Portal vein resection in pancreatic cancer: from technical feasibility to biological patient selection

Portal vein resection (PVR) has become an established component of pancreatic cancer surgery for selected patients with portal vein-superior mesenteric vein involvement. Although advances in surgical techniques and multidisciplinary treatment have improved perioperative outcomes, whether PVR itself independently improves long-term survival remains controversial.

This review summarizes the historical evolution of PVR, critically evaluates contemporary evidence regarding its safety and oncological outcomes, and examines the methodological limitations that prevent definitive conclusions regarding its independent survival benefit. We further discuss pathological venous invasion as a marker of aggressive tumor biology and review the emerging concept of biological resectability, incorporating neoadjuvant treatment response, serum CA19-9 dynamics, circulating tumor DNA, molecular profiling, and artificial intelligence into patient selection for surgery.

The value of PVR should no longer be judged solely by technical feasibility or anatomical resectability. Instead, portal vein invasion should be interpreted as both an anatomical and biological finding, and indications for PVR should be guided by integrated biological assessment within a multidisciplinary treatment strategy. Future progress will depend on identifying patients most likely to derive meaningful oncological benefit through biologically informed precision surgical oncology.