The standard surgical treatment for cancer of the pancreatic head remains the pancreaticoduodenectomy, first described by Dr. A.O. Whipple in 1935.
This article on the Whipple procedure is accompanied by a full set of images and illustrations in a PDF document that describes the operation in detail. Many of these illustrations have appeared in lectures that Dr. Evans has given on the topic of pancreatic surgery for cancer.
The goals of surgical therapy are:
- Reasonable opportunity for cure
- Risk of death should not outweigh the prospects for cure
- Patient should be left in as normal a condition as possible
Recent advances in surgical technique, anesthesia and hospital care have resulted in a 30-day in-hospital mortality rate of less than 1 percent for pancreaticoduodenectomies performed at major referral centers by experienced surgeons. Patient selection, preoperative medical evaluation, surgical technique, and postoperative care are all critically important in minimizing patient morbidity and mortality and optimizing long-term oncologic outcome. A reasonable level of experience with major pancreatic resection necessary to achieve good results.
Vein Resection During Whipple Procedure
It is generally felt that surgical resection of the primary tumor is necessary to cure the patient with pancreatic cancer. 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.
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) and may require an interposition graft (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, inflow occlusion of the superior mesenteric artery (SMA) is usually used to prevent bowel edema which may complicate the post-resection pancreatic and biliary reconstructions.
At Froedtert & 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.
The above is a contribution from Douglas B. Evans, MD and Kathleen Christians, MD. Dr. Evans came to Froedtert & the Medical College of Wisconsin from the University of Texas MD Anderson Cancer Center, where he and his group defined how to manage patients with localized pancreatic cancer. Learn more about this procedure through his publications.
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.