**2. History**

**1. Introduction**

196 Challenges in Pancreatic Pathology

series [6].

Nowadays, radical surgical treatment remains the only potentially curative treatment for patients with pancreatic cancer. Radical surgical resection followed by adjuvant chemo‐ therapy can be performed in about 20% of all pancreatic ductal adenocarcinoma (PDAC) patients by the time of diagnosis and quite often is the only chance for long‐term survival of the patients, with an average 5‐year survival of 20–25% [1, 2]. More than 80 % of them are unresectable at the moment of diagnosis due to invasion of retroperitoneal tissue, por‐ tal vein (PV)/superior mesenteric vein (SMV), invasion of mesenteric artery, presence of liver or peritoneal metastases, or inability to sustain major surgical resection. As a result of the development of surgical techniques and technologies, extended operations, including vascular resections, have become more frequently performed in specialized centers [3]. This has led to a significant change in pancreatic surgery and has enlarged the border of resectability and ensured the possibility to achieve a curative surgical approach combined with neoadjuvant and adjuvant treatment strategies in patients with pancreatic cancer. Pancreatic carcinoma is characterized with high biological activity and early involvement of retroperitoneal tissue, lymph nodes, and peripancreatic blood vessels. The majority of pancreatic cancers are diagnosed at an advanced stage. Between 30 and 35% of them are classified as unresectablebecause of the isolated involvement of superior mesenteric/portal vein (**Figure 1**) [4]. For the first time the idea for resection of the portal vein for the sake of complete removal of the tumor was presented systematically by Fortner [5]. Currently, porto‐mesenteric vein resection is a standard procedure at high‐volume pancreatic cen‐ ters. Experience in vascular surgery is indispensable for a modern pancreatic surgeon. Nowadays, only arterial resections are still a controversial issue. Nevertheless, attempts at resection involving reconstruction of the main arteries such as the coeliac axis, hepatic artery, and superior mesenteric artery (SMA) have been reported, although in small case

**Figure 1.** Resectability of pancreatic cancer patients at the time of initial diagnosis [4].

Moore et al. performed the first superior mesenteric vein (SMV) resection and reconstruction, thus making the base for the treatment of locally advanced pancreatic cancer with aggressive surgery [7]. Twelve years later (1963), Asade et al. published their results, followed by Fortner who first described a"regional pancreatectomy" involving total pancreatectomy, radical lymph node clearance, combined portal vein resection (Type 1), and/or combined arterial resection and reconstruction (Type 2) [6, 8]. These surgical interventions carried a greater morbidity and mortality than conventional surgery, so lately they were abandoned. Fuhrman et al. were the first to report that infiltration of the portal vein/SMV was not a function of the biological aggressiveness of the tumor but of the proximity of the tumor to the pancreatic head [9].

With the improvement of surgical technique, anesthesia, and critical care support, the interest in vascular resection in cases with isolated involvement of the portal vein (PV) and/or supe‐ rior mesenteric vein (SMV) in locally advanced pancreatic cancer has gradually been renewed during the last decade (**Figure 2**) [3]. There are numerous reports on portal vein resection in locally advanced pancreatic cancer in the last decade, but still the results are conflicting [10–17]. Nowadays, it is accepted that the pancreatoduodenectomy with vein resection does not increase the postoperative risk, but there are still no reliable proofs that it significantly improves survival.

**Figure 2.** Improvement of surgical results for pancreatic cancer [3].
