Venous Resection During Pancreatoduodenectomy for Pancreatic Cancer: A Systematic Review and Meta-Analysis

Background: Venous resection during pancreatoduodenectomy is increasingly performed to achieve margin-negative resection in patients with pancreatic ductal adenocarcinoma involving the portomesenteric venous axis. However, its impact on oncologic and perioperative outcomes remains debated. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines. Comparative observational studies evaluating pancreatoduodenectomy with venous resection versus standard pancreatoduodenectomy were included. The primary outcome was overall survival (OS). Secondary outcomes included disease-free survival (DFS), R1 resection rate, and major postoperative morbidity. Secondary outcomes included R1 resection rate and major postoperative morbidity. Random-effects models were applied, and subgroup and sensitivity analyses were performed. Results: Nine studies were included in the quantitative synthesis. Venous resection was not associated with inferior overall survival compared with standard pancreatoduodenectomy (pooled HR = 1.01, 95% CI 0.94-1.09). Disease-free survival was significantly shorter in the venous resection group (pooled HR = 1.21, 95% CI 1.02-1.44), and venous resection was associated with a higher likelihood of R1 resection (pooled OR = 1.44, 95% CI 1.22-1.70). Major postoperative morbidity did not differ significantly between groups (pooled OR = 1.07, 95% CI 0.94-1.22). Subgroup analyses demonstrated inferior survival outcomes following segmental compared with tangential venous resection. Conclusions: Venous resection during pancreatoduodenectomy can be performed safely in experienced centers without compromising overall survival or increasing major postoperative morbidity. Shorter disease-free survival and higher R1 rates appear to reflect advanced local tumor biology rather than the vascular procedure itself. The extent of venous involvement plays a critical role in prognosis and should be considered in surgical decision-making and future study design.