Fig. 1

Images of representative patients who underwent surgical spacer placement. a Concept of surgical spacer placement. b Operative finding shows that surgical spacer (Gore-Tex sheet) was trimmed and interposed between the pancreas and gastrointestinal tract, and applied as a spacer after suturing tightly to the anterior surface of the pancreas and surrounding tissues. c Preoperative CT image and dose volume histogram reveal that the dose intensity for the gross tumor volume, and the clinical and planning target volume was restricted due to the close proximity of the pancreas (yellow arrow) to the stomach (white arrow). d Postoperative CT image and dose volume histogram reveal that a sufficient space between the pancreas (yellow arrow) and stomach (white arrow) was obtained by surgical spacer (arrowhead), and improved the dose intensity for the gross tumor volume, and the clinical and planning target volume while respecting the dose constraints of the gastrointestinal tract