Better margins in the treatment of pancreatic cancer
I would say that talking about pancreatic margins influence on the outcome of pancreatic cancer is not a new subject at all for a hepatobiliary and pancreatic surgeon. But my goal here is educating my patients about the importance of a good surgical margin and I feel that knowing this important aspect of your treatment goes a long way to improve the patient's survival.
Over years, I have slowly worked out many ways to improve pancreatic cancer margins. In this blog, I would like to highlight the changes we have made in treating pancreatic cancer so that we are able to provide better results to our patients.
Extending the uncinate dissection to the right margin of the superior mesenteric artery
One of the first unforgettable lessons that I learnt in Chennai is that there are very few surgeons who take the time to dissect and remove the entire uncinate process. (The uncinate process is the part of the pancreas that goes below the two blood vessels to the small and large intestine. The uncinate wraps the vessels on the right side of the blood vessels) The margin is designated as the retroperitoneal margin in a biopsy report. Dissecting the uncinate takes 30 - 45 minutes and this process should be done meticulously. Once the pancreatic tissue at the level of the artery is taken off, a good margin is easily obtainable.
A good specimen shows the groove of the superior mesenteric vessels which is readily identified.
Resecting the involved portal or superior mesenteric vein
When the tumour touches the portal vein axis, resection provides the best option for cure. We are now able to remove the cancer involved vein and reconstruct it using various options (direct suturing, patch grafts and jump grafts) and provide cancer free margins. These patients were considered for just chemotherapy till recently and most of them died in a short time.
Removing the entire pancreas
If there is no clearance margin at the neck of the pancreas, or if there are multiple lesions or early pancreatic cancer changes called PIN (pancreatic intraepithelial neoplasm), it is better to remove the entire pancreas and provide good medical support for the management of diabetes. With the availability of insulin pumps in India, this has become a viable option. Doing auto islet cell transplantation in patients with cancer is not recommended.
I will update this post with pictures of surgeries that illustrate these principles to highlight the importance of good surgical technique to achieve excellent results in the treatment of pancreatic cancer. It is important that as a patient you must know how good results can be obtained.
Please feel free to ask any questions in the comments section.
Over years, I have slowly worked out many ways to improve pancreatic cancer margins. In this blog, I would like to highlight the changes we have made in treating pancreatic cancer so that we are able to provide better results to our patients.
Extending the uncinate dissection to the right margin of the superior mesenteric artery
One of the first unforgettable lessons that I learnt in Chennai is that there are very few surgeons who take the time to dissect and remove the entire uncinate process. (The uncinate process is the part of the pancreas that goes below the two blood vessels to the small and large intestine. The uncinate wraps the vessels on the right side of the blood vessels) The margin is designated as the retroperitoneal margin in a biopsy report. Dissecting the uncinate takes 30 - 45 minutes and this process should be done meticulously. Once the pancreatic tissue at the level of the artery is taken off, a good margin is easily obtainable.
A good specimen shows the groove of the superior mesenteric vessels which is readily identified.
Resecting the involved portal or superior mesenteric vein
When the tumour touches the portal vein axis, resection provides the best option for cure. We are now able to remove the cancer involved vein and reconstruct it using various options (direct suturing, patch grafts and jump grafts) and provide cancer free margins. These patients were considered for just chemotherapy till recently and most of them died in a short time.
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| The basic surgical diagram to the approach for SMV in the surgical treatment of pancreatic cancer. The jejunal and the ileocolic branches join to form the SMV and run towards the inferior border of the pancreas. From my HPB notes. |
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| Portal vein reconstruction after pancreatic resection performed by the author. |
Removing the entire pancreas
If there is no clearance margin at the neck of the pancreas, or if there are multiple lesions or early pancreatic cancer changes called PIN (pancreatic intraepithelial neoplasm), it is better to remove the entire pancreas and provide good medical support for the management of diabetes. With the availability of insulin pumps in India, this has become a viable option. Doing auto islet cell transplantation in patients with cancer is not recommended.
I will update this post with pictures of surgeries that illustrate these principles to highlight the importance of good surgical technique to achieve excellent results in the treatment of pancreatic cancer. It is important that as a patient you must know how good results can be obtained.
Please feel free to ask any questions in the comments section.
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