Chapter 142: Borderline Resectable Pancreatic Cancer and Techniques of Vascular Resection

INTRODUCTION

Reports of the use of vascular resection at the time of pancreatectomy have circulated since Fortner attempted to popularize the techniques approximately 40 years ago. At that time, resection of major mesenteric vessels was advocated as part of a regional pancreatectomy procedure designed to maximize soft-tissue clearance in the face of infiltrating cancers of the pancreas.^1,2 Although vascular resection subsequently lost favor, as it was perceived to be associated with significant morbidity and mortality, the past 20 years have seen a greater understanding of both its role and its limitations. Experienced surgeons have steadily been increasing the use of vascular exposures and resection techniques to achieve margin negative resections as part of comprehensive multimodality treatment strategies for patients with pancreatic ductal adenocarcinoma (PDAC).

In this chapter, the role of vascular resection at pancreatectomy is reviewed within the context of a discussion of “borderline resectable” disease. Controversies with regard to staging and management of borderline resectable PDAC are discussed. Finally, surgical techniques are reviewed and illustrated in detail.

BORDERLINE RESECTABLE PANCREATIC CANCER

A complete microscopic (R0) pancreatectomy operation has long been considered necessary for long-term survival of patients with PDAC.³ In contrast, incomplete (R2) resection has long been considered a palliative procedure that is not associated with any extension of survival relative to other less invasive strategies.

The likelihood of R0 resection in a patient with PDAC can be estimated prospectively on the basis of cross-sectional computed tomography (CT) studies. Tumors likely to be removed with microscopically negative margins at surgery have historically been considered “potentially resectable” and can be distinguished from patients with “unresectable” tumors—for whom surgery is expected to be associated with positive margins and early treatment failure—on the basis of good imaging.

Over the past several years, however, it has increasingly been recognized that a subset of patients with scans suggesting that R0 resection is unlikely may actually undergo resection and have postoperative survival durations similar to those of patients with resectable cancers. However, such tumors are at high risk for positive microscopic (R1) margins when surgery is attempted de novo, even when surgery is performed by the most skilled of pancreatic surgeons. Patients with these advanced cancers may therefore benefit from preoperative therapy delivered by multidisciplinary treatment teams prior to radical surgical operations that may involve resection of major mesenteric vasculature.^4,5 These advanced tumors, for which potentially curative therapy is a rational consideration, are considered “borderline resectable.”

Pretreatment Evaluation and Management

ANATOMIC (RADIOGRAPHIC) DISEASE STAGING

Anatomic staging of PDAC is routinely accomplished using multidetector CT scanners and a specialized protocol optimized to image pancreatic tumors. Intravenous contrast and a low-density oral contrast are administered, and images are obtained in arterial, portal-venous, and noncontrast phases. Thin slices obtained every 2 to 3 mm ...