Vascular Resection, Reconstruction, and Divestment in Pancreatoduodenectomy: Expanding Boundaries in Pancreatic Cancer Surgery

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors

Your manuscript is about an interesting topic, it is well written, and easy to read. 

Main problem: In the abstract, you define a bibliographic search, which readers could interpret as a systematic review, but I think it is a narrative review.

If you have performed a systematic review, all information should follow PRISMA guidelines: databases, years, search strategy, exclusion and inclusion criteria, PICOS, bias assessment, ...

If you have performed a narrative review, you should remove all information about the search from the abstract and inform readers that you are conducting a narrative review. I think that is. a narrative review

As you know, a narrative review is less powerful than a systematic review because selection bias exists. 

Tables about each point of interest should be done

Minor: Point 2 venous resection should be marked in black as the other points.

 

Author Response

Dear Reviewer,

We sincerely thank you for your thoughtful and constructive comments. We appreciate your positive assessment of the manuscript’s clarity, readability, and clinical relevance.

Main comment — Narrative vs. systematic review:
We agree with your assessment that the manuscript represents a narrative review rather than a systematic review. Our intention was to provide a comprehensive, experience-informed synthesis of the literature rather than a PRISMA-compliant systematic analysis. In response to your comment, we have removed all references to formal database search methodology from the abstract and explicitly clarified in the revised manuscript that this is a narrative review. This ensures that readers are not misled regarding the methodological framework and appropriately interpret the level of evidence and potential for selection bias.

We also acknowledge your important point regarding the inherent limitations of narrative reviews, however we think that the present format serves better the purpose of presenting the data in informative way since the studies are very heterogeneous and do not allow analysis in systematic review basis.

Tables summarizing key evidence:
the pre-existing tables include the key points described in the review

Minor comment — Venous resection formatting:
Thank you for noting this detail. The formatting of Point 2 (venous resection) has been corrected so that it is consistent with the other section headings.

Once again, we thank you for your insightful feedback, which has substantially improved the clarity, methodological transparency, and overall quality of the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

This article reviews the evolution of vascular resection and reconstruction techniques during pancreaticoduodenectomy (PD) for pancreas cancer. Venous resection is standardized in high-volume centers with a 30-day mortality rate of 3–5% and median survival of 18–26 months after R0 resection. Although arterial resection is technically challenging and has higher morbidity, selected patients who have undergone neoadjuvant therapy can achieve an R0 rate of 65–75% and a median survival of 20–28 months. The emerging “arterial peeling” technique preserves arterial integrity and reduces morbidity while achieving comparable survival benefits. Key takeaways include: 1) venous reconstruction techniques are well established, but negative margins must be ensured; 2) arterial intervention should be strictly limited to patients responding to neoadjuvant therapy; 3) intraoperative fluorescent angiography and hybrid procedures represent future directions. Radiotherapy improves R0 resection rates but may increase the complexity of vascular reconstruction, necessitating multidisciplinary evaluation. Data suggest that modern vascular surgical techniques have significantly expanded the frontiers of surgery for locally advanced pancreatic cancer.

 

1. The author should allocate more space in the introduction section to present background information on pancreatic cancer.
2. The subsequent references are closely associated with the author's topic and are recommended for the author to cite. Specifically, the author is required to elaborate on and demonstrate the tumor - neural - vascular crosstalk.

[1] Y. Wu, R. Sun, S. Ren, G. Zengin, M.-Y. Li. Neuronal Reshaping of the Tumor Microenvironment in Tumorigenesis and Metastasis: Bench to Clinic. Medicine Advances 2025, 3(4), 364-371. https://doi.org/10.1002/med4.70044

[2] A.-Q. Li, J.-H. Fang, Anti-angiogenic therapy enhances cancer immunotherapy: Mechanism and clinical application. Interdiscip. Med. 2024, 2, e20230025. https://doi.org/10.1002/INMD.20230025

[3] Qaderi, K., Shahmoradi, A., Thyagarajan, A. et al. Impact of targeting the platelet-activating factor and its receptor in cancer treatment. Military Med Res 12, 10 (2025). https://doi.org/10.1186/s40779-025-00597-0

3. To enhance the transparency and credibility of the research, it is recommended to provide a comprehensive description of the specific strategies employed for literature retrieval, keywords used, time ranges, inclusion and exclusion criteria, as well as methods for quality assessment of included studies in the methodology section.
4. In the results and discussion sections, it is suggested to include evaluations of the quality and biases of the included studies, discuss variations among study findings, and elucidate possible reasons to improve the academic depth of the article.
5. In the conclusion, address existing knowledge gaps by proposing specific research questions or hypotheses and recommend types of future studies (e.g., prospective trials, comparative studies) that could further validate and refine current conclusions.
6. Based on existing evidence, propose practical recommendations regarding when vascular resection or arterial dissection should be performed to assist clinicians in making informed decisions in their practice.

Author Response

Response to Reviewer

Dear Reviewer,

We sincerely thank you for your detailed, constructive, and insightful comments. We appreciate your positive evaluation of the manuscript’s clinical relevance and clarity, and we are grateful for the opportunity to further strengthen its scientific depth, methodological transparency, and translational impact.

1. Expansion of background on pancreatic cancer in the Introduction
We agree that the Introduction benefits from a broader contextual foundation. Accordingly, we have expanded the background section to provide a more comprehensive overview of pancreatic ductal adenocarcinoma (PDAC), including its epidemiology, aggressive biology, patterns of locoregional invasion, limitations of current multimodal therapies, and the rationale for expanding surgical boundaries in locally advanced disease.

2. Tumor–neural–vascular crosstalk and integration of recommended references
We appreciate the reviewer’s recommendation to elaborate on tumor–neural–vascular interactions. We think that this direction recommended is beyond the scope of the manuscript. The manuscript is a narrative review/atlas of surgical techniques, options and outcomes to support the idea of vascular reconstruction techniques in the management of LAPC

3. Clarification of review type and literature retrieval methodology
The abstract was revised to prevent confusion about the design of the manuscript, that is a narrative review rather than a systematic review.

4. Evaluation of study quality, heterogeneity, and bias

Not applicable to the format of a narrative review. Indeed the studies cites are highly heterogeneous thats why we did not opt to perform a systematic review

5. Future research directions and knowledge gaps
In response to your suggestion, the Discussion has been expanded to explicitly identify key unanswered questions.

6. Practical clinical recommendations for vascular and arterial resection
To improve clinical applicability, we have added a practice-oriented section summarizing actionable recommendations, including a table.

These recommendations aim to support real-world surgical decision-making while emphasizing patient selection and oncologic prudence.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript has improved with your changes