Vascular Resection, Reconstruction, and Divestment in Pancreatoduodenectomy: Expanding Boundaries in Pancreatic Cancer Surgery

Vascular resection and reconstruction during pancreatoduodenectomy (PD) have evolved from rare and controversial procedures into essential components of surgical management for selected patients with locally advanced pancreatic ductal adenocarcinoma (PDAC). Venous resection is now widely accepted and routinely performed in high-volume centers, whereas arterial resection and artery-sparing divestment remain selectively applied because of their technical demands and concerns regarding perioperative risk and oncologic benefit. Accumulating contemporary evidence indicates that venous resection can be performed with acceptable safety, with 30-day mortality rates generally ranging from 3% to 5% and median overall survival of approximately 18–26 months when margin-negative (R0) resection is achieved. Arterial resections, most commonly involving the common hepatic, celiac, or superior mesenteric arteries, have been increasingly utilized in highly selected patients, particularly following neoadjuvant therapy, achieving R0 resection rates of approximately 65–75% and median overall survival of 20–28 months. Arterial divestment has emerged as a promising artery-sparing strategy, offering comparable oncologic outcomes with reduced surgical morbidity in appropriately selected cases. Collectively, these advances have expanded the boundaries of resectability in PDAC, enabling surgical intervention in patients previously deemed inoperable. Venous resection is now considered an oncologically sound extension of standard PD, whereas arterial resection and divestment should remain restricted to carefully selected patients demonstrating favorable biologic behavior and response to neoadjuvant therapy. Future progress in this field will likely depend on improved biologic stratification, enhanced intraoperative perfusion assessment, and the integration of hybrid open and endovascular techniques.