Surgery for Locally Advanced Pancreatic Cancer: Oncological Landmarks for Venous and Arterial Reconstruction.

backgroundAccording to the National Comprehensive Cancer Network (NCCN) guidelines, pancreatic cancer is classified as borderline resectable (BR-PC) on the basis of three criteria: (1) anatomical-the involvement of major vessels such as the celiac axis, hepatic artery (HA), superior mesenteric artery (SMA), or the mesenterico-portal venous axis; (2) biological-an elevated CA19-9 level exceeding 500 kU/L; and (3) conditional-patient unfitness for surgery due to general health status. The extensive involvement of major vessels is classified as locally advanced pancreatic cancer (LAPC). In such cases, neoadjuvant therapy is recommended. PATIENTS AND

methodsWe present the case of a 74-year-old patient with biopsy-confirmed pancreatic ductal adenocarcinoma of the pancreatic head, involving a completely replaced CHA with abutment of the SMA and encasement of the SMV (see Fig. 1 and video) with the tumor considered locally advanced. Fig. 1 Preoperative assessment of reconstructability and vascular anatomy is essential. Pancreatic phase CT scan A Axial view. Tumor encasement of the SMV, and RHA Michels IX. RHA take-off from the SMA is free; it is essential to ensure that a stump is available to avoid SMA resection B Coronal view showing RHA Michels IX encasement but SMA abutment. Evaluation for divestment as there is no disparity in caliber of the SMA C CC Coronal view. It is essential to target venous inflow in the root of the mesentery, as this is the cornerstone of reconstructabilit. CT, computed tomography; SMA, superior mesenteric artery artery; SMV, superior mesenteric vein; RHA, right hepatic artery PERIOPERATIVE MANAGEMENT: At our institution, surgical indication for BR-PC and LAPC is guided primarily by oncologic principles. We implement an extended neoadjuvant regimen-typically a minimum of eight cycles of FOLFIRINOX-aiming for normalization of CA19-9 levels. Para-aortic lymph node sampling is routinely performed, and arterial reconstruction is undertaken only if a frozen section analysis confirms the absence of metastasis. The preoperative planning includes a high-resolution computed tomography (CT) angiography with three-dimensional (3D) reconstruction performed within 3 weeks of surgery to assess vascular involvement. This imaging is critical for evaluating the feasibility of arterial divestment and for planning potential vascular reconstructions. The key intraoperative strategies include the precise identification of vascular segments suitable for reconstruction (the "suitable target" concept