Fig. 3

Surgical findings and resection specimen sections. The abdomen is opened through a midline incision on the upper abdomen. The tumor (T) is located on the dorsal side of the pancreatic (P) head, which is ventrally compressed and thinned. The superior mesenteric vein (SMV), extrahepatic portal vein (PV), and SMA are highly adherent to the tumor but can be dissected while ligating the arteriovenous branches to the tumor. Reconstruction consists of anastomosis of the upper intestine, pancreas, bile duct, and stomach. Braun anastomosis is performed. Drains are placed dorsal (drain 1) and ventral (drain 2) to the bile duct jejunal anastomosis and pancreatic jejunal anastomosis, respectively. Tumor section: The tumor is covered with a thick coat-like structure, and the interior is a mixture of substantial and hemorrhagic necrotic areas. IVC inferior vena cava, AA abdominal aorta, SMA superior mesenteric artery