الفهرس 
Acknowledgment
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Abstract
Cancer pancreas ranks the fourth cause of death in cancer list in USA. Surgical resection with negative margins is one of the most important factors influencing the survival, hence it is considered the only and best modality of choice for achieving curative treatment. Systematic review of histopathological data confirms that Retropancreatic margin “mesopancreatic margin” in special and resection margins involvement in general are poor prognostic factors as regard intention of curative cancer pancreas resection. After evolution of the concept of mesorectum and the important prognostic outcome of total mesorectal excision in cancer rectum, Gockel et al. in 2007 proposed the concept of Mesopancreas. “Artery-first approach” is a surgical technique characterized by meticulous dissection of arterial planes and clearing of retropancreatic tissue in an attempt to achieve a higher rate of R0. The aim of the study is to assess the feasibility of Artery-first approach in comparison to classic approach in pancreatoduodenectomy and its impact on recurrence after mesopancreatic dissection in periampullary cancer. And to assess if the histopathological parameters including mesopancreatic margin in particular as prognostic factors for periampullary carcinoma influencing recurrence. And overall survival for both approaches on 40 cases operated at Assiut and Mansoura university hospitals during the period between 2017 and 2020. We excluded metastatic cases, locally advanced and surgically unfit cases. As regard site of the tumor for Standard approach was 13 cases in head of pancreas, 5 cases in ampulla of vater, 1 case in uncinate process, 1 case in 2nd part of duodenum, 1 case in distal CBD and 1 case in body of pancreas, while in Artery-first approach group was 8 cases in head of pancreas, 7 cases inampulla of vater, 1 casein uncinate process and 2 case in 2nd part of duodenum with no significant difference as regard site for both of groups with (p value = .625) There was no significant difference as regard operative time, blood loss and need for blood transfusion, postoperative complications and mortality between both groups with (p values= .502, .225,.860) respectively. postoperative complications for group A (standard) vs group B were (artery-first) were statistically insignificant including pancreatic fistula, delayed gastric emptying, and Hematemesis and melena, bile leak, postoperative bleeding, reoperation, acute sever pancreatitis, wound infection and pulmonary embolism with (p values = .230, .336, .263, .263, .263, .263, .263, .433 and .360) respectively. The mean hospital stay was comparable without significant difference between the two approaches (p value=.108). The postoperative mortality was one in group A and two in group B within significant difference between them with (p value =.433) As regard pathological data there was in significant difference as regard R0, R2 mesopancreatic margin with (p values=.368, .093) but there was significant higher number of R1 in standard approach than in artery-first approach (p value=.020). There was significant difference between R0, R1, R2 mesopancreatic margin vs recurrence rates in univariate and multivariate analysis with p values = .020,.024 respectively.N stage was significant in univariate (p value=.043) but not in multivariate analysis (p value=.212) for recurrence. There was significant higher tumor size in artery-first approach (2.17 ± .618 cm) more than standard approach (1.7 ± .550 cm) with (p value=.023).