How far can you push the limits of resection in pancreatic cancer?
The number of patients who actually complete surgical treatment for pancreatic cancer remains dismally low. The main reasons for inability to resect the tumor is spread of the cancer. Spread of the cancer is either local, where it invades the nearby blood vessels and distant spread (called metastases) to the liver and the lining of the abdominal cavity (called peritoneum). There is no surgical solution for liver and peritoneal metastases. But we do have advanced surgical procedures to tackle local invasion of pancreatic cancers. I have discussed this in this post. Please remember that the solutions provided require ability to perform resections of blood vessels that supply the liver and the intestines and the expertise to do this is limited to fewer centers in India. Such expertise requires a combination of pancreatic surgical expertise and training in transplant surgery. But this blog is not about our expertise but about information regarding how even advanced pancreatic cancers can be resected.
Resecting venous structures in pancreatic cancer
The blood supply to the liver - the portal vein is formed by the joining of splenic vein (which carries the blood from the spleen) and the superior mesenteric vein ( which carries blood from the intestines). These blood vessels join behind the pancreas and the place where the go behind the pancreas is called the neck of the pancreas, which serves as a borderline between the right and left sides of the pancreas. The right side of the veins have small venous connections to the pancreas. When a patient has a tumor in the head of the pancreas, it can invade the vein. A while ago, it was thought that these tumors represented aggressive cancers, but now we know that these are just cancers that lie near the vein. If we are able to cut a portion of the vein, and remove it along with the cancer, we will be able to increase the number of patients whose cancers can be successfully removed. With expertise in connecting venous structures to the liver in transplant surgery, these advanced resections are easily performed by surgeons with liver transplant expertise. A portion of the vein can be removed and reconnected directly or by using another vein to bridge the gap.
Resecting arterial structures in pancreatic cancer
These cancers were considered unresectable till very recently. Cancers that involve arterial blood vessels usually have access to the nerves sound the arteries and have gained one more access for spread, but the pancreatic surgical community has noted that certain arterial vessels can be resected safely. The question always has been to preserve the blood supply to the liver. While the complexities of deciding how this is done, is difficult to understand for a patient. This again is complex surgery and is done only after preoperative chemotherapy is given for 6 cycles. It opens up the vista to increase the number of patients who can undergo resections for this violent cancer. We follow the Appleby resection and spare the liver supply through the gastroduodenal artery to the liver and increase liver blood flow by augmenting flow thorough the stump of the hepatic artery. Being a transplant team, we have also developed a protocol to resect the entire pancreas and reperfuse the liver by means of a novel vessel reconstruction technique. This will take a while to be established as a standardized technique.
These vistas, though complex and require intensive surgical care, can open up the options for many patients with pancreatic cancer. Our hope is to prolong the survival from this aggressive cancer by increasing the number of patients who under go resection and will benefit from preoperative chemotherapy in meaningful way.
Resecting venous structures in pancreatic cancer
The blood supply to the liver - the portal vein is formed by the joining of splenic vein (which carries the blood from the spleen) and the superior mesenteric vein ( which carries blood from the intestines). These blood vessels join behind the pancreas and the place where the go behind the pancreas is called the neck of the pancreas, which serves as a borderline between the right and left sides of the pancreas. The right side of the veins have small venous connections to the pancreas. When a patient has a tumor in the head of the pancreas, it can invade the vein. A while ago, it was thought that these tumors represented aggressive cancers, but now we know that these are just cancers that lie near the vein. If we are able to cut a portion of the vein, and remove it along with the cancer, we will be able to increase the number of patients whose cancers can be successfully removed. With expertise in connecting venous structures to the liver in transplant surgery, these advanced resections are easily performed by surgeons with liver transplant expertise. A portion of the vein can be removed and reconnected directly or by using another vein to bridge the gap.
Resecting arterial structures in pancreatic cancer
These cancers were considered unresectable till very recently. Cancers that involve arterial blood vessels usually have access to the nerves sound the arteries and have gained one more access for spread, but the pancreatic surgical community has noted that certain arterial vessels can be resected safely. The question always has been to preserve the blood supply to the liver. While the complexities of deciding how this is done, is difficult to understand for a patient. This again is complex surgery and is done only after preoperative chemotherapy is given for 6 cycles. It opens up the vista to increase the number of patients who can undergo resections for this violent cancer. We follow the Appleby resection and spare the liver supply through the gastroduodenal artery to the liver and increase liver blood flow by augmenting flow thorough the stump of the hepatic artery. Being a transplant team, we have also developed a protocol to resect the entire pancreas and reperfuse the liver by means of a novel vessel reconstruction technique. This will take a while to be established as a standardized technique.
These vistas, though complex and require intensive surgical care, can open up the options for many patients with pancreatic cancer. Our hope is to prolong the survival from this aggressive cancer by increasing the number of patients who under go resection and will benefit from preoperative chemotherapy in meaningful way.
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