Diagnosis and Surgical Management for Advanced Pancreatic Cancer Requiring Vascular Resection

Pancreatic ductal adenocarcinoma (PDAC) remains one of the most aggressive malignancies, with overall survival outcomes that have improved only modestly in recent years. Careful preoperative evaluation is essential for defining resectability and planning surgery. Modern imaging modalities, including high-resolution, contrast-enhanced CT, MRI and endoscopic ultrasound, provide a detailed assessment of vascular involvement and allow accurate staging according to various international criteria and consensus statements. In borderline and locally advanced cases, neoadjuvant therapy can aid in downsizing the tumor and increasing the likelihood of achieving negative margin resection (R0), offering long-term survival along with quality of life. When vascular invasion limits resectability, venous resection and reconstruction may permit an R0 resection in patients with borderline resectable disease that is both technically operable and physiologically tolerable for the patient. Arterial resection, however, remains controversial and is rarely justified because of its limited perioperative and survival benefits. Arterial divestment has emerged as an interesting alternative, allowing tumor clearance while avoiding full arterial reconstruction. Vascular reconstructions can be achieved through venorrhapy, end-to-end anastomosis, or segmental replacement using either autologous or synthetic grafts. With the advances in neoadjuvant treatment, the appropriate selection of candidates for vascular resection significantly increases the resectability rate, offering long-term survival along with satisfactory quality of life. In this review, a detailed literature review is performed regarding the best strategies in the diagnosis and surgical management of patients with borderline resectable and locally advanced pancreatic cancer requiring vascular resection.