Vascular resection during PD adds complexity to an already challenging operation with potential for significant morbidity and mortality. Patient selection is critically important and is largely based on CT imaging. Resectability should be defined by clear, consistent, objective anatomic criteria that must be accurately interpreted on cross-sectional imaging studies. For potentially resectable patients, the survival benefit of surgery is predicated on negative surgical margins and the successful delivery of multimodality therapy. Therefore, the surgeon must avoid inadvertent venous injury that will necessitate rapid removal of the tumor and increase the chances of an incomplete gross resection.
Preoperative planning is key; the surgeon must plan for possible vascular resection prior to surgery rather than discovering the need for revascularization in the operating room. The vascular dissection must be done in a careful fashion so that all of the relevant anatomy is clearly defined prior to attempted removal of the specimen. With adequate exposure and a controlled approach to vascular resection and reconstruction, PD with vascular resection can offer patients the chance for cure and a median survival identical to that of patients who undergo standard PD without the need for vascular reconstruction. Isolated involvement of venous structures is not a contraindication to PD, however, the procedure should be performed by experienced surgeons at high-volume centers as part of a multidisciplinary protocol-based approach to patients with pancreatic cancer.
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