resection or survival outcomes were eligible. Data were extracted independently, and random-effects meta-analyses were performed for dichotomous (risk ratios, RR) and continuous outcomes (mean differences, MD). Sensitivity analyses included fixed-effect models, alternative continuity corrections, and exclusion of zero-event studies. Publication bias was assessed with funnel plots and Egger's test.

RESULTS

Twenty-two studies (2 randomized trials, 20 retrospective; 945 AFA, 1,173 standard PD patients) were included. R0 resection was reported in 15 studies. Pooled analysis favored AFA (RR: 1.13, 95% CI=1.08-1.19; I2=9.1%), robust across sensitivity analyses, with no evidence of publication bias (Egger p=0.47). Estimated blood loss was significantly reduced with AFA (MD -86.7 ml, 95% CI=-164.8 to -8.7; I2=63.8%), though results were moderately sensitive to individual studies. Other perioperative outcomes - including operative time, complications, and hospital stay - showed no consistent differences. Long-term survival outcomes were inconsistently reported but suggested at least equivalence. Subgroup analysis indicated that randomized trials did not consistently replicate the R0 advantage seen in retrospective series.

CONCLUSION

AFA for PD is associated with higher R0 resection rates and lower blood loss compared to standard PD, without added morbidity. Observational data strongly support AFA, but confirmatory evidence from well-powered randomized trials remains essential.