Tips and tricks of the surgical technique for borderline resectable pancreatic cancer: mesenteric approach and modified distal pancreatectomy with en-bloc celiac axis resection.

Borderline resectable (BR) pancreatic cancer involves the portal vein and/or superior mesenteric vein (PV/SMV), major arteries including the superior mesenteric artery (SMA) or common hepatic artery (CHA), and sometimes includes the involvement of the celiac axis. We herein describe tips and tricks for a surgical technique with video assistance, which may increase the R0 rates and decrease the mortality and morbidity for BR pancreatic cancer patients. First, we describe the techniques used for the "artery-first" approach for BR pancreatic cancer with involvement of the PV/SMV and/or SMA. Next, we describe the techniques used for distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) and tips for decreasing the delayed gastric emptying (DGE) rates for advanced pancreatic body cancer. The mesenteric approach, followed by the dissection of posterior tissues of the SMV and SMA, is a feasible procedure to obtain R0 rates and decrease the mortality and morbidity, and the combination of this aggressive procedure and adjuvant chemo(radiation) therapy may improve the survival of BR pancreatic cancer patients. The DP-CAR procedure may increase the R0 rates for pancreatic cancer patients with involvement within 10 mm from the root of the splenic artery, as well as the CHA or celiac axis, and preserving the left gastric artery may lead to a decrease in the DGE rates in cases where there is more than 10 mm between the tumor edge and the root of the left gastric artery. The development of safer surgical procedures is necessary to improve the survival of BR pancreatic cancer patients.