Background: Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.Methods: This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high-volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.Results: A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60⋅5 per cent versus 38 per cent in those having RPD; P = 0⋅014), and consequently they received neoadjuvant therapy less often (7⋅9 versus 25 per cent respectively; P < 0⋅001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66⋅1 per cent) of those in the SPD group (P = 0⋅016), although perioperative outcomes were comparable between the groups. Median recurrence-free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0⋅003; OS: P = 0⋅004).Conclusion: RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

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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.

objective pre-operative tool, based only on clinical and biochemical parameters to predict the outcome following pancreatoduodenectomy that could be implemented on an outpatient basis. Methods: Using a multivariate regression model, the significant predictors of post-operative outcome were identified in a set of retrospective database of patients (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017), and a risk score developed by binary logistic regression method. This was validated in a set of prospective patients (2017)(2018)(2019)(2020). The model's predictive accuracy and discriminative ability were assessed using the receiver operating characteristics (ROC) analysis and Hosmer-Lemeshow goodness of fit tests respectively. Results: On multivariate analysis in the retrospective cohort (n=442), the significant predictors of post-operative outcome were identified as peak bilirubin levels, preoperative stenting and diagnosis (benign/malignant). A risk score was derived and validated on the prospective cohort (n=185) [Table 1]. The mean risk for an unfavourable outcome was 24% for a score of < /=7, 44% for a score of 8-14 and 70% for a score of >/=15. This was further tested on the validation cohort for individual risk scores (AUC=0.708) and scores categorised (AUC=0.698). There was no significant difference between observed and expected risk of major complications (p=0.31). Conclusion:The risk score showed a fair accuracy in predicting post-operative morbidity in the prospective cohort. Therefore, we propose this be used as a quick aid to predict the operative outcome in patients posted for pancreatoduodenectomy on an outpatient basis using simple pre-operative clinical and laboratory variables.