SMA-first approach yields comparable R0 resection and survival in periampullary cancerTrial shows SMA-first approach yields similar outcomes for pancreatic cancer

European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology Published October 3, 2026 Study authors: Jain Hemant Ashok, Sahota Gursagar Singh, Singh Anand Narayan, Yadav Rajni, Das Prasenjit, Dash Niha… PubMed ↗ DOI ↗ Editorial oversight: Dr. Julia Lee, PhD · Oncology, Genomics & Drug Development

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Key Takeaway

Note that SMA-first and standard approaches yield comparable R0 resection and survival in periampullary cancer.

This randomized trial evaluated the impact of surgical approach on outcomes for patients undergoing pancreatoduodenectomy for periampullary cancer. A total of 203 patients were randomized, with 183 analyzed (90 SMA-first and 93 standard approach).

Primary outcomes included R0 resection rates and the number of lymph nodes retrieved. The R0 resection rate was 82.2% for the SMA-first group versus 78.5% for the standard approach (p=0.53). The number of lymph nodes retrieved was 18 versus 17 (p=0.63). Secondary outcomes, including median recurrence-free survival (48 vs 44 months; p=0.85) and median overall survival (53 vs 51 months; p=0.69), were comparable between groups.

Safety data showed that blood loss was significantly higher in the SMA-first group (675 ml vs 600 ml; p=0.02). Other complications, including ISGPS Grade B/C pancreatojejunostomy leaks (20% vs 24.7%), post-pancreatectomy hemorrhage (8.8% vs 14%), and Clavien-Dindo grade >=III complications (27.7% vs 31.2%), did not show statistically significant differences. Both surgical approaches appear to provide equivalent oncologic outcomes for periampullary cancer, despite a statistically significant increase in blood loss for the SMA-first technique.

How this fits prior evidence

How this fits prior evidence: This study addresses a gap in surgical technique comparison for periampullary cancer. While prior coverage noted that a high CALLY index correlates with improved survival in pancreatic malignancies, this trial focuses on the surgical approach's impact on R0 resection and survival. The findings confirm that both SMA-first and standard approaches yield comparable survival outcomes, similar to the focus on survival metrics in other pancreatic cancer contexts.

Researchers conducted a randomized controlled trial to compare two surgical methods for patients with periampullary cancer undergoing a pancreatoduodenectomy. The study compared the posterior (SMA-first) approach against the standard surgical approach. The study included 183 patients in total to evaluate how each method affected cancer removal and patient survival.

The results showed that both surgical methods were comparable in several key areas. Both techniques achieved similar rates of complete tumor removal (R0 resection) and similar numbers of lymph nodes retrieved. Additionally, patients in both groups showed similar median recurrence-free survival and overall survival times.

One notable difference was the amount of blood lost during surgery, which was higher in the SMA-first group. However, other safety markers and complication rates were similar between the two groups. Because the primary outcomes for cancer removal and survival were comparable, these results suggest that both surgical techniques are effective options for patients facing this type of cancer.

What this means for you:

Both surgical approaches for periampullary cancer showed similar success rates for tumor removal and patient survival.

Common questions

How do the two surgical methods compare for cancer removal?

The study found that both the SMA-first and standard surgical approaches resulted in comparable R0 resection rates (82.2% vs 78.5%) and similar numbers of lymph nodes retrieved (18 vs 17). These results suggest that both methods are effective at removing the primary tumor and nearby lymph nodes.

Are there differences in patient survival between the two methods?

The trial showed no significant difference in survival between the two groups. The median recurrence-free survival was 48 months for the SMA-first group and 44 months for the standard group. The median overall survival was 53 months versus 51 months, respectively.

Were there any safety concerns or different side effects?

The SMA-first group had a significantly higher amount of blood loss (675 ml vs 600 ml). However, other complications, such as delayed gastric emptying and specific leak types, were reported at similar rates in both surgical groups.

Study Details

Study typeRct

Sample sizen = 299

EvidenceLevel 2

Follow-up44.0 mo

PublishedOct 2026

PMID42693632

View Original Abstract ↓

INTRODUCTION: SMA-first-approach in pancreaticooduodenectomy (PD) was found to be associated with better oncological outcomes as compared to the standard approach both in our pilot study and a few retrospective studies. Hence, we performed a randomized controlled trial to compare these two approaches in terms of resection margins, lymph node-retrieval, and long-term survival. METHODS: Between January 2014 to December 2018, all the consecutive patients undergoing PD for periampullary cancer at the Department of Gastrointestinal Surgery, AIIMS, New Delhi were assessed for randomization. Primary outcomes were R0 resection rate and number of lymph nodes retrieved. The secondary outcomes were operating time, blood loss, postoperative complications, recurrence free and overall survival. RESULTS: Of 299 patients assessed, 203 were randomized and 183 analyzed (20: excluded after randomization, 90: patients-SMA, 93: patients-classical). The median age of the study population was 56 (14-78) years, with predominantly male (138, 68%) and with periampullary tumors (89%). The demographic profile, preoperative clinical and laboratory parameters were comparable. The blood loss was significantly higher in SMA first group (675 vs 600 ml, p = 0.02), however the operating time and the need for blood transfusion were comparable in both groups. ISGPS Grade B/C pancreatojejunostomy leak (20 vs 24.7%, p = 0.68), post-pancreatectomy hemorrhage (8.8 vs 14%, p = 0.38), delayed gastric emptying (37.8 vs 40.9%, p = 0.67) and Clavien-Dindo grade ≥III complications(27.7 vs 31.2, p = 0.85) were similar in both the groups. The R0 resection rates (82.2 vs 78.5%, p = 0.53) and total lymphnodes retrieved (18 vs 17, p = 0.63) were similar between the two groups. Both groups were comparable in terms of median recurrence free (48 vs 44 months, p = 0.85) and overall survival (53 vs 51 months, p = 0.69). CONCLUSIONS: 'Posterior (SMA-first) approach' and 'Standard approach' for pancreatoduodenectomy for periampullary cancer yielded equivalent results in terms of R0 resection rate, number of lymph nodes retrieved, recurrence-free and overall-survival.

SMA-first approach yields comparable R0 resection and survival in periampullary cancerTrial shows SMA-first approach yields similar outcomes for pancreatic cancer

How this fits prior evidence

Common questions

Study Details

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SMA-first approach yields comparable R0 resection and survival in periampullary cancerTrial shows SMA-first approach yields similar outcomes for pancreatic cancer

How this fits prior evidence

Common questions

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