Is distal pancreatectomy with en-bloc celiac axis resection effective for patients with locally advanced pancreatic ductal adenocarcinoma? -Multicenter surgical group study

Distal Pancreatectomy with and without Celiac Axis Resection for Adenocarcinoma: A Comparison in the Era of Neoadjuvant Therapy

BACKGROUND

Distal pancreatectomy with celiac axis resection (DP-CAR) has been used for selected patients with pancreatic cancer infiltrating the celiac axis. We compared the short- and long-term outcomes between DP-CAR and distal pancreatectomy alone (DP) in patients receiving neoadjuvant therapy.

METHODS

Patients undergoing DP-CAR from 2013 to 2022 were retrospectively reviewed. Clinicopathologic features, post-operative morbidity, and survival outcomes were compared with patients undergoing DP after neoadjuvant chemotherapy.

RESULTS

Twenty-two DP-CAR and thirty-four DP patients who underwent neoadjuvant chemotherapy were identified. There were no differences in comorbidities or CA19-9 levels. OR time was longer for DP-CAR (304 vs. 240 min, p = 0.007), but there was no difference in the transfusion rate (22.7% vs. 14.7%). Vascular reconstruction was more common in DP-CAR (18.2% vs. 0% arterial, p = 0.05; 40.9% vs. 12.5% venous, p = 0.04). There was no difference in morbidity or mortality between the two groups. Although there was a trend towards larger tumors in DP-CAR (5.1 cm vs. 3.8 cm, p = 0.057), the overall survival from the initiation of treatment (32 vs. 28 months, p = 0.43) and surgery (30 vs. 24 months, p = 0.43) were similar.

DISCUSSION

DP-CAR is associated with similar survival and morbidity compared to DP patients requiring neoadjuvant chemotherapy and should be pursued in appropriately selected patients.

Evolution and improved outcomes in the era of multimodality treatment for extended pancreatectomy

BACKGROUND

The evolution and outcomes of extended pancreatectomies at a single institute over 15 years are presented in this study.

METHODS

A retrospective analysis of the institutional database was performed from 2015 to 2022 (period B). Patients undergoing extended pancreatic resections, as defined by the International Study Group for Pancreatic Surgery, were included. Perioperative and survival outcomes were compared with data from 2007-2015 (period A). Regression analyses were used to identify factors affecting postoperative and long-term survival outcomes.

RESULTS

A total of 197 (16.1%) patients underwent an extended resection in period B compared to 63 (9.2%) in period A. Higher proportions of borderline resectable (5 (18.5%) versus 51 (47.7%), P = 0.011) and locally advanced tumours (1 (3.7%) versus 24 (22.4%), P < 0.001) were resected in period B with more frequent use of neoadjuvant therapy (6 (22.2%) versus 79 (73.8%), P < 0.001). Perioperative mortality (4 (6.0%) versus 12 (6.1%), P = 0.81) and morbidity (23 (36.5%) versus 83 (42.1%), P = 0.57) rates were comparable. The overall survival for patients with pancreatic adenocarcinoma was similar in both periods (17.5 (95% c.i. 6.77 to 28.22) versus 18.3 (95% c.i. 7.91 to 28.68) months, P = 0.958). Resectable, node-positive tumours had a longer disease-free survival (DFS) in period B (5.81 (95% c.i. 1.73 to 9.89) versus 14.03 (95% c.i. 5.7 to 22.35) months, P = 0.018).

CONCLUSION

Increasingly complex pancreatic resections were performed with consistent perioperative outcomes and improved DFS compared to the earlier period. A graduated approach to escalating surgical complexity, multimodality treatment, and judicious patient selection enables the resection of advanced pancreatic tumours.

Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report

BACKGROUND

Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions.

CASE PRESENTATION

This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP-CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP-CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases.

CONCLUSIONS

The case highlights the importance of recognizing and managing potential complications associated with DP-CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP-CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.

Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist

Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.

15-Year Experience of Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer-A Korean Nationwide Investigation

BACKGROUND

As systemic treatment for pancreatic cancer advances, distal pancreatectomy with celiac axis resection (DP-CAR) has been considered a curative-intent surgical option for advanced pancreatic cancer. This study aimed to review the surgical and oncologic outcomes of patients undergoing DP-CAR based on Korean nationwide data.

METHODS

We collected the data of patients who underwent DP-CAR for pancreatic cancer between 2007 and 2021 at seven major hospitals in Korea. The clinicopathological characteristics, postoperative complications, and data on the survival of the patients were retrospectively reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications and survival.

RESULTS

A total of 75 patients, consisting mainly of borderline resectable (n = 32) or locally advanced (n = 30) pancreatic cancer, were included in the analysis. Forty-two (56.0%) patients underwent neoadjuvant treatment (NAT). Twenty (26.7%) patients experienced Clavien-Dindo grade ≥ 3 complications, including four patients with ischemic gastropathy, two with hepatic ischemia, and two procedure-related mortalities. Neoadjuvant chemotherapy increased the risk of postoperative complications (p = 0.028). The median recurrence-free and overall survival were 7 and 19 months, with a 5-year survival rate of 13% and 24%, respectively. In the NAT group, a decrease in CA 19-9 and the post-NAT maximum standardized uptake value (SUVmax) in positron emission tomography were associated with survival after surgical resection.

CONCLUSIONS

Despite the possibility of major complications, DP-CAR could be a feasible option for achieving curative resection with fair survival outcomes in patients with borderline resectable or locally advanced pancreatic cancer. Further studies investigating the safety of the procedure and identifying proper surgical candidates with potential survival gains are necessary.

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using retroperitoneal-first laparoscopic approach (Retlap): A novel minimally invasive approach for determining resectability and achieving tumor-free resection margins of locally advanced pancreatic body cancer

BACKGROUND

Conventional open distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using the ventral approach is technically challenging, highly invasive, and not easy to ensure ample dorsal surgical margins. Hence, we describe a novel minimally invasive strategy for DP-CAR using the retroperitoneal-first laparoscopic approach (Retlap), i.e., Retlap DP-CAR, for locally advanced pancreatic body cancer (LAPC), and assess its utility.

METHODS

Retlap DP-CAR was performed in 10 patients with LAPC that was categorized as either unresectable (UR-LA, n = 4) or borderline (BR-A, n = 6). Neoadjuvant chemotherapy was applied on 8 patients and upfront surgery on 2. Retlap was used to create a working space in the retroperitoneal cavity between the pancreatic body and the left kidney and confirm technical resectability, such as securing the celiac axis and preserving the superior mesenteric artery in an early operative stage. Retlap DP-CAR was laparoscopic in 8 patients and robotic in 2. Surgical procedures are directly manipulated from the dorsal side of the pancreas and tumor, facilitating confirmation of technical resectability and obtaining ample dorsal margins in a no-touch isolation approach. Once technical resectability was confirmed, the procedure was converted to the ventral approach for completing DP-CAR.

RESULTS

Median operating time and blood loss during Retlap were 271 min and 10 mL, respectively, while median resection time and intraoperative blood loss were 582 min and 412 mL, respectively. Tumor-free resection margins were obtained in all cases. The major morbidity rate (C-D > IIIa) was 10%. No mortality was recorded within 90 days. Median overall survival was 53.8 months [95% confidence interval 32.7-75.0].

CONCLUSIONS

Retlap DP-CAR is a novel minimally invasive procedure for resecting LAPC located close to the celiac axis. It is both safe and feasible, enables determination of technical resectability, achieves dorsal surgical margins, and can improve outcomes and QOL in patients with LAPC.

Optimal lymph-node dissection for pancreatic tail cancer

PURPOSE

The optimal range of lymph-node dissection for pancreatic tail cancer remains unclear. We investigated the location and frequency of lymph-node metastases to identify the correct range of lymph-node dissection for pancreatic tail cancer.

METHODS

We analyzed clinical data retrospectively, on patients who underwent distal pancreatectomy for resectable left-sided pancreatic cancer, between February, 2006 and March, 2021. Eligible patients were divided into two groups according to the tumor location: those with pancreatic tail cancer (Pt group) and those with pancreatic body or body and tail cancer (non-Pt group).

RESULTS

Of the 96 patients analyzed, 61 (64%) were assigned to the Pt group and 35 (36%) were assigned to the non-Pt group. Metastases to stations 7, 8, 9, 10, 11, 14, and 18 were found in 0 (0%), 0 (0%), 0 (0%), 4 (7%), 18 (30%), 2 (4%), and 10 (17%) patients in the Pt group, and in 1 (3%), 4 (12%), 2 (6%), 1 (3%), 18 (51%), 3 (9%), and 6 (17%) patients in the non-Pt group, respectively.

CONCLUSION

Lymph-node dissection at stations 7, 8, and 9 might not be necessary in patients with resectable pancreatic cancer confined to the pancreatic tail.

Laparoscopic versus open distal pancreatectomy with or without splenectomy: A propensity score analysis in Japan

BACKGROUND

Although the laparoscopic approach has been applied to distal pancreatectomy, its benefits with regard to the short-term outcomes of distal pancreatectomy remain unclear.

MATERIALS AND METHODS

Using a Japanese nationwide inpatient database, we identified patients who underwent laparoscopic (n = 6647) and open (n = 21,843) distal pancreatectomy between July 2012 and March 2020. We conducted a 1:2 propensity score-matched analysis with adjustment for background characteristics (e.g., comorbidities, preoperative diagnosis, and hospital background) to compare in-hospital morbidity and mortality, reoperation requirement, duration of anesthesia and drainage, postoperative length of stay, and total hospitalization costs. For sensitivity analyses, we performed overlap propensity score-weighted analysis, instrumental variable analysis, and subgroup analyses for hospital volume, patients with benign tumors, and those with malignant tumors that required splenectomy.

RESULTS

In-hospital morbidity and mortality were 27% and 0.7%, respectively. The 1:2 propensity score-matched analysis showed that compared to open surgery, laparoscopic surgery was significantly associated with lower in-hospital morbidity (odds ratio [95% confidence interval]: 0.78 [0.73 to 0.84]) and mortality (0.26 [0.14 to 0.50]), lower occurrence of postoperative pancreatic fistula (0.78 [0.72 to 0.85]), postoperative bleeding (0.59 [0.51 to 0.69]), and reoperation (0.65 [0.58 to 0.75]), longer duration of anesthesia (difference, 59 [56 to 63] minutes), shorter duration of drainage (difference, -4.0 [-4.5 to -3.6] days) and postoperative length of stay (difference, -4.4 [-4.9 to -3.9] days), and lower total hospitalization costs (difference, -1510 [-1776 to -1243] US dollars). The sensitivity analyses showed compatible results with those from the main analysis.

CONCLUSION

In this large nationwide cohort, laparoscopic distal pancreatectomy showed lower in-hospital morbidity, mortality, and total hospitalization costs than open distal pancreatectomy. Laparoscopic distal pancreatectomy may be a favorable procedure in terms of both complications and costs.

Laparoscopic radical distal pancreatosplenectomy with celiac axis excision following neoadjuvant chemotherapy for locally advanced pancreatic cancer

A recent successful prospective randomized control study comparing open distal pancreatectomy with laparoscopic distal pancreatectomy (LDP) has shown that LDP is a safe and effective surgical modality in treating left-sided pancreatic pathological conditions requiring surgical extirpation. With the accumulating surgical experiences and improved surgical techniques, we recently reported several cases of successful LDP in advanced pancreatic cancer following neoadjuvant chemotherapy. Herein, we report a case of LDP with celiac axis resection (LDP-CAR) in locally advanced pancreatic cancer (LAPC) following neoadjuvant chemotherapy. A 58-year-old female with LAPC was referred to our institution. Computed tomography (CT) findings revealed a 24-mm mass in the pancreatic body that showed celiac artery (CA), common hepatic artery abutment. There was no abutment with superior mesenteric artery, superior mesenteric vein, and portal vein. From these findings, Neoadjuvant chemotherapy (FORFIRINOX) was performed biweekly. After 8 cycles of chemotherapy, the tumor size was slightly decreased (24 mm to 16 mm), but still abutting to CA. After 14 cycles of chemotherapy, CT revealed the same tumor size (16 mm) still abutting to CA. LDP-CAR was performed. Intraoperative ultrasonography gastric perfusion and hepatic perfusion were confirmed using indocyanine green. The patient recovered without complications and was discharged from the hospital nine days after the surgery.

The role of coeliac axis resection in resected ductal adenocarcinoma of the distal pancreas: A result of tumour topography or a prognostic factor?

BACKGROUND

Whether coeliac axis resection (CAR) results from tumour topography or a prognostic factor for distal pancreatic ductal adenocarcinoma (PDAC) remains unclear. We aimed to compare the clinicopathological data between distal pancreatectomy with en bloc CAR (DP-CAR) and distal pancreatectomy plus splenectomy (DP-S) and analyse the prognostic factors.

METHODS

We retrospectively analysed clinicopathological data from 102 patients who underwent distal pancreatectomy for PDAC and the factors affecting disease-free survival (DFS) and overall survival (OS). Of these patients, 45 and 57 underwent DP-CAR and DP-S, respectively.

RESULTS

DP-CAR was associated with more operative challenges than DP-S: more portomesenteric vein resections (48.9% vs. 14.0%), longer operations (320 vs. 242 min), and greater estimated blood loss (EBL) (600 vs. 200 ml). DP-CAR had larger tumours (5 vs. 4 cm), more perineural invasion (91.1% vs. 73.7%), and more microscopically positive surgical margins (20% vs. 3.5%), compared to DP-S. The major complication was clinically relevant postoperative pancreatic fistula (20.6%). The median DFS was 15.8 months and the median OS was 20.1 months. CAR was not associated with DFS or OS. EBL>700 ml, lymphovascular invasion (LVI), and adjuvant chemotherapy independently affected DFS and OS.

CONCLUSION

DP-CAR was associated with larger tumours and more surgical challenges but not with poorer DFS and OS than DP-S. CAR was more likely to result from tumour topography rather than from an adverse prognostic factor for resected distal PDAC. EBL>700 ml, LVI, and adjuvant chemotherapy were independent factors affecting the survival of patients with distal PDAC who underwent surgical resection.

Preoperative hepatic artery embolization before distal pancreatectomy plus celiac axis resection does not improve surgical results: A Spanish multicentre study

BACKGROUND

Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical procedure with high morbidity and mortality performed in patients with locally advanced pancreatic cancer. Preoperative embolization of hepatic artery (PHAE) has been postulated as a technical option to increase resection rate.

OBJECTIVE

comparison of morbidity and mortality at 90 days, operative time, hospital stay and survival between patients that performed DP-CAR with and without PHAE.

METHODS

Observational retrospective multicentre study.

INCLUSION CRITERIA

patient operated in Spanish centers with DP-CAR for pancreatic cancer from April 2004 until 23 June 2018. Preoperative (PHAE, neodjuvant treatment), intraoperative (operative time and blood loss) and postoperative data (morbidity, hospital stay, R0 and survival) were studied. Complications were measured with Clavien classification at 90 days. Specific pancreatic complications were measured using ISGPS classifications. Data were analyzed using R version 3.1.3 (http://www.r-project.org). Level of significance was set at 0.05.

RESULTS

41 patients were studied. 26 patients were not embolized (NO-PHAE group) and 15 patients received PHAE. Preoperative BMI and percentage of neoadjuvant chemotherapy were the only preoperative variables different between both groups. The operative time in the PHAE group was shorter (343 min) than in the non-PHAE group (411 min) (p < 0.06). Major morbidity (Clavien > IIIa) and mortality at 90 days were higher in the PHAE group than in the non-PHAE group (60% vs 23% and 26.6% vs 11.6% respectively) (p < 0.004). No statistical difference in overall survival was observed between both groups (p = 0.14).

CONCLUSION

In our study PHAE is not related with less postoperative morbidity. Even more, major morbidity (Clavien III-IV) and mortality was higher in PHAE group.

Distal pancreatectomy with En-bloc celiac axis resection for locally advanced pancreatic body/tail cancer: A systematic review and meta-analysis

Distal pancreatectomy with En-bloc celiac axis resection (DP-CAR) is a challenging procedure that has yielded certain clinical efficacy in the treatment of locally advanced pancreatic body/tail cancer, especially in patients with invasion of abdominal vessels. However, the clinical efficacy and safety of DP-CAR remain controversial. The study aimed to systematically review efficacy and safety of DP-CAR in the treatment of locally advanced pancreatic body/tail cancer. We systematically searched PubMed, EMBASE, Cochrane Library, and Web of Science databases from inception to 1 October 2020. Two studiers independently accomplished the study selection, data extraction, and quality assessment. Initially, of 1032 studies were searched, among which 11 high quality studies including 1072 patients were finally identified. The pooled results showed that DP-CAR versus Distal pancreatectomy (DP), the rate of R0 resection (RR = 0.76; 95%CI: 0.66 to 0.88; p = 0.0002) and 3-year survival (RR = 0.65; 95%CI: 0.43 to 0.98; p = 0.04) was lower, postoperative mortality (RR = 2.48; 95%CI: 1.02 to 6.03; p = 0.04) was higher, the operation time (MD = 104.67; 95%CI: 84.70 to 124.64; p < 0.001) and hospital stay (MD = 3.94, 95% CI 1.35 to 6.53; p = 0.003) were longer. There was no statistical difference between the DP-CAR and DP group in 1-year, 2-year survival rate (RR = 0.84; 95%CI: 0.57 to 1.23; p = 0.37) (RR = 0.70; 95%CI: 0.45 to 1.10; p = 0.12). In conclusion, compared with DP, DP-CAR has worse efficacy and prognosis survival and is more dangerous, but it can obtain better survival benefit and quality of life than palliative treatment. We suggest that DP-CAR can be carefully attempted for effective margin-negative resection. However, surgeons and patients need to know its potential perioperative risk.

Details and Outcomes of Distal Pancreatectomy with Celiac Axis Resection Preserving the Left Gastric Arterial Flow

BACKGROUND

To describe the technical details and efficacy of distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) flow preservation for pancreatic ductal adenocarcinoma (PDAC).

METHOD

This single-center, retrospective analysis investigated short- and long-term outcomes of DP-CAR performed on 55 patients with PDAC from 2011 to 2019. Our method included LGA reconstruction after total resection of the CA (rDP-CAR group; 24 patients) or LGA preservation if the tumor invasion was away from its root (pDP-CAR group; 31 patients), a CA-first approach to reduce blood loss during dissection, and conservative drain management with or without jejunal serosal patching at the pancreatic stump.

RESULTS

Among the study patients, 23 had locally advanced PDAC and 22 had borderline resectable PDAC. Median operation duration was 443 min (248-810), estimated blood loss was 600 mL (150-2280), and incidence of transfusion was 2%. Ischemic complications occurred exclusively in the rDP-CAR group, including two patients with ischemic gastropathy (8%) and three patients with findings of liver ischemia on computed tomography (13%). One patient underwent relaparotomy for stomach perforations, and 19 patients (35%) had pancreatic fistula, including 8 patients who underwent conservative drain placement for more than 3 weeks without specific symptoms. There were no Clavien-Dindo grade 4 or higher postoperative complications. Preoperative therapy showed improved 3-year overall survival rates than without (54% vs. 37%, p = 0.027).

CONCLUSIONS

Using the standardized technique, DP-CAR was safely performed with no mortality and acceptable long-term survival.

Distal pancreatectomy with celiac artery resection acquires satisfactory survival for locally advanced pancreatic neck-body cancer

BACKGROUND

s As a curative surgical procedure for pancreatic neck-body cancer with invasion to celiac artery (CA), the security and efficacy of distal pancreatectomy (DP) with en bloc resection of the celiac artery (DP-CAR) remain controversial. The purpose of this study was to identify the postoperative outcomes of DP-CAR.

METHODS

A retrospectively analysis between January 2010 and January2019 was performed in a single center. 21 patients who underwent DP-CAR and 71 patients who underwent traditional DP for pancreatic neck-body cancer were included. Postoperative morbidity, mortality, overall survival (OS) and disease-free survival (DFS) were evaluated.

RESULTS

There were no significant differences in major complications and mortality between two groups. The patients in DP-CAR group had more T4 tumor (61.9 vs 7.0%, P < 0.001). DP-CAR group had similar R0 resection compared with DP group (71.4% vs 87.3%, P = 0.090). The patients in DP-CAR group suffered more gastric ulcer, DGE and elevated levels of postoperative hepatic enzymes. OS (27.4 vs 32.6 months) and DFS (14.9 vs 19.5 months) between DP-CAR and DP groups were comparative (P = 0.305; P = 0.065).

CONCLUSIONS

For the patients who had pancreatic neck-body cancer with invasion to CA, DP-CAR is safety and could achieve satisfactory R0 resection, OS, and DFS.

Surgical Treatment of Pancreatic Ductal Adenocarcinoma

Simple Summary

Surgery is the only potential cure for pancreatic ductal adenocarcinoma and should always be combined with adjuvant chemotherapy or other multimodal treatment. Besides the advances in such multimodal approaches, there has been substantial progress in surgical techniques to especially address advanced resections. These techniques include specific operative steps, such as ‘artery first’ or ‘uncinate first’ approaches as well as techniques that allow safe vascular resection and reconstruction to achieve radical tumor removal. Most recently, also minimally-invasive and robotic approaches have been adopted for pancreatic cancer surgery; however, there is no high-level evidence on these evolving techniques especially with regards to long-term results compared to conventional surgical techniques.

Abstract

Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.

Surgical Treatment of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.

Distal Pancreatectomy with Celiac Axis Resection: Systematic Review and Meta-Analysis

BACKGROUND

Major vascular invasion represents one of the most frequent reasons to consider pancreatic adenocarcinomas unresectable, although in the last decades, demolitive surgeries such as distal pancreatectomy with celiac axis resection (DP-CAR) have become a therapeutical option.

METHODS

A meta-analysis of studies comparing DP-CAR and standard DP in patients with pancreatic adenocarcinoma was conducted. Moreover, a systematic review of studies analyzing oncological, postoperative and survival outcomes of DP-CAR was conducted.

RESULTS

Twenty-four articles were selected for the systematic review, whereas eleven were selected for the meta-analysis, for a total of 1077 patients. Survival outcomes between the two groups were similar in terms of 1 year overall survival (OS) (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.34 to 1.31, p = 0.24). Patients who received DP-CAR were more likely to have T4 tumors (OR 28.45, 95% CI 10.46 to 77.37, p < 0.00001) and positive margins (R+) (OR 2.28, 95% CI 1.24 to 4.17, p = 0.008). Overall complications (OR, 1.72, 95% CI, 1.15 to 2.58, p = 0.008) were more frequent in the DP-CAR group, whereas rates of pancreatic fistula (OR 1.16, 95% CI 0.81 to 1.65, p = 0.41) were similar.

CONCLUSIONS

DP-CAR was not associated with higher mortality compared to standard DP; however, overall morbidity was higher. Celiac axis involvement should no longer be considered a strict contraindication to surgery in patients with locally advanced pancreatic adenocarcinoma. Considering the different baseline tumor characteristics, DP-CAR may need to be compared with palliative therapies instead of standard DP.

Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy-Arterial Resection, Arterial Divestment and Total Pancreatectomy

Simple Summary

Aggressive arterial resection or total pancreatectomy in surgical treatment for locally advanced pancreatic cancer (LAPC) has gradually been encouraged thanks to new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel, which have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. The development of surgical techniques provides the safety of arterial resection (AR) for even major visceral arteries, such as the celiac axis or superior mesenteric artery. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for locally advanced pancreatic cancer (LAPC) and discuss the rationale of such an aggressive approach in the treatment of PC.

Abstract

Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.

Survival impact of distal pancreatectomy with en bloc celiac axis resection combined with neoadjuvant chemotherapy for borderline resectable or locally advanced pancreatic body carcinoma

BACKGROUND

The survival benefit associated with distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for patients with borderline resectable or locally advanced pancreatic body carcinoma is controversial. The aim of this study was to evaluate the impact of DP-CAR following neoadjuvant chemotherapy on survival in patients with borderline resectable or locally advanced pancreatic body carcinoma.

METHODS

Medical records of patients with pancreatic ductal adenocarcinoma who underwent distal pancreatectomy (DP, n = 102) and DP-CAR following neoadjuvant chemotherapy (n = 32) between 2008 and 2019 were analyzed retrospectively. Short- and long-term outcomes were compared between the two groups.

RESULTS

All patients who underwent DP-CAR had tumor contact with the celiac axis. Of these, 30 patients underwent preoperative embolization of the common hepatic artery. The pretreatment tumor size of patients who underwent DP-CAR was larger (P < 0.001), and rates of blood transfusion (P = 0.003) and postoperative complications (P = 0.016) were higher in patients who underwent DP-CAR compared with patients who underwent DP. The 5-year survival rate of patients who underwent DP and DP-CAR were 50.6% and 41.1%, respectively (median survival time, 65.9 vs 37.0 months). For all 134 patients, pretreatment serum CA19-9 levels (P < 0.001), adjuvant chemotherapy (P < 0.001), and lymph node status (P = 0.035) were independent prognostic factors of overall survival by multivariate analysis.

CONCLUSIONS

DP-CAR following neoadjuvant chemotherapy for patients with borderline resectable or locally advanced pancreatic body carcinoma may bring the same survival impact as DP, despite increased morbidity.

[Radiologic Evaluation for Resectability of Pancreatic Adenocarcinoma]

Imaging studies play an important role in the detection, diagnosis, assessment of resectability, staging, and determination of patient-tailored treatment options for pancreatic adenocarcinoma. Recently, for patients diagnosed with borderline resectable or locally advanced pancreatic cancers, it is recommended to consider curative-intent surgery following neoadjuvant or palliative therapy, if possible. This review covers how to interpret imaging tests and what to consider when assessing resectability, diagnosing distant metastasis, and re-assessing the resectability of pancreatic cancer after neoadjuvant or palliative therapy.

Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors

Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.

Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas

Background

Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy.

Main body

To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity.

Conclusion

This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

BACKGROUND

Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates.

METHODS

Observational retrospective multicenter study.

INCLUSION CRITERIA

patient undergoing TP, PD or DP plus CAR for a pancreatic cancer.

RESULTS

Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups.

CONCLUSION

It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

Successful conversion surgery of distal pancreatectomy with celiac axis resection (DP-CAR) with double arterial reconstruction using saphenous vein grafting for locally advanced pancreatic cancer: a case report

Background

Pancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.

Case presentation

A 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/m²) plus nab-paclitaxel (125 mg/m²) every 4 weeks were followed by irradiation (2 Gy/day, total 50 Gy over 25 days) together with S-1 administration (80 mg/m²/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).

Conclusion

For locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis.

Efficacy of Neoadjuvant Chemotherapy in Distal Pancreatectomy with En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer

BACKGROUNDS

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is an extended surgical procedure for patients with locally advanced cancer of the pancreatic body and tail. Recently, the usability of neoadjuvant chemotherapy (NAC) in pancreatic cancer was reported. The purpose of this study was to clarify the impact of NAC on surgical outcomes and prognosis in DP-CAR patients.

METHODS

This study retrospectively reviewed 20 consecutive patients who underwent DP-CAR at a single institution.

RESULTS

Eleven of 20 patients (55.0%) received NAC. Their first regimens were gemcitabine (GEM) plus nab-PTX (n = 7, 63.6%), GEM plus S-1 (n = 3, 27.3%), and GEM (n = 1, 9.1%). Although two patients converted to a second regimen, none abandoned NAC due to adverse effects or could not undergo a planned procedure for disease progression. There were no significant differences in intraoperative variables, morbidity, including pancreatic fistula and delayed gastric emptying, and mortality between patients with and without NAC; however, patients with NAC had a significantly lower proportion of arterial invasion (p = 0.025), lymphatic invasion (p < 0.0001), and vascular invasion (p = 0.035). There were no significant differences in the induction rate of adjuvant chemotherapy (p = 0.201). The recurrence-free survival and overall survival rates in patients with NAC were significantly higher than in patients without NAC (p = 0.041 and p = 0.018, respectively).

CONCLUSION

DP-CAR following NAC was associated with a preferable prognosis and had no negative effect on surgical outcomes. Therefore, NAC in DP-CAR patients might be a beneficial and safe therapeutic strategy.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).

Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.

Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).

Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC

BACKGROUND AND AIMS

It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable.

MATERIALS AND METHODS

This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction.

RESULTS

Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification.

CONCLUSION

The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.

Conversion Surgery for Pancreatic Cancer-The Impact of Neoadjuvant Treatment

Pancreatic ductal adenocarcinoma (PDAC) has still a dismal prognosis, mainly because only 15–20% of all patients present with resectable tumor stages at the time of diagnosis. Due to locally extended tumor growth or distant metastases upfront resection is not reasonable in the majority of patients. Considerably, PDAC will be the 2nd most frequent cause of cancer-related deaths within the next 10 years for both men and women. While there is currently no convincing evidence for the use of neoadjuvant therapy in resectable PDAC, there are controversial results from studies investigating neoadjuvant treatment concepts in borderline resectable PDAC (BR-PDAC). However, the definition of BR-PDAC is a topic of debate. While BR-PDAC has originally been defined on merely anatomical criteria, the International Association of Pancreatology (IAP) has recently suggested a broader definition based on a combination of anatomical (A) findings, biological (B) criteria (which reflect tumor aggressiveness), and conditional (C) aspects (which respect host-related condition). In case of BR-PDAC with venous invasion alone, upfront resection is generally recommended whenever technically possible in patients fit for surgery and without evidence for lymph node metastases. In contrast, in case of arterial invasion neoadjuvant therapy is regarded as the treatment of choice. The same accounts for high CA 19-9 levels, suspected or proven lymph node involvement and poor performance status. In locally advanced PDAC (LA-PDAC), neoadjuvant treatment represents the standard of care resulting in proportionally high rates of secondary resection. This “conversion” surgery offers the chance for improved survival times in an otherwise palliative situation. Herein, we summarize the current evidence of different treatment strategies for pancreatic cancer with a focus on conversion surgery and the impact of neoadjuvant treatment in this setting.

Prognostic value of adjacent organ resection in patients with left-sided pancreatic ductal adenocarcinoma following distal pancreatectomy

BACKGROUND

We evaluated whether distal pancreatectomy (DP) with adjacent organ resection (AOR) affected perioperative outcomes and survival in patients with left-sided pancreatic ductal adenocarcinoma (PDAC).

METHODS

Retrospective cohort study was conducted at single large volume academic medical center from January 2000 to December 2016.

RESULTS

Five hundred and twenty-three patients had undergone standard DP (without additional vessel/organ resection) and 40 had undergone DP with AOR due to adjacent organ infiltration. There were no differences of postoperative morbidity and hospital stay between the two groups. In the patients with AJCC 8th stage I and II PDAC, there were significant differences of median disease-specific and progression-free survivals between the standard and AOR groups (37.9 vs. 20.2 months; P = 0.05, 20 vs. 10 months; P = 0.028, respectively). DP with AOR was identified as independent prognostic factor of stage I and II PDAC by multivariate Cox regression analysis.

CONCLUSIONS

Distal pancreatectomy with AOR could be an acceptable surgical treatment for left-sided PDAC. However, AOR group shows poor prognosis than that of the standard group in patients with AJCC 8th stage I and II PDAC. AOR should be considered indicative of a more aggressive tumor in AJCC 8th stage I and II PDAC.

Should a standard lymphadenectomy include the No. 9 lymph nodes for body and tail pancreatic ductal adenocarcinoma?

OBJECTIVES

This study aimed to use a retrospective data base to investigate whether a standard lymphadenectomy during distal pancreatectomy should include the No. 9 lymph nodes (LNs) for resectable pancreatic ductal adenocarcinoma (PDAC) located in the body and tail of the pancreas.

METHODS

Data from 169 patients undergoing curative distal pancreatectomy for PDAC between Jan 1, 2013 and Dec 31, 2016 were collected. According to the tumor location, patients were divided into three groups: pancreatic neck tumor, pancreatic body and tail tumor with margin-to-bifurcation-distance (MTBD) ≤ 2.5 cm and pancreatic body and tail tumor with MTBD > 2.5 cm. The metastatic rate of the No. 9 LNs was compared among the 3 groups. The survival outcomes were analyzed.

RESULTS

The involvement rate for No. 9 LNs was 20.7% (6/29) for pancreatic neck tumors, 17.6% (15/85) for body and tail tumors with MTBD ≤ 2.5 cm and 1.8% (1/55) for MTBD > 2.5 cm. The No. 9 LNs were significantly more frequently involved in neck or body and tail tumors with MTBD ≤2.5 cm than with the cases with MTBD >2.5 cm (OR 0.082, P = 0.016). No. 9 LN involvement was not associated with worse survival compared with survival associated with involvement of other LNs (P = 0.780).

CONCLUSIONS

For PDAC located in the neck or in the body and tail of the pancreas with MTBD ≤ 2.5 cm, the involvement rate for No. 9 LNs is high. Standard lymphadenectomy should include the No. 9 LNs.

Appleby Procedure (Distal Pancreatectomy With Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Indications, Outcomes, and Imaging

OBJECTIVE. We describe the indications, surgical technique, outcome, and imaging findings in patients with pancreatic ductal adenocarcinoma (PDAC) treated with distal pancreatectomy and celiac artery resection (modified Appleby procedure). CONCLUSION. Distal pancreatectomy and celiac artery resection is a feasible surgery in selected patients with locally advanced PDAC. Knowledge of surgical technique and imaging features may aid radiologists in identifying patients with locally invasive PDAC who might benefit from resection and identifying characteristic distal pancreatectomy and celiac artery resection complications.

Radical pancreatic cancer surgery-with arterial resection

Extended surgery with arterial resection in pancreatic cancer remains a controversial topic. Although not recommended as a standard procedure, arterial resection may be feasible in selected patients and with the availability of new multimodal treatment approaches it may gain increasing impact in pancreatic cancer therapy as a complete tumor removal is still the only opportunity to achieve long-term survival for this disease. With regard to the surgical approach, one must differentiate between resection and reconstruction of the celiac axis and the hepatic artery as its most important branch, and resection/reconstruction of the superior mesenteric artery. Both procedures are technically possible and require a distinct level of surgical experience as well as interdisciplinary management for preoperative diagnosis and treatment of postoperative complications to achieve good outcomes. Besides arterial resection followed by reconstruction, there are specific situations when arteries may be resected without reconstruction, e.g., during distal pancreatectomy with celiac axis resection. In addition, in some cases arterial resections can be avoided despite a suspected tumor attachment by sharp dissection on the adventitial layer of the respective artery, especially after neoadjuvant therapy which is increasingly performed for borderline resectable and locally advanced tumor findings. This review summarizes definitions, diagnostics, technical aspects and outcomes of arterial resection in pancreatic cancer surgery in the context of the current literature and evidence.

Surgery for Pancreatic Cancer after neoadjuvant treatment

Pancreatic ductal adenocarcinoma (PDAC) remains to be a therapeutic challenge as only 15%-20% of all patients present with resectable tumor stages by the time of diagnosis. In the remaining patients, either local tumor extension or systemic spread are obstacles for a surgical therapy as the only chance for long-term survival. With regard to local tumor extension, PDAC has been classified as resectable, borderline-resectable (BR) or locally advanced (LA). While there is currently no evidence for neoadjuvant therapy in resectable PDAC, this issue remains controversial in BR-PDAC. In the case of venous tumor involvement, guidelines mostly recommend upfront resection, when technically possible; whereas arterial involvement is regarded as an indication for chemotherapy or chemoradiotherapy first. Furthermore, in locally advanced PDAC, neoadjuvant treatment approaches have recently resulted in high rates of secondary resection, thus allowing "conversion" surgery in an otherwise palliative treatment situation. The present review gives an overview on the current literature of treatment concepts in these situations and additionally focuses of evaluation of resectability after neoadjuvant therapy as well as technical aspects in this specific situation.