Surgical trategies and key points for operation after conversion therapy in locally advanced pancreatic cancer

YIN Jie; JIANG Kui-rong

doi:10.19538/j.cjps.issn1005-2208.2025.06.07

Abstract：Locally advanced pancreatic cancer(LAPC),defined by tumor invasion of major peripancreatic vessels or critical structures,has traditionally been considered unresectable and is associated with a poor prognosis.Conversion therapy can downstage tumors in selected patients,enabling opportunities for radical(R0)resection and significantly improving survival.Preoperative selection of surgical candidates requires the comprehensive evaluation of contrast-enhanced computed tomography(CT),positron emission tomography-CT(PET-CT),changes in carbohydrate antigen 19-9(CA19-9)levels,and patient performance status,and the application of the four-dimensional criteria of anatomy,biology,clinical condition,and duration of chemotherapy(the"ABCD"criteria).Surgical strategies include an artery-first approach with periadventitial dissection to enhance vascular control,with distal pancreatectomy and celiac axis resection(DP-CAR)or arterial reconstruction performed when necessary.Portal vein(PV)and superior mesenteric vein(SMV)resection and reconstruction follow the International Study Group of Pancreatic Surgery(ISGPS)classification,employing direct patch repair,end-to-end anastomosis,or interposition grafting as appropriate.Lymphadenectomy should encompass the Heidelberg triangle and level Ⅲ peripancreatic mesenteric nodal stations to reduce the risk of local recurrence.Given the high morbidity and mortality associated with these procedures,priority should be given to patients demonstrating favorable biological response and good tolerance,and surgeries should be performed by experienced multidisciplinary teams to balance radicality with safety.