Liver, Pancreas and Bile Duct Cancer Program

Vein Resection at the Time of Whipple Procedure

The following is a brief contribution from Douglas B. Evans, MD, Medical College of Wisconsin surgeon, and Kathleen Christians, MD, Medical College of Wisconsin surgeon.

Dr. Evans came to Froedtert & The Medical College of Wisconsin in January 2009 from the University of Texas MD Anderson Cancer Center, where he and his group defined how to manage patients with localized pancreatic cancer. Additional information can be found in manuscripts on this site as well as in the interview with Dr. Evans which appears on the Lustgarten Foundation Web site.

Dr. Christians has been with the Medical College since 1999 and has been voted one of the "Best Doctors in America."

Patients can be referred to Drs. Evans or Christians by talking directly with Gail Laschen in the Clinical Cancer Center at 414-805-6849.

Dr. A.O. Whipple described the operation that bears his name in 1935, and in 1946, Waugh and Clagett modified the Whipple operation to a procedure very similar to that which is done today. Most importantly, they outlined the goals of surgical therapy for pancreatic cancer:

There should be a reasonable opportunity for cure,
The risk of death should not outweigh the prospects for cure, and
The patient should be left in as normal a condition as possible.

The debate over whether major vascular resection should be performed at the time of pancreatectomy should be considered with these goals in mind. Clearly, surgeons who perform such extended operations should be able to do them safely and patients should be selected carefully based upon the biology of the disease and the general health of the patient. Fortunately, in the current era of more effective systemic therapies and the ability to deliver radiation therapy in a more targeted fashion (thereby reducing toxicity), we can carefully select those patients in whom the risk of a major operation can be justified.
Please see related publications by Dr. Evans.

In contrast to tumor-artery (celiac axis, hepatic artery, superior mesenteric artery) abutment, which can be accurately interpreted on good quality CT imaging, tumor abutment of the lateral or posterolateral wall of the superior mesenteric vein (SMV) or the superior mesenteric-portal vein (SMPV) confluence may not always be appreciated on preoperative imaging. Because of this, surgeons without the technical ability to perform venous resection may be in the position of being unable to separate the SMV from the tumor predisposing to an incomplete resection or an inadvertent venotomy. Importantly, deformity of the vein wall at the tumor interface (see figure 1 in the accompanying illustrations), even if subtle, often indicates tumor adherence. This may only be appreciated if the CT images are performed with a venous phase of contrast enhancement and are accurately interpreted.

Illustrations

This contributed article is accompanied by images and illustrations, presented in a slideshow format.

When vascular resection and reconstruction is performed by experienced surgeons at institutions where such surgery is frequently done, morbidity and mortality are not increased compared to a standard Whipple procedure without vascular resection.

It is generally felt that surgical resection of the primary tumor is necessary to cure the patient with pancreatic cancer, even if often not sufficient (chemotherapy and radiation also very important components of a successful treatment program). Indeed, for those patients who are deemed unresectable due to local tumor extension to adjacent blood vessels, the median survival is 10 to 12 months. In contrast, if the primary tumor can be resected (to include adjacent vessels when necessary), median survival is 2-3 years and almost one-third of such patients survive 5 years from the time of diagnosis. Resection of the SMV or SMPV confluence can be performed with or without ligation of the splenic vein (figure 2 in the accompanying illustrations shows SMV resection with preservation of the splenic vein) and may require an interposition graft (left internal jugular vein most frequently used as shown in figure 3) or a patch (saphenous vein). The various technical options for repair of the SMV or portal vein are illustrated in figure 4. When performing reconstruction of the SMPV confluence, we usually use inflow occlusion of the superior mesenteric artery (SMA) to prevent bowel edema which may complicate the post-resection pancreatic and biliary reconstructions.

Importantly, at the Medical College of Wisconsin all patients are evaluated in a multidisciplinary fashion by experts in diagnostic radiology, gastroenterology, medical oncology, radiation oncology, and surgery. For the pancreatic cancer patient, surgery is just one part of a successful treatment program. Additional information can be found in the references which are available in PDF format on our Web site.

Incredible Story

Chicago resident Sally Levin benefited from a combined treatment approach that included chemotherapy, radiation and surgery. Read her incredible story.

References

Von Hoff DD, Evans DB, Hruban RH. Pancreatic Cancer. Sudbury, MA: Jones and Bartlett, 2005.

Katz MHG, et al. Anatomy of the superior mesenteric vein with special reference to the surgical management of first-order branch involvement at pancreaticoduodenectomy. Ann Surg. 2008;248(6):1098-102.

Tseng, et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg 2004;8:935-49.

Author: Douglas Evans, MD, and Kathleen Christians, MD

Date: Feb. 10, 2009