{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T19:00:37Z","timestamp":1790622037867,"version":"4.1.0"},"reference-count":26,"publisher":"Wiley","issue":"5","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100007338","name":"All-India Institute of Medical Sciences","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100007338","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Surgical Oncology"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>SMA\u2010first\u2010approach 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\u2010retrieval, and long\u2010term survival.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Of 299 patients assessed, 203 were randomized and 183 analyzed (20: excluded after randomization, 90: patients\u2010SMA, 93: patients\u2010classical). The median age of the study population was 56 (14\u201078) 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\u2009ml,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.02), 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%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.68), post\u2010pancreatectomy hemorrhage (8.8 vs 14%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.38), delayed gastric emptying (37.8 vs 40.9%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.67) and Clavien\u2013Dindo grade \u2265III complications(27.7 vs 31.2,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.85) were similar in both the groups. The R0 resection rates (82.2 vs 78.5%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.53) and total lymphnodes retrieved (18 vs 17,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.63) were similar between the two groups. Both groups were comparable in terms of median recurrence free (48 vs 44 months,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.85) and overall survival (53 vs 51 months,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.69).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\u2018Posterior (SMA\u2010first) approach\u2019 and \u2018Standard approach\u2019 for pancreatoduodenectomy for periampullary cancer yielded equivalent results in terms of R0 resection rate, number of lymph nodes retrieved, recurrence\u2010free and overall\u2010survival.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/jso.70347","type":"journal-article","created":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T05:31:11Z","timestamp":1788499871000},"page":"730-738","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["\u2018Posterior (SMA\u2010first) Approach\u2019 Versus \u2018Standard Approach\u2019 in Terms of Resection Margin and Long\u2010Term Survival After Pancreaticoduodenectomy for Periampullary and Pancreatic Carcinoma: A Randomized Trial"],"prefix":"10.1002","volume":"134","author":[{"given":"Hemant Ashok","family":"Jain","sequence":"first","affiliation":[{"name":"Department of Gastrointestinal Surgery and Liver Transplantation All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gursagar Singh","family":"Sahota","sequence":"additional","affiliation":[{"name":"Department of Gastrointestinal Surgery and Liver Transplantation All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7179-8270","authenticated-orcid":false,"given":"Anand Narayan","family":"Singh","sequence":"additional","affiliation":[{"name":"Department of Gastrointestinal Surgery and Liver Transplantation All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7597-4895","authenticated-orcid":false,"given":"Rajni","family":"Yadav","sequence":"additional","affiliation":[{"name":"Department of Pathology All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prasenjit","family":"Das","sequence":"additional","affiliation":[{"name":"Department of Pathology All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nihar Ranjan","family":"Dash","sequence":"additional","affiliation":[{"name":"Department of Gastrointestinal Surgery and Liver Transplantation All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8806-2625","authenticated-orcid":false,"given":"Kumble Seetharama","family":"Madhusudhan","sequence":"additional","affiliation":[{"name":"Department of Radiodiagnosis All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siddhartha","family":"Dattagupta","sequence":"additional","affiliation":[{"name":"Department of Pathology All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sujoy","family":"Pal","sequence":"additional","affiliation":[{"name":"Department of Gastrointestinal Surgery and Liver Transplantation All India Institute of Medical Sciences, New Delhi New Delhi India"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"issue":"6","key":"e_1_2_12_2_1","doi-asserted-by":"crossref","first-page":"1258","DOI":"10.1016\/j.ejso.2021.01.001","article-title":"Improved Survival After Pancreatic Re\u2010Resection of Positive Neck Margin in Pancreatic Cancer Patients. A Systematic Review and Network Meta\u2010Analysis","volume":"47","author":"Crippa S.","year":"2021","journal-title":"European Journal of Surgical Oncology"},{"issue":"6","key":"e_1_2_12_3_1","doi-asserted-by":"crossref","first-page":"1651","DOI":"10.1245\/s10434-008-9839-8","article-title":"Most Pancreatic Cancer Resections Are R1 Resections","volume":"15","author":"Esposito I.","year":"2008","journal-title":"Annals of Surgical Oncology"},{"issue":"3","key":"e_1_2_12_4_1","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1007\/s12029-017-9933-x","article-title":"Posterior Superior Mesenteric Artery (Sma) First Approach Vs. Standard Pancreaticoduodenectomy in Patients With Resectable Periampullary Cancers: A Prospective Comparison Focusing on Circumferential Resection Margins","volume":"49","author":"Pal S.","year":"2018","journal-title":"Journal of Gastrointestinal Cancer"},{"issue":"6","key":"e_1_2_12_5_1","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1002\/bjs.10832","article-title":"Meta\u2010Analysis of An Artery\u2010First Approach Versus Standard Pancreatoduodenectomy on Perioperative Outcomes and Survival","volume":"105","author":"Ironside N.","year":"2018","journal-title":"British Journal of Surgery"},{"key":"e_1_2_12_6_1","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.ijsu.2019.11.007","article-title":"Superior Mesenteric Artery First Approach Can Improve the Clinical Outcomes of Pancreaticoduodenectomy: A Meta\u2010Analysis","volume":"73","author":"Jiang X.","year":"2020","journal-title":"International Journal of Surgery"},{"issue":"1","key":"e_1_2_12_7_1","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1001\/archsurg.2007.17","article-title":"Influence of Resection Margins and Treatment on Survival in Patients With Pancreatic Cancer: Meta\u2010Analysis of Randomized Controlled Trials","volume":"143","author":"Butturini G.","year":"2008","journal-title":"Archives of Surgery"},{"issue":"1","key":"e_1_2_12_8_1","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1111\/j.1477-2574.2008.00013.x","article-title":"Impact of Margin Status on Survival Following Pancreatoduodenectomy for Cancer: The Leeds Pathology Protocol (Leepp)","volume":"11","author":"Menon K. V.","year":"2009","journal-title":"HPB: The Official Journal of the International Hepato Pancreato Biliary Association"},{"issue":"1","key":"e_1_2_12_9_1","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1097\/01.sla.0000259391.84304.2b","article-title":"Impact of Resection Status on Pattern of Failure and Survival After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma","volume":"246","author":"Raut C. P.","year":"2007","journal-title":"Annals of Surgery"},{"issue":"10","key":"e_1_2_12_10_1","doi-asserted-by":"crossref","first-page":"1232","DOI":"10.1002\/bjs.5397","article-title":"Redefining the R1 Resection in Pancreatic Cancer","volume":"93","author":"Verbeke C. 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