The Role of Vascular Resection in Pancreatic Cancer Treatment

Abstract

Currently, porto-mesenteric vein resection is a standard procedure at high-volume pancreatic centers. Experience in vascular surgery is indispensable for a modern pancreatic surgeon. Nowadays, only arterial resections still are a controversial issue. Nevertheless, attempts at resection involving reconstruction of the main arteries such as the coeliac axis, hepatic artery, and superior mesenteric artery (SMA) have been reported, although in small case series. An overview of the historical and contemporary methods for surgical management of superior mesenteric/portal vein involvement as well as arterial involvement by pancreatic cancer is presented. We compare the data from the literature with our data based on the examination and long-term follow-up of more than 300 radical pancreatic resections. Seventy-two of the presented patients underwent pancreatic resection with simultaneous vascular resection-SMPV in 65 cases (44 with resection of the portal vein, 15 with resection of the superior mesenteric vein, 6 with resection of the portomesenterial confluence), arterial in 2 and partial resections of IVC in 5 cases. Combined vascular resections were done in three cases. Both groups PVR and PR showed similarly close results in complication rates, mortality, and morbidity. Three and 5 years survival rates were 42 and 38% in PD group and 28 and 19% in the PVR group. The vascular resection must be performed only upon carefully selected patients with data for presence of resectable tumors or tumors with borderline resectability from the preoperative imaging studies. The prompt management of pancreatic cancer with vascular involvement should involve multidisciplinary consultation in high-volume centers.

Hepatic artery reconstruction after extended resection for borderline resectable pancreatic head cancer: A case report

“…Regarding the most commonly encountered arterial resections which are needed during pancreaticoduodenectomy, they are represented by celiac axis and hepatic artery resection followed by reconstruction (23)(24)(25). In cases presenting hepatic artery involvement reconstruction is needed in all cases except when patients present aberrant hepatic arteries (6,7,26). As for the techniques of arterial reconstruction of the hepatic arteries, any kind of arterial or venous graft interposition seem to be suitable; however, ultrasound evaluation is mandatory in order to investigate the liver perfusion and to detect early any sign which might suggest the appearance of liver ischemia (3,27).…”

“…In cases in which the resected segment of the hepatic artery is shorter than 1.5-2 cm, direct anastomosis between the two remaining stumps might be taken in consideration; meanwhile, in cases presenting more extended arterial resections or in which an end to end anastomosis is not feasible an arterial or venous graft might be interposed with good results (26). A particular situation is represented by the presence of an aberrant hepatic artery from the superior mesenteric artery which might provide an adequate blood supply of the liver even if the common hepatic artery is no longer reconstructed (28).…”