Pancreatectomy with arterial resection following neoadjuvant FOLFIRINOX: a single-institution experience.

Backgrounds/aims: Arterial resection in pancreatic cancer remains controversial. This study evaluates outcomes of pancreatic resection with arterial involvement following neoadjuvant chemotherapy.

Methods: Retrospective analysis of 100 pancreatic adenocarcinoma patients undergoing resection after neoadjuvant FOLFIRINOX (2010-2024): 26 with arterial resection (ArP), 39 with portal-venous resection (PoP), and 35 without vascular involvement (NoP). Primary outcomes included perioperative morbidity, mortality, and survival.

Results: ArP patients had significantly more stage III disease (73.1% vs 58.9% vs 28.6%, p < 0.001) but achieved acceptable R0 resection rates (76.9% vs 84.6% vs 91.4%, p = 0.04). ArP procedures required longer operative time (386 ± 71 minutes), greater blood loss (1,100 ± 560 mL), and more transfusions (57.7%; all p < 0.001). Major complications (Clavien-Dindo ≥ III) were higher in ArP (26.9% vs 21.6% vs 8.6%, p = 0.03), with extended ICU stays (3.5 ± 1.5 vs 2.0 ± 1.0 vs 1.0 ± 0.5 days). Ninety-day mortality was 0% (ArP), 2.5% (PoP), and 5.7% (NoP) (p = 0.78). Despite shorter disease-free survival in ArP (7.4 vs 9.7 vs 13.2 months, p = 0.01), median overall survival was comparable (ArP: 19.1, PoP: 18.3, NoP: 22.7 months; p = 0.0652).

Conclusions: Arterial resection following neoadjuvant therapy in selected pancreatic cancer patients demonstrates acceptable perioperative risk and achieves survival outcomes comparable to less advanced cases. This approach is justified in experienced high-volume centers for appropriately selected patients with favorable response to neoadjuvant therapy, offering potential cure in rare circumstances.