Portal vein resection during surgical therapy of pancreatic head carcinoma- clarification of indication by improved preoperative diagnostic procedures?

Tumor invasion of the portal vein by ductal adenocarcinoma of the pancreati c head is classically known as a criterion for inoperability. Despite impro vement in operation techniques for portal vein resection during Whipple's p rocedure and acceptable mortality and morbidity, in the case of uncertain t umor infiltration vascular resection cannot be recommended in general. The problem is the preoperative detection of tumor infiltration of the portal v ein. Often the surgeon is confronted with unsuspected macroscopic portal ve in infiltration or tumor adhesion during the operation. Between 1986 and 19 95 105 patients underwent Whipple's procedure for ductal adenocarcinoma of the pancreatic head in our department. In eight of these cases partial port al vein resection was performed because of macroscopic tumor infiltration o r tumor adhesion. In all eight cases the preoperative diagnostic procedures with CT and portography did not show any suspicion of tumor infiltration. In four of the eight cases histological tumor infiltration of all vascular layers was found. In the others we found no or only adventitial tumor invas ion. The patients without tumor infiltration of the portal vein showed a su rvival time after surgery of 27.78 months in contrast to 6.67 months in the group with histologically proven tumor infiltration. Endovascular, intrapo rtal ultrasound (IPEUS), a new diagnostic procedure, can give helpful infor mation regarding portal vein involvement. Although the IPEUS is not a stand ard diagnostic procedure it was shown to detect portal vein infiltration wi th high sensitivity and specificity. Our results indicate that in such case s where portal vein infiltration has been excluded by IPEUS, patients with macroscopic tumor adhesion do benefit from partial portal vein resection.