Pancreatic cancer is a highly fatal disease with a 5-year survival rate of approximately 10% in the USA, and it is becoming an increasingly common cause of cancer mortality. Risk factors for developing pancreatic cancer include family history, obesity, type 2 diabetes, and tobacco use. Patients typically present with advanced disease due to lack of or vague symptoms when the cancer is still localised. High quality computed tomography with intravenous contrast using a dual phase pancreatic protocol is typically the best method to detect a pancreatic tumour and to determine surgical resectability. Endoscopic ultrasound is an increasingly used complementary staging modality which also allows for diagnostic confirmation when combined with fine needle aspiration. Patients with pancreatic cancer are often divided into one of four categories based on extent of disease: resectable, borderline resectable, locally advanced, and metastatic; patient condition is also an important consideration. Surgical resection represents the only chance for cure, and advancements in adjuvant chemotherapy have improved long-term outcomes in these patients. Systemic chemotherapy combinations including FOLFIRINOX (5-fluorouracil, folinic acid [leucovorin], irinotecan, and oxaliplatin) and gemcitabine plus nab-paclitaxel remain the mainstay of treatment for patients with advanced disease. Data on the benefit of PARP inhibition as maintenance therapy in patients with germline BRCA1 or BRACA2 mutations might prove to be a harbinger of advancement in targeted therapy. Additional research efforts are focusing on modulating the pancreatic tumour microenvironment to enhance the efficacy of the immunotherapeutic strategies.Copyright © 2020 Elsevier Ltd. All rights reserved.

Locally advanced cancers of the pancreatic body can abut or involve the celiac axis, hepatic artery, or superior mesenteric artery. Recent evidence suggests that these tumors are amenable to surgery after neoadjuvant chemotherapy (Hackert et al., Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60 % of the patients. Ann Surg 264:457-463, 2016; Rangelova et al., Surgery improves survival after neoadjuvant therapy for borderline and locally advanced pancreatic cancer: a single-institution experience. Ann Surg 273:579-86, 2021). An arterial divestment technique can be used for these cancers to get an R0 clearance, thereby avoiding morbid arterial resections (Miao et al., Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC). Pancreatology 16:S59, 2016; Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). Two techniques are described for arterial divestment. In the periarterial divestment technique, the plane of the dissection is between the tumor and the adventitia (Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). In sub-adventitial dissection, the plane of dissection is between the tunica adventitia and the external elastic lamina (Gao et al., Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 406:691-701, 2021). The TRIANGLE operation also is one of the surgical techniques to achieve R0 resection in locally advanced pancreatic cancer (Hackert et al., The TRIANGLE operation: radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single-arm observational study. HPB Oxford 19:1001-1007, 2017). This multimedia article aims to demonstrate peri-arterial and sub-adventitial divestment techniques as well as the TRIANGLE operation for a locally advanced cancer of the body of the pancreas. The video also highlights the technique of posterior radical antegrade modular pancreato-splenectomy (RAMPS) together with lymph node clearance.A 57-year-old women was detected to have pancreatic body adenocarcinoma with tumor contact of the artery and superior mesenteric artery. After neoadjuvant chemotherapy, she was planned to undergo surgical resection.The surgical technique consisted of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS (Fig. 1). The procedure was performed within 240 min and involved blood loss of 250 mL. After the procedure, pancreatic leak (POPF-B), chyle leak and diarrhea developed, which were managed conservatively. The final histopathology showed residual, viable, moderately differentiated adenocarcinoma (ypT2N1M0) with all resection margins free.The surgical technique consisting of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS helps in R0 resection of locally advanced pancreatic body cancer without any compromise in oncologic outcomes and offers an alternative surgical approach to morbid arterial resection.© 2024. The Author(s).

To determine the benefit, measured as complete removal of a tumor so that no tumor cells are detectable during histopathologic examination of the resection margin (R0 resection rate), of induction chemotherapy plus chemoradiotherapy (CRT) compared with chemotherapy alone for unresectable pancreatic tumors.CONKO-007, an investigator-initiated open-label, multicentric, phase III randomized clinical trial, enrolled 525 patients with unresectable tumors, and 495 patients received induction chemotherapy (402 with fluorouracil, irinotecan, and oxaliplatin [FOLFIRINOX] and 93 with gemcitabine). Patients without progression after 3 months of induction chemotherapy (n = 336) were randomly assigned for continuation of the same chemotherapy (n = 167) or CRT (n = 169; 50.4Gy concurrently with gemcitabine). Resectability was centrally reassessed by a panel of surgeons. Surgery was recommended if possible. After an interim analysis, the primary end point was changed from overall survival (OS) to overall R0 resection rate because of slow recruitment. The median follow-up was 76 months. Important planned secondary end points were R0 resection rate in the surgically treated population and OS.The primary end point (overall R0 resection rate) was not significantly different between treatment arms with 25% (43 of 169) in the CRT arm versus 18% in the chemotherapy arm (30 of 167; =.113). Secondary end point analysis showed that surgery was performed equally often ( =.91); R0 resection rate in patients who underwent surgery was higher after CRT, 69.4% (43 of 62) compared with chemotherapy alone: 50.0% (30 of 60 patients, =.04). Other parameters of resection (ratio of R0/R1/R2/no resection) also favored CRT ( =.02). No difference in OS was seen between treatment arms (hazard ratio [HR], 0.937 [95% CI, 0.747 to 1.174]; =.57; randomly assigned intention-to-treat patients). Surgery was associated with longer OS (<.001, HR, 0.525 [95% CI, 0.408 to 0.676]).Although not improving overall R0 resection rate or survival, CRT enables a R0 resection in surgically treated patients more often than chemotherapy alone.

Complete oncological resection of pancreatic cancer remains the cornerstone in treatment of pancreatic cancer. Anatomical relations to major vessels continue to play an ongoing important role in the decision-making regarding treatment options in pancreatic cancer. Despite concomitant venous resections being routinely performed in major centers, arterial resections remain controversial. The aim of this study was to compare the short- and long-term outcomes of pancreatic cancer surgery with concomitant arterial resections to standard non-arterial resections from modern studies. We included studies comparing pancreatic cancer surgery with arterial resections to standard non-arterial surgery for pancreatic cancer published from 2018 to 2024. A total of seven articles involving 5465 patients met the inclusion criteria and were included for analysis. Arterial resections are associated with a greater risk of mortality compared to standard resections (Risk ratio (RR): 3.28; 95% confidence interval (CI) [0.75–14.46]; p = 0.0365). There were no significant differences in overall morbidity (RR: 1.48; 95% CI [1.16–1.89]; p = 0.2923) or serious complications (Mean Difference (MD): 2.6; 95% CI: [−21.52–16.32]; p = 0.738). Arterial resections were associated with a 3.1-fold increased chance of R0 resection (RR: 3.11; 95% CI [1.65–5.86]; p &lt; 0.0227). Arterial resection in pancreatic cancer continues to be associated with an increased risk of mortality; however, recent studies show no significant increase in morbidity whilst significantly increasing R0 resections.

With better surgery and chemotherapeutic agents, borderline resectable or locally advanced pancreatobiliary tumours are being treated with curative intent. This study presents real-world evidence of porto-mesenteric vein resections (PVR) with pancreatectomy and generates predictive nomograms for postoperative mortality (POM) and major complications (MC).A retrospective multicentre study, including 11 high-volume centres, evaluated patients undergoing PVR. Factors affecting 90-day POM and MC (Clavien-Dindo grades ≥ 3a) were assessed, and predictive nomograms were generated. Overall survival (OS) and disease-free survival (DFS) were estimated for patients with pancreatic ductal adenocarcinoma (PDAC). Cox regression analysis was performed to ascertain factors affecting OS and DFS.Among 389 patients, POM was 6.4%, and MCs were 32.6%. Charlson comorbidity index > 4, preoperative biliary drainage, preoperative radiotherapy (PRT), segmental PVR, and additional organ resection (AOR) were predictive of POM. The independent predictors of MCs were American Society of Anesthesiologists status 3/4, PRT, and AOR. The generated model had an area under the curve (AUC) of 0.757, cutoff > 1.79 to predict POM, and AUC of 0.669, cutoff > 0.678 for MCs. In the 263 patients with PDAC, the median OS was 25.01 months (95% confidence interval [CI] 21.9-28.11), and DFS was 16.72 months (95% CI 14.56-18.89). Perineural invasion, segmental PVR, and margin positivity predicted worse survival, while completing multi-modality treatment was protective.The POM and MCs of PVR with pancreatectomy were at par with the world standards. The generated predictive nomograms for POM and MC revealed a good predictive potential. In patients with PDAC, completion of multimodality treatment offers better long-term survival.© 2025. The Author(s).

This study assesses the safety and outcomes of the largest cohort of pancreatectomy with arterial resection (P-AR).A high postoperative mortality rate and uncertain oncologic benefits have limited the use of P-AR for locally advanced pancreatic adenocarcinoma.We retrospectively reviewed a prospectively maintained database of patients who underwent P-AR between January 1990 and November 2017. Univariate and multivariate Cox analyses were used to assess prognostic factors for survival.There were 118 consecutive resections (51 pancreaticoduodenectomies, 18 total pancreatectomies, and 49 distal splenopancreatectomies). Resected arterial segments included the coeliac trunk (50), hepatic artery (29), superior mesenteric artery (35), and other segments (4). The overall mortality and morbidity were 5.1% and 41.5%, respectively. There were 84 (75.4%) patients who received neoadjuvant chemotherapy, 105 (89%) simultaneous venous resections, and 101 (85.5%) arterial reconstructions. The rates of R0 resection and pathologic invasion of venous and arterial walls were 52.4%, 74.2%, and 58%, respectively. The overall survival was 59%, 13%, and 11.8% at 1, 3, and 5 years, respectively. The median overall survival after resection was 13.70 months (CI 95%:11-18.5 mo). In multivariate analysis, R0 resection (HR: 0.60; 95% CI: 0.38-0.96; P = 0.01) and venous invasion (HR: 1.67; 95% CI: 1.01-2.63; P = 0.04) were independent prognostic factors.In a specialized setting, P-AR for locally advanced pancreatic adenocarcinoma can be performed safely with limited mortality and morbidity. Negative resection margin and the absence of associated venous invasion might predict favorable long-term outcomes.

For locally advanced pancreatic cancer (LAPC) involving the superior mesenteric artery (SMA), periarterial and sub-adventitial divestment offers oncologic efficacy while minimizing postoperative complications and mortality. However, safe and standardized techniques for circumferential SMA dissection remain limited. We adopted a dual SMA-first strategy-posterior and left-sided approaches-to improve arterial control, enhance surgical exposure, and ensure procedural safety.Two patients (a 70-year-old female and a 30-year-old male) with pancreatic uncinate process tumors measuring 34-36 mm, both encasing 180° of the SMA and invading the superior mesenteric vein (SMV), underwent conversion pancreaticoduodenectomy with SMA adventitial divestment and SMV resection. Key operative steps included the Cattell-Braasch maneuver for wide exposure; posterior SMA-first approach for early control and mobilization of a 3-4 cm avascular segment of the artery; and left-sided approach from below the mesentery to access the distal SMA. The inferior pancreaticoduodenal artery (IPDA) and first jejunal artery (JA1) were ligated at their origins to facilitate dissection. A combined proximal-down and distal-up pathway allowed for safe and effective circumferential sub-adventitial divestment. Sharp dissection with angled scissors was employed to minimize vascular trauma, aneurysm formation, or stenosis. The dual approach provided excellent visualization of arterial landmarks and optimal access to the tumor-infiltrated mesopancreas. RESULTS: Both patients had uneventful postoperative courses. One developed grade A lymphatic leakage; neither experienced bleeding or pancreatic fistula. Both were discharged within 2 weeks and remained recurrence-free at 20-month follow-up. Literature comparisons highlight lower morbidity and comparable survival in periarterial divestment versus arterial resection. CONCLUSIONS: The dual posterior and left-sided SMA-first approach provides a safe, effective, and anatomically strategic method for circumferential SMA divestment in LAPC. Larger series are needed to validate long-term oncologic outcomes.© 2025. Society of Surgical Oncology.

The absence of major-vessel involvement is a crucial factor in the resectability and prognosis of pancreatic cancer. However, arterial invasion cannot be evaluated adequately using imaging findings alone. We therefore developed a scoring system to assess arterial invasion by pancreatic adenocarcinoma using multidetector row computed tomography (MDCT) and serum tumor markers.Twenty patients who underwent distal pancreatectomy and splenectomy for pancreatic adenocarcinoma were examined retrospectively using 4-, 16- or 64-row MDCT and serum tumor markers. Splenic arterial invasion was evaluated in terms of length of tumor contact, circumferential involvement (<180° or ≥180°) and deformity of vascular diameter. Preoperative expression of carbohydrate antigen 19-9 (CA19-9), DUPAN-2 and S-Pancreas-1 antigen (SPan-1) were also evaluated. The presence or absence of arterial invasion was confirmed histopathologically in all 20 cases.In 11 of 20 cases invasion into splenic arteries was observed histopathologically, mostly involving the external elastic lamina and periarterial nerves. Sensitivity, specificity and accuracy were 100%, 88.9% and 95%, respectively, for length of tumor contact (<16 mm or ≥16 mm), 90.9%, 77.8% and 85% for circumferential involvement (<180° or ≥180°), and 100%, 66.7% and 85% for deformity of vascular diameter. Furthermore, the sensitivity, specificity and accuracy were all increased to 100% when tumor markers were included in the score.MDCT is a useful technique for diagnosing arterial invasion of pancreatic body and tail cancer, even in comparison with pathological examination; however, this new scoring system can be further complemented and made more reliable by measurements of serous tumor markers.Copyright © 2013 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Pancreatic adenocarcinoma has a predisposition to invade the neural tissue surrounding the superior mesenteric artery (SMA). Before the advent of neoadjuvant chemotherapy (NAC), any invasion of this tissue was often considered as unresectable disease. Currently, patients who respond favourably to NAC have potentially resectable disease. There is debate over the exact technique of removing this shell of tumour tissue surrounding the SMA, and whether it is comparable to arterial resection and reconstruction.

目的&nbsp;&nbsp;&nbsp; 探索左右联合路径联合血管重建的全胰腺切除术在治疗胰颈恶性肿瘤中的应用与临床疗效。方法&nbsp;&nbsp;&nbsp; 回顾性分析2015年3月至2017年3月期间12例在海军军医大学附属长海医院行左右联合路径整块切除联合血管切除重建的全胰腺切除术的胰颈恶性肿瘤病人的临床资料，重点分析该组病人的一般临床资料、手术技术、住院时间、围手术期并发症、术后病理学检查结果、切缘情况、预后等指标。结果&nbsp;&nbsp;&nbsp; 12例病人均为胰颈部恶性肿瘤，均侵犯胰周静脉，术中施行联合静脉切除重建。其中，男性6例，女性6例；中位年龄58岁，体重指数（BMI）中位数23.41，无术中死亡病例，中位手术时间235 min；中位出血量800 mL；中位输少浆血量600 mL；中位血管切除长度4.10 cm；中位门静脉阻断时间15 min，术后标本9例行组织大切片检查，肿瘤切缘R0切除率91.7%，所有病人术后均采用快速康复技术管理，术后疼痛缓解率达100%，术后A级胃排空障碍1例，感染2例，术后30 d无死亡病人，术后中位住院天数12 d，中位生存时间19.8个月。结论&nbsp;&nbsp;&nbsp; 左右联合路径整块切除联合血管重建的全胰腺切除术治疗胰腺颈部恶性肿瘤安全有效，可以提高手术安全性、改善病人的生活质量，但手术难度大，建议在高流量胰腺外科中心开展。