Justifying vein resection with pancreatoduodenectomy

Interest in radical surgery to achieve complete resection and improve long-term survival in patients undergoing pancreatoduodenectomy for ductal adenocarcinoma has been renewed. This surgery includes extended lymphadenectomy, multivisceral resections, and synchronous arterial and venous resections. The evidence that these surgeries improve long-term survival is poor, except perhaps for synchronous venous resection, which can be justified if a margin negative (R0) resection is achieved without increased morbidity and mortality, and if there is no invasion of the vein wall. The recognition of patients with borderline resectable pancreatic cancer and the increasing use of neoadjuvant treatment makes it more difficult to know if the vein is invaded, increases reliance on trial dissection to establish resectability, and might increase the number of synchronous venous resections done. This Personal View seeks to review the justification for pancreatoduodenectomy with synchronous venous resection to promote debate and draw attention to the gaps in knowledge for further research.