Portal Vein Resection in Whipple's Surgery - March 2008

Portal vein resections are part of the skills of most pancreatic cancer surgeons in the UK and abroad who, in the UK, regularly use the technique in up to 20% of their operations to help remove tumours as long as they aren't involved with arteries or extensively with blood vessels. They may by preference use other replacement veins such as from the body or leg rather than the neck. In the past many surgeons would turn down a patient for surgery due to portal vein involvement but these days most, if not all, designated regional pancreatic cancer surgical centres in the UK routinely offer this type of surgery to a carefully selected group of patients to whom they think it will be beneficial.

If surgeons cannot remove all of the tumour there is a high risk of the cancer returning at the site of the surgery or to spread elsewhere in the body such as the liver. In the UK chemotherapy is usually given after surgery to help reduce this risk. Portal vein resections similar to that reported in the press and TV have been undertaken in the UK for more than 20 years in selected patients. (A similar type of surgery was in fact first done in 1951. The Whipple operation itself - the main operation performed to remove pancreatic tumours - was first described in the 1930’s by Allan Whipple.). The replacement of the portal vein (by jugular, femoral or renal veins etc or grafts/patches) is undertaken (routinely) by many experienced surgeons providing specialist pancreatic cancer surgery in the pancreatic cancer regional centres in London and the rest of the UK as well as abroad to enable patients to have more or all of their tumour removed.

The main issue is which patients will get benefit from this technique and that is still debated by surgeons nationally and internationally. Once the tumour has encased the portal vein there is a risk the cancer is already in the blood system and so may spread elsewhere so systemic treatment with chemotherapy is still likely to be required and surgery may not be beneficial.

Surgeons are very careful to only operate when they think the surgery will be of real benefit to patients in extending their quality or quantity of life. The question is not necessarily whether they CAN operate but whether the surgery will be of BENEFIT to the patient. It can take a long time to get a confirmed diagnosis and treatment plan for patients with suspected pancreatic cancer as the specialists try to rule out benign disease and to try to find out from nonivasive imaging such as CT/MRI/PET or endoscopic ultrasound whether the cancer has spread elsewhere in the body such as liver or lungs or far lymph nodes or has involved local veins and arteries. If the cancer has spread elseswhere surgery will have little or no benefit. This is major surgery with significant recovery time so decisions about who will benefit are taken carefully by surgeons in consultation with their patients.

The UK guidelines ( Gut 2005 Jun; 54 (Suppl 5) : 1-16.) say

"9.4.5 Venous involvement Most surgeons agree that resection should not be undertaken with intent to excise tumours where there is clear preoperative evidence of venous encasement. It is believed that this situation is more hazardous for the patient, as a result of preoperative segmental portal hypertension, and some evidence exists that survival is not greatly different to that seen in patients who are not resected. Resection of the portal or superior mesenteric vein as a means of ensuring that resection with tumour free margins becomes feasible is appropriate if vein involvement is discovered during pancreaticoduodenectomy. This extension of the procedure does not increase operative morbidity or mortality and long term outcome is not affected by the need for vein resection.

Recommendations for surgical resection

• Resectional surgery should be confined to specialist centres to increase resection rates and reduce hospital morbidity and mortality (grade B).
• Pancreatoduodenectomy (with or without pylorus preservation) is the most appropriate resectional procedure for tumours of the pancreatic head (grade B).
• Extended resections involving the portal vein or total pancreatectomy may be required in some cases but do not increase survival when carried out routinely (grade B).
• Resection in the presence of preoperative detection of portal vein encasement is rarely justified (grade C).
• Percutaneous biliary drainage prior to resection in jaundiced patients does not improve surgical outcome and may increase the risk of infective complications (grade A).
• Left sided resection (with splenectomy) is appropriate for localised carcinomas of the body and tail of the pancreas. Involvement of the splenic vein or artery is not in itself a contraindication to such resection (grade B)."

The USA guidelines (NCCN Clinical Practice Guidelines in Oncology ) say early attempts at vein resection in the 1970s were unsuccessful but as surgical techniques improved and surgery became safer and more successful a subset of patients were identified who needed resection of the veins in order to get negative margins in the removal of their tumours. Thus there was renewed interest in the 1990s in vein resection for complete resections (rather than just scraping the tumour off the portal vein). There are some groups who are strong advocates of the technique to enable mpre patients to have surgical removal of tumours and others who advocate caution and only use it in selected patients.

The critical issues are

• whether the outcomes in terms of survival and quality of life for patients who have needed portal vein resection to remove all their tumour are similar to patients who have had complete removal of their tumour without involvement of the blood vessels,
• whether the outcomes are better than if some tumour is left behind if portal vein resection is not done (for instance it is scraped off the portal vein) and
• whether the outcomes are better than if surgery was not done and just chemotherapy or chemoradiotherapy used for palliative treatment.

These issues are still debated by surgeons and there are some papers on them in the literature. Patients need to discuss this with their specialists.

It is clear that outcomes for patients are better if there has been no spread of the tumour beyond the pancreas eg if none of the adjacent lymph nodes are shown to have pancreatic cancer cells and all the tumour is removed by surgery.

Surgeons are always endeavoring to see whether treatment can be improved to provide longer term survival to more patients and this is always a matter of debate until new guidelines (eg through NICE) are produced based on experience with large series of patients. The greater use of adjuvant (after surgery) or neoadjuvant (before surgery) chemotherapy or chemoradiotherapy for instance may mean that the benefits of portal vein resection can be extended to a wider range of patients but this needs to be the subject of future trials and investigations.

It is not mentioned in the press stories whether the patients have also had neoadjuvant or adjuvant chemotherapy. The benefits of adjuvant chemotherapy have been investigated in large scale trials such as ESPAC and others.

Further information on surgery for pancreatic cancer can be found on the CancerHelp UK web-site

The Johns Hopkins web-site in USA provides some information on spread of cancer away from the pancreas and its impact on the possibility of surgery

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Carrère N, Sauvanet A, Goere D, Kianmanesh R, Vullierme MP, Couvelard A, Ruszniewski P, Belghiti J. Department of Digestive Surgery, Hôpital Beaujon, University Paris VII, 100 Bd du Général Leclerc, 92118, Clichy Cedex, France. "Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head." World J Surg. 2006 Aug;30(8):1526-35.

Jaeck D, Bachellier P, Oussoultzoglou E, Audet M, Rosso E, Wolf P. Centre de Chirurgie Viscérale et de Transplantation, Hôpital de Hautepierre, Avenue Molière, 67098 Strasbourg, France. "Analysis of a series of 100 mesenterico-portal vein resections during pancreatic resection" Bull Acad Natl Med. 2006 Oct;190(7):1495-506; discussion 1506-9.

Raut, Chandrajit P. ; Tseng, Jennifer F. ; Sun, Charlotte C. ; Wang, Huamin ; Wolff, Robert A. ; Crane, Christopher H. ; Hwang, Rosa ; Vauthey, Jean-Nicolas ; Abdalla, Eddie K. ; Lee, Jeffrey E. ; Pisters, Peter W. T. ; Evans, Douglas B. 2007 "Impact of Resection Status on Pattern of Failure and Survival After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma." Annals of Surgery. 246(1):52-60, July 2007.

Riediger H, Makowiec F, Fischer E, Adam U, Hopt UT. Department of Surgery, University of Freiburg, Freiburg, Germany. "Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection." J Gastrointest Surg. 2006 Sep-Oct;10(8):1106-15.

Tseng JF, Raut CP, Lee JE, Pisters PWT, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. . 2004;8(8):935-950.

Varadhachary G.R., Tamm E.P., Abbruzzese J.L., Xiong H.Q., Crane C.H.,Wang H., Lee J.E., Pisters P.W.T., Evans D.B. and Wolff R.A. 2006 "Borderline Resectable Pancreatic Cancer: Definitions, Management, and Role of Preoperative Therapy" Annals of Surgical Oncology 13(8) 1035-1046