Pancreaticoduodenectomy with Portal Vein Resection
The only chance of long-term survival for patients suffering from pancreatic ductal adenocarcinoma (PDAC) is surgery followed by adjuvant chemotherapy. Only app. 20% of all patients primarily qualify for a surgical approach by the time of diagnosis. Where
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Pancreaticoduodenectomy with Portal Vein Resection Thilo Hackert, Jörg Kaiser, and Markus W. Büchler
Abbreviations BR Borderline resectable CA 19-9 Carbohydrate antigen 19-9 CA Celiac axis CE-CT Contrast-enhanced computed tomography DP Distal pancreatectomy HA Hepatic artery ISGPS International Study Group for Pancreatic Surgery MRI Magnet resonance imaging NCCN National Comprehensive Cancer Network PD Pancreato-duodenectomy PDAC Pancreatic ductal adenocarcinoma PV Portal vein SMA Superior mesenteric artery SMV Superior mesenteric vein SV Splenic vein
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Diagnostic Workup
For the definition of local resectability in PDAC with venous involvement, the extension of the tumor towards the vascular structures, namely the superior mesenteric (SMV) and the portal vein (PV), must be evaluated preoperatively. A valid T. Hackert • J. Kaiser • M.W. Büchler, M.D. (*) Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany e-mail: [email protected] © Springer Science+Business Media Singapore 2017 H. Yamaue (ed.), Innovation of Diagnosis and Treatment for Pancreatic Cancer, DOI 10.1007/978-981-10-2486-3_8
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evaluation can be done by contrast-enhanced computed tomography (CE-CT) [1]. This diagnostic modality is available in nearly all institutions and has become the standard diagnostic tool with sensitivity and specificity rates of 63–82% and 92–100%, respectively, with regard to PDAC diagnosis [2]. The use of a pancreas- specific CE-CT examination protocol with a 30° right-sided position of the patient and oral water intake to enhance the contrast in the gastroduodenal region is the basis to maximize accuracy in the preoperative diagnostics [3]. In case of contraindications for a CE-CT, magnet resonance imaging (MRI) can be used instead of CE-CT as the accuracy of MRI is comparable to CE-CT regarding diagnosis of PDAC and evaluation of the local tumor extension [2]. With regard to possible vascular involvement, the use of endoscopic ultrasound (EUS) has gained widespread acceptance today. This diagnostic tool shows best rates of sensitivity and specificity compared to CE-CT and MRI as it offers a very high resolution local imaging along the vessels [2]. The possible disadvantages of EUS include that—besides the invasive character of EUS from the patients’ perspective—the region of interest is limited, the accuracy of EUS is depending on the examiner’s experience, and the results of this dynamic examination can be reproduced only during the procedure itself. Therefore, EUS has to be regarded as a complementary tool to CE-CT or MRI and is not available as a standard procedure in all institutions. Resectability is defined as (1) primary resectable PDAC, (2) borderline resectable (BR-PDAC), or (3) unresectable PDAC according to the criteria published by the International Study Group for Pancreatic Surgery (ISGPS) in 2014 [4], which are mainly based on the recommendations of the National Comprehensiv
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