Prognostic impact of pathologically confirmed venous infiltration during upfront pancreatectomy: multicenter survival analysis.

PURPOSE: Pancreatectomy with venous resection (PVR) for resectable pancreatic ductal adenocarcinoma (PDAC) may be preoperatively planned or intraoperatively required due to suspected vascular involvement. The prognostic impact of pathologically confirmed venous infiltration (PVI) in upfront PVR remains unclear. This study assesses such impact on overall survival (OS). METHODS: Patients who underwent upfront PVR for PDAC were identified from a prospectively maintained database across three high-volume institutions. Clinical and pathological variables, including PVI status, were collected. Survival outcomes and predictors were analyzed using Cox regression models. RESULTS: A total of 295 patients underwent upfront PVR. Segmental end-to-end reconstruction (Type III) was the most common approach (69%). PVI was confirmed in 66% of cases. Adjuvant therapy was administered to 69% of patients. Median OS was 32 months for PVI-negative vs. 21.1 months for PVI-positive patients (HR 1.49, 95% CI: 1.02–2.17, p = 0.037). One- and three-year survival rates were significantly lower in the PVI-positive group. Among PVI-positive patients, OS was 7 months without adjuvant therapy and 29.5 months with, aligning with outcomes in PVI-negative patients who received adjuvant treatment (HR 1.51, p = 0.104). Independent predictors of OS included PVI (HR 1.67), age ≥ 75 (HR 1.93), N2 status (HR 1.89), total pancreatectomy (HR 2.42) and adjuvant therapy (HR 0.33). CONCLUSIONS: More than one-third of patients undergoing upfront PVR for suspected venous infiltration are overtreated as they lack pathologically confirmed vessel involvement. Conversely, when PVI is present, survival is significantly impaired. The successful delivery of adjuvant chemotherapy in case of PVI ameliorates outcomes as in cases lacking venous involvement.