**5. Arterial resections**

Arterial resection is usually performed in cases of advanced tumors that infiltrate the ret‐ roperitoneal nerve plexus and are related with poor prognosis. Some studies doubted the question whether performing of arterial resection in patients with pancreatoduodenectomy is necessary because the procedure itself is a technical challenge. They confirmed that the arte‐ rial resection is possible, but there were not enough data in favor, and that is why it is applied in the context of randomized controlled trials (RCTs) [25].

Neoadjuvant treatment should be evaluated to achieve a better local tumor control in case of arterial tumor infiltration. It can be performed following different study protocols and is not standardized yet [26]. Following the restaging, patients should be subjected to surgical exploration as long as no signs of systemic tumor spread are visible. Further mobilization of the pancreatic head could be performed. First an incision of the peritoneal layer at the liga‐ ment of Treitz from the left side is made and then is continued with clearing of the tissue along the artery down to the origin from the aorta via this access. This preparation is used for confirmation or ruling out of the tumor infiltration, so that further needed procedures could be determined.

As a whole, arterial resections and reconstructions are limited to the common hepatic artery or resections (with or without any reconstruction) of the right or left hepatic artery in the presence of aberrant hepatic arterial anatomy. Segmental resections of the common hepatic artery may be considered in isolated involvement usually in the area of branching of

The TVI‐classification of Tran Cao et al. [24] considers the radiographic tumor‐vein circumfer‐

A consensus statement standardizing the definition of the term "borderline resectability" in accordance with the guidelines of the National Comprehensive Cancer Network (NCCN) as well as the definition of extended resections published by the International Study Group for

The approach should be different when borderline findings in venous and arterial vessel involvement are diagnosed. No neoadjuvant treatment is recommended in venous borderline resectability. Upfront surgery should be performed and, if the intraoperative finding matches the presumed borderline situation as defined above, completed as an en bloc tumor removal with venous replacement [21]. In contrast, palliative treatment should be regarded as the stan‐ dard of care when suspected arterial borderline resectability is intraoperatively confirmed as a true arterial involvement. Stratification and recognition of the patients with borderline findings who do not benefit from extended resections could be done with the neoadjuvant treatment. Patients with a clear tumor progression under neoadjuvant treatment should be

Vascular resection must be performed only upon carefully selected patients with data for presence of resectable tumors or tumors with borderline resectability from the preoperative

Arterial resection is usually performed in cases of advanced tumors that infiltrate the ret‐ roperitoneal nerve plexus and are related with poor prognosis. Some studies doubted the question whether performing of arterial resection in patients with pancreatoduodenectomy is necessary because the procedure itself is a technical challenge. They confirmed that the arte‐ rial resection is possible, but there were not enough data in favor, and that is why it is applied

Neoadjuvant treatment should be evaluated to achieve a better local tumor control in case of arterial tumor infiltration. It can be performed following different study protocols and is not standardized yet [26]. Following the restaging, patients should be subjected to surgical exploration as long as no signs of systemic tumor spread are visible. Further mobilization of the pancreatic head could be performed. First an incision of the peritoneal layer at the liga‐ ment of Treitz from the left side is made and then is continued with clearing of the tissue along the artery down to the origin from the aorta via this access. This preparation is used for confirmation or ruling out of the tumor infiltration, so that further needed procedures could

As a whole, arterial resections and reconstructions are limited to the common hepatic artery or resections (with or without any reconstruction) of the right or left hepatic artery in the presence of aberrant hepatic arterial anatomy. Segmental resections of the common hepatic artery may be considered in isolated involvement usually in the area of branching of

ential interface and its value as a predictive factor for concomitant vessel resection.

Pancreatic Surgery (ISGPS) (**Table 1**) [21–23].

200 Challenges in Pancreatic Pathology

excluded from secondary exploration.

in the context of randomized controlled trials (RCTs) [25].

computed axial tomography.

**5. Arterial resections**

be determined.

**Figure 3.** Combined resection of the common/proper hepatic artery with T‐T anastomosis, along with segmental portal vein resection with T‐T anastomosis.

gastroduodenal artery [6]. The transition between the common and proper hepatic artery is usually long enough and makes primary anastomosis possible, when the area of gastroduo‐ denal artery is resected (**Figure 3**). The use of an interpositional graft from reversed saphe‐ nous vein is sometimes required. Due to the communication of the right and left hepatic artery inside the liver, ligation of the right hepatic artery is well tolerated, on providing that normal levels of the serum bilirubin and normal blood flow through the portal vein are maintained. Despite that, revascularization of these blood vessels is usually required

**Figure 4.** Distal spleno‐pancreatectomy with resection of the celiac trunk and segmental resection of SMV. Ligated common hepatic artery is pointed by the forceps.

because the proximal hepatic duct receives almost all of its arterial blood flow from the right hepatic artery after interruption of the blood flow from the right gastric artery. The aber‐ rant right hepatic artery may be infiltrated by the tumor, when the latter reaches the celiac trunk (upon early bifurcation and low position of the left hepatic artery) or when the artery branches from the superior mesenteric artery. Replaced right hepatic artery, branching from the superior mesenteric artery, in contrast to the accessory hepatic arteries, represents the only direct arterial branch toward the right lobe of the liver. When the right hepatic artery, branching from the superior mesenteric artery is infiltrated along the postero‐lateral bor‐ der of the head of pancreas, the pancreatoduodenal resection does not frequently require removal of these blood vessels, because the larger part of these tumors are localized more in front of the head of pancreas and uncinate process of pancreas. The whole common hepatic artery may rarely branch from the superior mesenteric artery (type IX), no identification of that anatomical variant and inattentive ligation of the hepatic artery requires performing of reconstruction.

A high rate of complete resection and favorable prognosis (estimated overall 5‐year survival rate of 42%) could be observed in selected patients with distal pancreatectomy with en bloc coeliac axis resection for locally advanced pancreatic body cancer (**Figure 4**) [27, 28].
