LAUSR

Pancreatic cancer (PC) has been a poor prognosis tumor for many years. The general factors that have always contributed to this, such as the anatomical location of the gland with its extensive lymphatic connections and the absence of clinical symptoms that allow an early diagnosis, add up to the scarce accomplishment of radical surgical procedures capable of achieving free-margins resections and the absence of effective chemo and radiotherapeutic procedures. Due to these circumstances, survival results have been very disappointing. Thus, a marked skepticism about this disease has been spread among patients and medical professionals1. In the last ten years, notable therapeutic changes have occurred. Through them, it was possible to prove a slow but progressive improvement in results, with special repercussion in some reference groups that, due to their large series, have a wide experience in this field2. The diagnostic methodology has improved remarkably. Through radiology, endoscopy and radioisotopes, it is now possible to detect patients with disseminated and / or locally advanced disease. The greatest problem arises in the evaluation of vascular involvement. In our country, the combination of helical computed tomography and echo-endoscopy allows us to preoperatively detect 75% of patients with PC who will require arterial or venous resection associated with pancreatic resection. The study of these patients should be as broad as possible to clearly define local commitment and its possible dissemination. The goal is to operate only those patients who may benefit from an oncologic resection, avoiding unnecessary procedures (surgeries with positive margins) that in some occasions surpass 40% of the operated patients3. Venous infiltration of pancreatic tumors located in the cephalic position or on the isthmus was considered a criterion of irresectability for a long time. The technical complexity and the apparent small oncological benefit seemed to justify this attitude. Currently this criterion has been clearly overcome. A better surgical technique in the field of vascular surgery, achieved by specialists in pancreatic surgery, has made venous resection a standard procedure in the treatment of suchh patients. In order to obtain free margins, about 30% of our patients require venous resection. From an oncological perspective, a question that currently does not have a clear answer is whether vascular invasion is always a sign of greater aggressiveness and, consequently, worse prognosis. In some patients it may be considered as such, especially in large lesions. However, in others, the aforementioned invasion stems only from an “unfavorable anatomical tumor location” and does not represent greater biological aggressiveness. Similar results obtained in many PC patients treated with or without vascular resection support the latter theory. Arterial resection represents a different, though controversial, scenario. Virtually all clinical guidelines consider patients with this type of vascular involvement to be inoperable and unresectable. The first descriptions of combined pancreatic and arterial resections occurred in lesions located in the pancreatic body with invasion of the celiac trunk. The modified Appleby technique4, described in 1953, allows its realization without the need to perform hepatic revascularization. The hepatic vascularization is maintained through the pancreatoduodenal branches of the superior mesenteric artery. The