Pancreatectomy with concomitant portal vein resection in the current neoadjuvant era.

HepatoBiliary Surg Nutr 2022 | https://dx.doi. org/10.21037/hbsn-21-547 I’ve read with great interest the paper of Machairas et al. (1) which is of great interest for the oncological and surgical community. Pancreatic adenocarcinoma (PDAC) is still considered a malignancy with an extremely poor prognosis, being currently the 4 cause of death for cancer and, according to the Global Cancer Statistics in the next decade, it may ascend up to the third cause of death (2). During the last decades, there have been great efforts to improve survival of potentially resectable pancreatic cancer through several improvements. Firstly, the selection of patients: newer preoperative studies have been able to select those patients that might really benefit from resection. Secondly, the surgical procedure itself improved its outcome: proper mesopancreatic dissection and lymphadenectomy, superior mesenteric artery approach and vascular resection have been able to enhance the R0 resection rate with acceptable morbidity (3). Finally, newer chemotherapies regimens have been introduced, as well, with relevant survival improvement (4). The standard treatment for patients with resectable pancreatic cancer is surgery followed by adjuvant chemotherapy with the chance of long-term survival up to 20–25% (5). In 2011, the new regimens Gem-Nab-Paclitaxel and FOLFIRINOX with the MPACT and ACCORD11, respectively, have showed for the first time a remarkable improved survival in metastatic and locally advanced pancreatic cancer (LA-PDAC) (6,7). In 2012, these regimens have been implemented with the PRODIGE24 for the first time as adjuvant treatment for resectable pancreatic cancer, showing an increased mean survival up to 54.4 months, compared with the 34.8 months of the previous standard Gemcitabine regimen (8). In the last decade, neoadjuvant treatment (NAT) strategies are showing a crucial role in solid organ cancers such as breast, rectal, gastric cancer and pancreatic cancer, as well (9). Currently, several trials, such as the PRODIGE 48, 44 and 56 and NEOPAN are investigating with optimism the benefit of these regimens as NAT for potentially resectable pancreatic cancer (5). In this regard, NAT in borderline resectable (BR) or even resectable (R) PDAC has gained wide acceptance lately based on the results of several multicentric randomized clinical trials carried out in highly selected centers such as the PREOPANC, JANG and ESPAC-5F (5,10). The main potential claimed benefit of NAT is to improve the OS by increasing the R0 resections, treating micrometastasis, delivering chemotherapy to all patients, and making an adequate selection of patients who are likely to benefit from a pancreatectomy (11). To that purpose, portal venous resection (PVR) is an essential surgical maneuverer to achieve R0 resection in many cases of BL-PDAC or LA-PDAC (12). Many studies showed the feasibility and safety of venous resection during pancreatoduodenectomy for PDAC; however, although short-term postoperative outcomes are acceptable, existing evidence on long-term survival on this topic is still limited (12). Therefore, it is essential to address the impact Editorial