Venous resections of the portal or superior mesenteric vein have been performed during pancreatic cancer surgery for over 40 years. While initially performed to enhance nodal harvest, contemporary data shows that portal-superior mesenteric vein resection can be performed with acceptable morbidity and mortality when needed to achieve a negative margin resection. Preoperative imaging with CT scan is sufficient to determine resectability in most cases. Encasement of the celiac axis or superior mesenteric artery over 180 degrees remains a contraindication. With advances in surgical techniques and postoperative care, vascular reconstruction after venous resection now allows for long term survival similar to upfront resectable pancreatic cancer.

1. Venous resections in the surgical
treatment of pancreatic
adenocarcinoma
Eduardo A. Guzman MD
May 29, 2008

2. Outline
• History
• Indications
• Anatomy
• Technique
• Contemporary data
• Definitions
• Summary
• Conclusion

3. The 70’s
• Having recognized the poor survival associated with
pancreatic cancer, surgeons introduced extensive
pancreatic resections
• One of these, was the “regional pancreatectomy” or “en
bloc pancreatectomy”
• This operation required mesenteric vessel resections as
the standard approach regardless of invasion
• The goal was to enhance nodal harvest
• Did not impact survival but was associated with
increased morbidity and mortality

4. • Fortner et al. MSKCC
• “Regional pancreatectomy refers to an en bloc removal of a tumor in or
adjacent to the pancreas with an adequate soft tissue margin and with
its regional lymphatic drainage. The pancreatic segment of portal vein
is part of the en bloc resection with venous reconstruction by end-to-
end anastomosis without a graft. This operation, called a Type I
regional pancreatectomy, may utilize either a total or subtotal removal
of the pancreas. Localized arterial involvement by a neoplasm
necessitates adding a segmental resection of the artery with vascular
reconstruction, a Type II procedure”
• 1972-1982, 35 patients, 26% operative mortality
Fortner et al, Annals of Surgery, 1984

5. The 80’s
• Regional pancreatectomy was abandoned in favor of
extended nodal dissections without vessel resections
(R2 dissection)
• Refinements in surgical technique and postoperative
care made it possible to substantially improve outcomes
for pancreaticoduodenectomies

6. 1969 - 1980 1981 - 1986
Morbidity 59 % 36 %
Mortality 24 % 2%
Johns Hopkins Hospital
Crist and Cameron, Annals of Surgery, 1987

7. The 90’s
• Improved perioperative outcomes brought a renewed
interest for vein resections in locally advanced
pancreatic cancer
• Specific indications were developed

8.  35 patients who underwent a Whipple, R2 node
dissection and SMV/Portal vein resection
 Use arteriography to determine resectability
I
Ishikawa et al, Annals of Surgery, 1992
Resectable Unesectable

9. Ishikawa et al, Annals of Surgery, 1992
• Divided splenic vein
• Primary anastomosis between portal vein – SMV
• Bilateral SMV narrowing is an absolute contraindication
to resection

10. • MD Anderson – 23 patients
Fuhrman and Evans
Annals of Surgery 1996

11. • CT criteria for resectability
– Absence of metastatic
disease
– No tumor encasement of
the SMA or celiac axis
– Patent PV/SMV
confluence
Fuhrman and Evans
Annals of Surgery 1996

12. • Outcomes
– No difference in morbidity, mortality, hospital stay,
– Increased surgical time, blood loss and blood transfusions
– Similar pathologic features than no vein resection patients
Fuhrman and Evans
Annals of Surgery 1996

13. The millenium
• Widespread acceptance of portal vein resections
• Performance of arterial resections in selected patients
• Precise preoperative definitions
• Importance of negative resection margins (R0)
• Introduction of neoadjuvant chemoradiotherapy
approaches in borderline resectable patients

14. • The majority of cases did not
require an interposition graft
• Splenic vein ligation was
performed for tumors at the
confluence
• Re-implantation was only done
in patients with poor splenic
hylar collaterals
• Arterial resections ocassionally
performed
Yakebas et al. Annals of Surgery 2008

16. Fukuda et al. Archives of Surgery 2007

17. Indications for portal vein resection
• A high quality pancreatic protocol CT scan is the only
preoperative study required to determine resectability
– Absence of metastatic disease
– No tumor encasement of the SMA or celiac axis
– Patent PV / SMV confluence
– Good performance status
• SMV encasement likely signifies SMA involvement
• Patients that are borderline resectable are sometimes
referred to neoadjuvant chemotherapy approaches

18. Anatomical considerations
• The splenic vein is anterior to the base of the SMA
• Splenic vein transection allows access to the proximal SMA
• Transection of the splenic vein frees the portal structures to
the right and allows for primary repair of the PV – SMV
following vein resections at the confluence
• The first jejunal branch courses underneath the SMA
• Bleeding from the first jejunal branch is difficult to control
with the standard exposure
• Ligation of the first jejunal branch can be performed after
transection of the root of the mesentery

19. Some technical aspects
• Appropriate patient selection
• Perform dissection of the SMA first leaving the tumor
attached to the SMV only
• Facilitated by division of the splenic vein yet not essential
• Evans leaves the splenic vein intact due to concerns for
venous hypertension if this vessel is ligated
• Systemic heparinization
• Inflow occlusion of the SMA to prevent intestinal edema
• Repair with interrupted 6-0 prolene sutures
• In distal SMV, either the jejunal or the iliac branch can be
safely ligated if the other branch remains patent

20. Some technical aspects
• Reconstruction is done
with either
– Primary anastomosis
– Vein patch
– Interposition vein graft
• Grafts used
– Saphenous vein
– Internal Jugular vein
– Left renal vein

21. SMV tumor invasion
• Adherence of the tumor to the portal vein or SMV can be
caused by inflammatory pancreatitis in approximately 30
% of the time
• As such tumor adherence to the vessel is not equal to
vessel invasion
• Intraoperatively, it is not possible to determine if there is
tumor invasion without cutting through it
• In practice, vein resections are performed in all this
patients

22. Arterial resections
• Controversial
• Focal involvement of the hepatic artery or SMA can be
amenable to resection
• Reconstruction can be either with a primary anastomosis
or a short segment of saphenous vein
• The celiac plexus can be resected in distal pancreatic
resections as long as the SMA and gastroduodenal
artery remain intact (Appleby’s operation)

23. Preoperative definitions
• Resectable:
– Patent SMV – PV confluence
– Definable tissue plane between the tumor and regional arterial
structures (SMA, hepatic, celiac)
• Borderline resectable:
– An SMV – PV confluence that can be reconstructed even if short
segment venous occlusion is present
– Tumor abutment of the SMA < 180 degrees
– Short segment encasement of the hepatic artery amenable to
resection and reconstruction (GDA origin)
• Locally advanced / unresectable:
– Tumor encasement of the SMA or celiac axis, > 180 degrees
Evans for the Multidisciplinary Pancreatic Cancer Study Group, HPB 2006

24. Summary
• Venous resections in pancreatic cancer have been
performed for over four decades
• High quality CT scan is the only preoperative study required
• Encasement of the SMA or celiac axis is an absolute
contraindication for resection
• Portal-SMV resection can be performed with acceptable
morbidity and mortality
• Reconstruction is performed with primary repair, vein patch
or interposition vein graft
• Short and long term survival is similar to patients with
resectable pancreatic cancer
• Arterial resections are being explored

25. Conclusion
• Vessel resections have expanded the pool of patients
with pancreatic adenocarcinoma that are able to undergo
an R0 resection

26. But
• Many more patients with resectable disease are denied
surgery secondary to nihilistic views present in the
medical community
• 71 % of patients with Stage 1 pancreatic cancer do not
undergo surgery
Bilimoria et al.
National failure to operate on early stage pancreatic cancer
Annals of Surgery 2007